| 140000061 |
Vale Healthcare Center |
020009298 |
A |
14-May-12 |
4PBU11 |
17017 |
72311 (a) Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (A) Identification of care needs based upon an initial written and continuing assessment of the patient?s needs with input, as necessary, from health professionals involved in the care of the patient. Initial assessments shall commence at the time of admission of the patient and be completed within seven days after admission. (2) Implementing of each patient?s care plan according to the methods indicated. Each patient?s care shall be based on this plan. (3) Notifying the attending licensed healthcare practitioner acting with the scope of his or her professional licensure promptly of: (B) Any sudden and/or marked adverse change in signs, symptoms or behavior exhibited by a patient. 72313 (a) (2) Medications and treatments shall be administered as follows: Medications and treatments shall be administered as prescribed. The facility violated the aforementioned regulations by failing to: a. Continually assess Resident 1?s bowel function to identify the resident?s care needs; b. Implement Resident 1?s care plan by monitoring for constipation and administering the medication as ordered by Resident 1?s physician, and c. Notify the physician when Resident 1 did not have a bowel movement from 2/19/11 to 2/24/11 and when Resident 1 reported abdominal pain on 3/12/11, before she was transferred to the emergency room with a perforated bowel. These failures to assess and monitor Resident 1?s constipation, to administer the medication prescribed, and notify the physician of changes, resulted in Resident 1?s emergency transfer to the acute care hospital on 3/12/11 where she was diagnosed with a perforated bowel due to impacted feces causing her death from septic shock less than 72 hours later.Resident 1 was a 97 year old woman, admitted to the facility on 2/14/11 after hospitalization for a fractured left hip sustained after falling at home. According to the hospital discharge summary, dictated on 2/14/11, Resident 1 was discharged to the skilled nursing facility for rehabilitation. The hospital discharge summary listed diagnoses including anemia and heart disease, but did not list constipation as a diagnosis for Resident 1. The ?Physician Transfer Orders Total Hip Replacement? showed Resident 1 prognosis was good and her projected length of stay at the facility was 7-14 days. Nursing assessment upon admission to the facility showed Resident 1?s last bowel movement (BM) was on 2/14/11.On 2/15/11 the facility physician (Physician 1) examined Resident 1. Physician notes showed Resident 1 ?was having a lot of pain.? Physician orders, dated 2/15/11, included the following medications: FeSO4 (ferrous sulphate-an iron supplement for the anemia) twice daily, Norco (a narcotic pain reliever) every six hours and Calcium (a supplement for bone strength) twice daily. These three medications have constipation listed as a possible side effect. (Reference Nursing 2010 Drug Handbook pp. 1409, 479, and 881.)The Admission MDS (Minimum Data Set-comprehensive assessment of resident?s condition), with the assessment reference date of 2/21/2011, showed Resident 1 had short term memory problems and was totally dependent on staff for transfers, dressing and toilet use. Resident 1?s Care Plan dated 2/15/11 identified Resident 1 as at ?Risk for Constipation? due to diagnosis of fractured left hip and hip replacement, decreased physical mobility, and medications she received that listed constipation as a side effect. The planned interventions were to, ?monitor BM q (every) shift? and to administer Colace 200 mg (stool softener) twice a day. The Care Plan goal showed Resident 1 would have a bowel movement at least every two days. According to the Lippincott Manual of Nursing Practice, 9th edition, pages 1128-1131: monitoring for signs of constipation included: ?Monitor amount, consistency, and frequency of stool.? Monitoring for constipation is important because failure to have bowel movements regularly can lead to fecal impaction (a condition where the feces in the bowel continue to accumulate, become dehydrated and hard and partially or completely block the colon. Fecal impaction may be present even if a small amount of solid stool or watery loose stool is passed. Decrease in the size or consistency of a bowel movement needed to be reported to the attention of the physician for intervention, especially with predisposing factors for constipation present.) Fecal impaction requires dis-impaction (manual removal of feces from the colon).The facility?s policy for Bowel Elimination Pattern Assessment, dated 3/2000, instructed the nurses to, ?Assess the abdomen, anus and rectum?, to ?Inspect the abdomen for distention, visible peristalsis (movement of intestines/colon), masses, or bulges?, and to, ?Auscultate (listen to) the abdomen in all four quadrants to determine whether normal, hyperactive (more than normal), or hypoactive (less than normal) bowel sounds are present.? The facility policy further instructed the nursing staff, ?Assess for the major defining characteristics or symptoms of constipation?? The list of symptoms included no stool, decreased frequency of bowel movements (fewer than three times a week), distended abdomen, straining and pain on defecation.The monitoring record sheet used by the facility, ?Resident Functional Performance Record? (RFPR) for all three nursing shifts showed under the category ?Bowel Function? a series of boxes divided diagonally. Instructions were: to list in the upper half whether Resident 1 was ?C? for Continent (could control her bowel functions) or ?I? for Incontinent (unable to control her bowels). The lower half of the box instructions were: to list the number of times, per shift, that Resident 1 had a bowel movement. There was no assigned place on the form to record the amount or consistency of Resident 1?s bowel movements. The facility documentation tool did not give nursing staff vital information needed to determine if Resident 1 was developing constipation. For example, small hard, stool or loose stool could indicate that Resident 1 was becoming constipated or having fecal impaction. Without knowing the amount and consistency the assessment was incomplete. According to the ?Resident Functional Performance Record? (RFPR) for February 2011, the certified nursing assistants (CNAs) documented that Resident 1 did not have a bowel movement on any of the three shifts (day, evening or night) on 2/19, 20, 21, 22, or 2/23/11 (five consecutive days.) Resident 1 did not have BM on 2/26/11 during the night and p.m. shift. There was no documentation for the a.m. shift on 2/26, 2/27, and 2/28/11, for the night shift on 2/27, and the p.m. shift on 2/28/11. Nursing notes dated 2/19/11 through 2/24/11 did not contain any mention that for those five days, Resident 1 had no bowel movement. There was no documentation in Resident 1?s medical record to show that the physician was informed of this change in Resident 1?s condition. There was no documentation in Resident 1?s medical record that any interventions were being implemented to prevent or relieve the continuing accumulation of fecal matter that was collecting in Resident 1?s colon, prior to 3/1/11. In a telephone interview with Resident 1?s physician (Physician 1) on 11/2/11 at 9:45 a.m., he stated that he saw Resident 1 at the facility and in the hospital. He stated that he expected to be notified if Resident 1 had a change in bowel habits, change in amount eaten or symptoms of abdominal pain. The physician indicated that he had not been made aware of Resident 1?s constipation until 3/3/11 when he ordered Dulcolax suppositories to be given on days when Resident 1 had no BM and a Fleets enema given if there was no bowel movement for 2 days. He stated he was not made aware of any complaints of abdominal pain. When questioned if he had been asked for an order for manual bowel dis-impaction, and if an order was required, he responded, ?I would give an order if needed, and would expect the nurses to check the bowel and do a disimpaction, at least do a rectal exam. I was not asked for an order for manual bowel dis-impaction?sometimes it needs to be done; it?s part of the nursing practice.? He further stated that in general, a resident should have a bowel movement by every third day, in most cases, and that the staff should be more aggressive in assisting the residents to have regular bowel movements.Physician orders dated 3/3/11 showed an order for the administration of a Dulcolax suppository per rectum every day, if there was no bowel movement, and for a Fleets enema per rectum, if there was no bowel movement for two days. The Medication Administration Record (MAR) and the RFPR for March 2011 showed Resident 1 did not have a bowel movement on 3/5 and 3/10 and did not receive a Dulcolax suppository. On 3/9/11 at 10 p.m., Resident 1 was given a Dulcolax suppository, after no bowel movement during the day, for ?constipation;? the result documented was ?small.? Resident 1?s March RFPR showed that she did not have another bowel movement until the evening shift of 3/11/11.In interview with CNA 1 on 11/9/11 at 2:30 p.m., she stated that she took care of Resident 1 on 3/12/11. She stated that Resident 1 complained of stomach pain that morning. She stated that Resident 1 did not eat anything. When CNA 1 asked her if she was constipated, Resident 1 said, ?Yes. My stomach is hurting.? The CNA reported this to LVN (Licensed Vocational Nurse) 1, who was the charge nurse. LVN 1 gave Resident 1 a suppository in the presence of CNA 1 around 9 a.m., then with the help of LVN 1, CNA 1 took her to the toilet. Resident 1 was unable to immediately have a bowel movement and remained on the toilet while CNA 1 remade her bed. Then CNA 1 assisted Resident 1 back to bed. Resident 1 repeated to CNA 1, that she was in pain. CNA 1 stated that about 40 minutes later, Resident 1 passed two small pieces of feces and some loose stool, which CNA 1 reported to LVN 1. After CNA 1 returned from her lunch, Resident 1 stated she was still not feeling well and did not eat her lunch.There was no documentation in the medical record to show that Physician 1 was informed of Resident 1?s abdominal pain, that she was refusing to eat or that she was complaining that she was constipated.The nurse?s note written by LVN 1 on 3/12/11 at 3 p.m., showed Resident 1 denied pain, and was not feeling hungry. LVN 1 documented that bowel sounds were present and a Fleets enema was given because Resident 1 had no bowel movement for two days after the suppository. The documentation noted Resident 1 had a ?large? bowel movement after the enema, and staff would continue to monitor. In an interview with LVN 1 at the facility on 11/9/11 at 1:40 p.m., she stated that she did not recall Resident 1 other than what was documented in her notes. LVN 1 reviewed the medical record prior to the interview and had access to the record during the interview. She stated that she gave an enema on 3/12/11. When LVN 1 was questioned about the facility policy for identifying possible constipation, LVN 1 stated that the routine of the facility was that during morning report, the nurses instructed the CNAs to check the ADL (Activities of Daily Living) (RFSR) book, to see if their residents were constipated or had loose bowel movements, or if the residents were not eating. She stated that constipation meant that Resident 1 did not have a bowel movement for two to three days. The evening nurse?s note written by LVN 2, dated 3/12/11 at 6 p.m., showed that while passing medications, LVN 2 noticed that Resident 1 experienced a change in her level of consciousness. Resident 1 was weak and refused to eat. Resident 1 was able to respond verbally. Her oxygen saturation level was 75 percent on room air (normal values are 90-100 %) and LVN 2 immediately gave her oxygen. Resident 1?s oxygen saturation increased to 90 percent. The nurses note indicated that bowel sounds were present. Resident 1?s vital signs were: blood pressure 95/61, pulse 89, respirations 22 and temperature 96.8. Normal blood pressure range is 90/60-140/90, normal pulse is 60-100, normal respirations are 12-20 and normal temperature is 97.6-99.6. (Reference: www.faculty.de.gcsu.edu/-sdarby/fundamentals/Vital%Signs.htm). The nurse called 911 and Resident 1 was sent to the hospital. In a telephone interview with LVN 2 on 10/20/11 at 9:35 a.m., he stated that on the evening of 3/12/11 he went into Resident 1?s room and the resident was unable to talk. He took her vital signs and he gave oxygen due to her low oxygen saturation. He stated that he remembered reading the day shift nurse?s notes and noted that the nurse gave Resident 1 a laxative and that she had a bowel movement. He remembered auscultating (listening with a stethoscope) and palpating (feeling) her abdomen and stated there were bowel sounds and Resident 1?s abdomen was soft. LVN 2 stated he did not document the assessment. According to the ?Pre-hospital Care Report?, dated 3/12/11 at 7 p.m., the ambulance emergency medical team documented that when they arrived at the facility at 5:59 p.m., they found Resident 1 ?lying in bed, with her eyes open in a blank stare, and (Resident 1 was) unresponsive to all stimuli?? Resident 1 was transported to the emergency room and a physical exam was performed. Resident 1 was noted to have a distended (enlarged) abdomen. The general assessment was ?primary: unspecified shock, and secondary: abdominal pain, altered level of consciousness.? The physical findings were: ?level of distress, severe, abdomen, distended, tenderness and firm.? Her vital signs were: ?blood pressure 58/36, pulse 134, respirations 28, labored shallow and oxygen saturation level was 50 percent.? The emergency department report, dated 3/12/11 at 9:42 p.m., showed Resident 1 was, ?in an altered level of consciousness, but stated that her stomach hurt.? ?Resident 1?s abdomen was considered ?acute?, in the sense that it was distended, rigid with rebound and guarding (pain upon touching).? Resident was taken to have an abdominal CT scan immediately.The CT scan results transcribed on 3/14/11 at 12:36 p.m., documented the findings: ?free air seen throughout the peritoneum and mesentery (the layer that connects the parts of the small intestine to the back wall of the abdomen). The exact location of perforation was unknown but likely within the proximal (upper) colon. There was a large volume of stool within the rectum and sigmoid colon (above the rectum). Edema (swelling/fluid) consistent with inflammatory change was seen diffusely within the mesentery. There were small fluid collections seen throughout the mesentery as well.? The impression was documented as, ?bowel perforation with free air and extensive mesenteric and inflammatory edema (swelling). 2. Fecal obstipation (obstruction) involving the rectum and sigmoid colon.?On 3/15/11 at 10 a.m., the physician at the hospital documented in a family conference note that, ?There is no hope for (Resident 1?s) recovery and survival at this point. Overwhelming sepsis (infection) from the initial perforation is the underlying cause of the MOSF (multiple organ systems failure.)? The hospital final discharge summary, dated 3/27/11 at 8:54 p.m., outlined the course of her hospitalization: ?(Resident 1) was admitted on 3/12/11, brought in to the hospital with perforated viscous (bowel) in the abdomen and emergency surgery was performed by (physician). She (Resident 1) was in the critical care unit, intubated, and sedated. The resident was placed on multiple pressors, IV (intravenous) antibiotic, and IV fluid resuscitation. Despite all measures, 97 year old female with septic shock could not be able to revive [sic], and made comfort care [sic]?The resident was pronounced, died [sic] at 11:40 a.m. on 3/15/11.? The discharge diagnosis was, ?Septic shock with multiple organ failure.? The resident?s death certificate, issued on 3/23/11, documented the immediate cause of death, ?septic shock, irreversible?, and underlying causes were ?necrosis (tissue death) of rectum,? and ?fecal impaction.? The facility is in violation of the above regulations by its failure to: d. Continually assess Resident 1?s bowel function to identify the resident?s care needs; e. Implement Resident 1?s care plan to monitor for constipation and to administer the medication as ordered by Resident 1?s physician, and f. Notify the physician when Resident 1 did not have a bowel movement from 2/19/11 to 2/24/11 and when Resident 1 reported abdominal pain on 3/12/11, before she was transferred to the emergency room with a perforated bowel. These facility failure either jointly, separately, or in any combination presented either an imminent danger that death or serious physical harm would result or a substantial probability that death or serious physical harm would result. |
| 140000061 |
Vale Healthcare Center |
020010932 |
B |
14-Aug-14 |
OLBN11 |
7268 |
The facility violated the aforementioned regulation, by failing to protect one of one sampled resident (Resident 1) from injury during a transfer from the bathroom onto his motorized wheelchair.For Resident 1, Certified Nursing Assistants (CNA) 1 and CNA 4 lifted him under his arms and Resident 1's feet dragged along the floor as he was moved from the commode to his wheelchair located outside of the bathroom. Resident 1's feet became entangled as he was being turned in order to sit in the wheelchair.Resident 1 was to be moved with the assistance of 2-3 staff with a mechanical lifting device. This failure resulted in Resident 1 sustaining multiple fractures in both of his lower legs.Review of Resident 1's medical record, on 4/8/14, at 3 p.m., showed the facility admitted Resident 1, on 4/29/09, with multiple medical diagnoses including quadriplegia (paralysis of both arms and both legs).Review of Resident 1's Minimum Data Set (MDS) an assessment tool), dated 10/17/13, showed Resident 1 was unable to stand or walk or transfer between surfaces, without total assistance from two staff. Resident 1 did not normally use the bathroom or a commode to toilet. He was incontinent of bowel and bladder and used adult briefs.During an observation and concurrent interview, on 4/8/14, at 2:15 p.m., Resident 1 sat up in bed with both his legs out straight wearing soft braces from thigh to ankle. There was a pillow between his knees to prevent him from crossing his legs and a foot cradle at the bottom of the bed to lift the weight of the blankets from his feet. There was an electric wheel chair parked at the foot of his bed. Resident 1 stated, "I can't use my chair at all since this (pointed to his legs) happened. I sure want to. I'd go outside and listen to the birds. I'm used to being up and around. I'm an outside person."Resident 1 explained how his 3/24/14 injury occurred during a transfer from the commode in the bathroom to the wheelchair outside of the bathroom. He stated, "The two people (Certified Nursing Assistants, CNA 1 and CNA 4) worked to try to get me in my chair. It was a slip not a fall."Nurses notes for Resident 1, dated 3/25/14, at 8:30 p.m., showed Registered Nurse 2 (RN 2) wrote, "Pt (patient) has multiple intact blisters on bilateral lower extremities. Skin discolorations surrounding the blisters also noted." Nurses notes dated 3/26/14, at 2 p.m., showed RN 1 recorded, "Received x-ray results from imaging services...multiple fractures on bilateral lower extremities." A review of Resident 1's x-ray results, dated 3/26/14, showed:"1. Femur (thigh bone, right), comminuted (crushed or splintered into pieces) and impacted (wedged together) distal (farthest down) femoral shaft fracture;2. Ankle (right), non-displaced fracture of the distal tibial (shin bone) shaft in addition to the spiral fracture ( a curved break from a twisting motion) of the mid to distal tibia shaft.3. Femur (left) comminuted anterior (front) apex (summit or extremity) angulated and impacted distal femoral shaft fracture;4. Knee (left) fracture of the proximal (nearest the knee) tibial shaft and fibular (fibula; outer, smaller bone, alongside the tibia) neck without significant displacement." Resident 1's Doctor's progress notes, dated 3/28/14, showed, "Patient is extremely osteoporotic (had weakened bones, a frequent consequence of quadriplegia) - subject to fractures, even with minor trauma." In an interview, on 4/8/14, at 2:30 p.m., (CNA 1) stated, "I am his regular CNA. Usually, Resident 1 is incontinent or just passed gas." CNA 1 did not have an explanation for why Resident 1, who was always incontinent and never used the commode, was in the bathroom using a commode on that day. CNA 1 went on to say that on 3/24/14, after lunch, she helped get Resident 1 off the shower chair commode in Resident 1's bathroom. CNA 1 held Resident 1's left arm. Another CNA (CNA 4) held his right arm. The Restorative Nurse Assistant (RNA 1) was supposed to pull up Resident 1's pants and get the (motorized) chair into position at the bathroom door. "We hoisted him up under his armpits. RNA 1 took longer than expected to pull up his pants, they got stuck or something. We pulled him out to the door frame. The pants got twisted and one of his legs was crossed under his other knee. When I felt him slipping I said, 'Let's just get him back in the (wheel) chair.' I was holding onto the pants. I felt he was slipping."CNA 1 stated, "I could have taken the wheeled commode, with Resident 1 on it, out of the bathroom and placed it next to his wheel chair. We could have more safely transferred Resident 1 out there in the room." During an interview, on 4/10/14, at 9:30 a.m., RNA 1 stated, "My job was to bring up the wheel chair and pull up his pants once they had him (Resident 1) standing. They pivoted and brought him out, bottom first. I was attempting to work the electric wheel chair controls. It had been left in the rabbit mode (rapid acceleration). It came out of the corner quicker than I was prepared. I had to get it into turtle mode (slow speed) to put it in the doorway. I guess I fidgeted with it longer than I should. It seemed to me they were trying to dead lift him (lift a person who is completely unable to bear weight) (Resident 1) and carry him to the chair."In an interview and concurrent record review, on 4/9/14, at 12:15 p.m., the Director of Nursing (DON) looked through Resident 1's clinical record for a care plan for transferring between surfaces. The DON stated, "There isn't one. All I could find is the ADL (Activities of Daily Living) care plan. It says Resident 1 requires extensive assistance with ADL's and transfer."In an interview, on 4/10/14, at 9:45 a.m., the DON stated Resident 1 had osteoporosis. "It's probably because of his quadriplegia. Staff needed to take care with anyone with long term quadriplegia. Staff needed to take extra careful precautions for osteoporosis."In an interview, on 5/21/14, at 1 p.m., the Unit Manager at Station 2 (Registered Nurse, RN 1) explained that the instructions on how to transfer Resident 1 were located on the Kardex. RN 1 stated, "He was a two person lift, but now he is a mechanical lift (using a machine with a sling to lift Resident 1, operated by 2 staff.)" RN 1 went on to explain why Resident 1 hadn't been out of bed since his legs were broken, "They didn't know if he could use a manual wheel chair because he had always refused to try to get up."During a telephone interview on 7/17/14, at 11:30 a.m., Resident 1 said of his legs, "They are still there. They are still hurting. They are not knitting back together. The pain is still a real problem. The pain is around both knees, like I was being stung by ten thousand red ants, or wasps, or bees. They didn't hurt at all until they were broken. The pain I had before was in my back, but now that is overshadowed by my legs. Also, my legs have contracted-stiff like. They don't bend any more like they did (before fractures). They don't fit solidly in the foot rest on my wheel chair; they stick out about six inches. I have to watch where I'm going so as not to get caught."Therefore the facility failed to: Ensure that Resident 1 received adequate supervision and assistance to prevent accidents. |
| 100000851 |
Vintage Faire Nursing & Rehabilitation Center |
040011595 |
B |
06-Jul-15 |
C5B311 |
28293 |
The facility must permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless the transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility; The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility; The safety of individuals in the facility is endangered; The health of individuals in the facility would otherwise be endangered; The resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at the facility. For a resident who becomes eligible for Medicaid after admission to a nursing facility, the nursing facility may charge a resident only allowable charges under Medicaid; or The facility ceases to operate. The facility failed to ensure seven of seven sampled residents (Residents 4, 6, 3, 2, 7, 1, and 5) were permitted to remain in the facility when the residents were transferred to other skilled nursing facilities (SNF) without medical justification as necessary for resident welfare, needs or safety.These failures displaced residents from their home and caused residents to encounter unnecessary changes in staff, environment and routines. These unnecessary and avoidable changes resulted in the residents feeling emotional distress and sadness.1. Review of Resident 4's clinical record face sheet indicated Resident 4 was admitted to skilled nursing facility (SNF) 1 on 1/29/07 and resided at the facility until 3/13/15 (8 years) when she was transferred to SNF 2 located 38 miles from SNF 1.Review of Resident 4's "Physician Orders" dated 3/13/15 indicated, "May transfer to [SNF 2] with current orders and treatment." Review of Resident 4's "Transfer/Discharge Report" dated 3/13/15, had not contained any documentation of the "reason for transfer." Resident 4's "Interdisciplinary Discharge Summary" indicated, "Reason for discharge/discharge diagnosis(es)" as "Transferred to [SNF 2]." There was no documented evidence of a rationale for the transfer or of a planned discharge. There was no documented evidence for medical justification for the transfer.On 5/19/15 at 9 a.m., during a concurrent interview and clinical record review, the SSD stated Resident 4's clinical record had not contained documentation which indicated a reason for Resident 4's transfer. The SSD stated no discharge planning care plan had been completed for Resident 4. Review of Resident 4's Minimum Data Set (MDS) Assessment (a tool used in a SNF to assess physical and psychosocial function) dated January 15, 2015 indicated, Resident 4's "Cognitive Skills for Daily Decision Making," were "Severely Impaired - never/rarely made decisions." On 5/14/15 at 11:15 a.m., during a telephone interview, Resident 4's Responsible Party (RP) stated Resident 4 had lived at the facility "For years." The RP stated Resident 4 was elderly and spoke only Cantonese (a dialect of Chinese). The RP stated Resident 4 had a large extended family who lived in the area near SNF 1 and who spoke Cantonese. The RP stated Resident 4's family visited often. The RP stated he had not requested Resident 4 be transferred to SNF 2. The RP stated he received a phone call from the facility on 3/13/15 and was informed the facility was "getting rid of" long term care residents and Resident 4 would be transferred to SNF 2. The RP stated he was not given written notice, advance notice or right to appeal information. The RP stated Resident 4 was transferred later that same day. The RP stated he would have preferred Resident 4 stay at the facility but had not known if that would have been possible. The RP stated family was not able to visit SNF 2 often due to SNF 2's distance away and transportation difficulties. The RP stated he had wanted to visit Resident 4 on Mother's Day but did not have transportation and felt "very sad about it." The RP stated he was concerned for Resident 4 not having family or staff who spoke Cantonese (at SNF 2) because Resident was used to being spoken to in Cantonese at SNF 1. The RP voiced concern that he could not be there for Resident 1 at SNF 2 as he lived closer to SNF 1 and questioned the reasons for the transfer.On 5/19/15 at 12 p.m., during an interview in SNF 1's conference room, Certified Nursing Assistant (CNA) 1 stated Resident 4 had always eaten meals in the facility dining room. CNA 1 stated Resident 4's RP and other family members visited often and would take home cooked food to the dining room for her. CNA 1 stated Resident 4 could not communicate verbally but would look at her family members and smile. CNA 1 stated, "It looked like she was happy to see them." CNA 1 stated the RP and other family members would speak to Resident 4 in her native language and she would attempt to talk back to them. CNA 1 stated, as far as she knew, there was no change in Resident 4's behavior that led to the transfer and believed Resident 4's needs were being met at SNF 1 prior to the transfer.On 5/19/15 at 1 p.m., during an interview in the SNF 1 conference room, CNA 2 stated Resident 4's family visited often. CNA 2 stated the RP and other family members would speak in Resident 4's language and her expression would change; she seemed happy to see her family.CNA 2 stated Resident 4's RP often went to the dining room to help her eat and would bring her home cooked food. CNA 2 stated Resident 4 seemed to enjoy the food brought in by the family. CNA 2 stated Resident 4's needs were being met at SNF 1 and she was unaware of any medical justification for the transfer.On 5/20/15 at 8:30 a.m., during an observation in Resident 4's room at SNF 2, Resident 4 was lying in bed, sleeping. Resident 4 had not responded to a verbal command to open eyes.On 5/20/15 at 8:35 a.m., during an interview in the hallway of SNF 2, CNA 3 stated Resident 4 "sleeps a lot." CNA 3 stated Resident 4 ate breakfast and dinner in her room and went to the dining room for lunch. On 5/20/15 at 9:50 a.m., during an interview in SNF 2's Administrator's (Adm) 2 office, Adm 2 stated SNF 2 provided similar services for Resident 4 as SNF 1.On 5/21/15 at 11 a.m., during a telephone interview, Social Services Aid (SSA) 3 stated she had worked as a social services assistant at SNF 1 during March 2015. SSA 3 stated there had been no Social Service Director (SSD) working at SNF 1 during March 2015. SSA 3 stated she had been shown by SSA 1 how to discharge residents and what paperwork had to be completed. SSA 3 stated she had reviewed clinical records and decided which resident might be a good candidate to transfer. SSA 3 stated she had asked the residents or their Responsible Party (RP) if they would like to transfer. SSA 3 stated if the resident or the RP had agreed to the transfer, she completed the paperwork. SSA 3 stated there had not been any assessments done to determine if the transfer was in the best interest of the resident. SSA 3 stated, "I 'm not sure what you mean by assessment. I was not instructed [by SSA 1] to do anything like that."2. Review of Resident 6's clinical record face sheet indicated Resident 6 had been admitted to SNF 1 on 4/16/14 and had resided at the facility until 3/13/15 when he was transferred to SNF 2, 38 miles away.Review of Resident 6's "Physician Orders" dated, 3/13/15, indicated, "May transfer to [SNF 2] with current orders and treatment." On 5/5/15 at 11 a.m., during a concurrent interview and clinical record review, the SSD stated the "Transfer/Discharge Report" had not contained documentation of the "reason for transfer." The SSD stated Resident 6's, "Interdisciplinary Discharge Summary," was incomplete.On 5/5/15 at 2:15 p.m., during an interview, Resident 6 stated he had been admitted to SNF 2 in March 2015. Resident 6 stated, "They [staff at SNF 1] told me all long term people had to leave."Resident 6 stated his Family Member (FM) 1 had contacted SNF 2 and had him transferred back to the facility. Resident 6 stated he wanted to be at SNF 1, not at SNF 2.On 5/6/15 at 8 a.m., during an interview in the facility conference room, FM 1 stated she was Resident 6's only family in the state. FM 1 stated she was the agent responsible as the "Durable Power of Attorney for Healthcare" and "Power of Attorney for financial matters" for Resident 6. FM 1 stated she had visited Resident 6 at SNF 1 frequently since he had been admitted in April 2014. FM 1 stated she [FM 1] had become ill in January 2015 and had been unable to visit until March 2015. FM 1 stated she had gone to visit Resident 6 in March 2015 and found his room empty. FM 1 stated staff at SNF 1 told her he had been transferred to SNF 2. FM 1 stated she had been upset because no one had called to tell her Resident 6 had been transferred. FM 1 stated she had not been given an opportunity to talk with Resident 6 prior to the transfer. FM 1 stated she spoke with one of the SSA's in March and had asked why he had been transferred to SNF 2 without consulting her. FM 1 stated the SSA had told her she had no right to be notified because Resident 6 was alert and had not requested any family be notified. FM 1 was not informed of any medically justified reason to transfer Resident 6 for his welfare or needs. As far as FM 1 was aware Resident 6's care needs were being adequately and appropriately met by SNF 1. FM 1 stated she had become upset with the response she had been given. FM 1 stated she asked the SSA, "How well do you know [Resident 6]? He would agree to do whatever you ask him to do whether he wanted to or not!" FM 1 stated she was Resident 6's emergency contact. FM 1 stated prior to the transfer, SNF 1 had always notified her if Resident 6 had a change in his condition or had needed anything. FM 1 stated SNF 2 was a two hour drive time from her home and she would not have been able to visit Resident 6. FM 1 stated she called SNF 2 and spoke with Adm 2. FM 1 stated she had requested Resident 6 return to SNF 1 where she could visit. FM 1 stated, "The transfer to [SNF 2] was not right. I'm his only family, the only one to look out for him, and they didn't even call me." Review of Resident 6's clinical record, "Advance Health Care Directive," dated 7/11/14, contained Resident 6's witnessed signature that appointed FM 1 as "my agent to make health care decisions for me." 3. Review of Resident 3's clinical record indicated Resident 3 had been admitted to the facility on 1/22/14 and had resided at the facility until 3/13/15 when he was transferred to another skilled nursing facility (SNF 2) 38 miles away.Review of Resident 3's "Physician Orders" dated, 3/13/15, indicated, "May transfer to [SNF 2] with current orders and treatment." Review of Resident 3's "Transfer/Discharge Report" dated 3/13/15, had not contained any documentation of the "Reason for transfer. " Resident 3's "Interdisciplinary Discharge Summary" contained no documentation of the "Reason for discharge/discharge diagnosis(es)." On 5/19/15 at 9 a.m., during a concurrent interview and clinical record review, the SSD stated Resident 3's clinical record contained no documented evidence of a social service note or nursing progress note that indicated a reason for Resident 3's transfer. SSD stated "no discharge planning care plan had been completed" for Resident 3. On 5/20/15 at 9:35 a.m., during a concurrent observation and interview in Resident 3's room in SNF 2, Resident 3 was sitting in a wheelchair watching television. Resident 3 stated he had not requested to transfer to SNF 2. Resident 3 stated a female staff member had gone into his room at SNF 1 on 3/13/15 and told him there was a room available at SNF 2. Resident 3 stated he had not requested to transfer but had agreed to move. Resident 3 stated the staff at SNF 1 packed his belongings and moved him within "about two hours" after he was informed of the possible transfer. Resident 3 stated he had not had enough time prior to the transfer to call his family to tell them of the transfer or where he was going. Resident 3 stated his only child lived over 38 miles away from SNF 2 and would not be able to visit him due to a lack of transportation. Resident 3 stated, "The bad part is I miss my daughter. She can't get here." Resident 3 stated he was unaware of any medical justification for the transfer and stated SNF 1 had provided for his needs in a satisfactory manner and he had no complaints about his care there. 4. Review of Resident 2's clinical record indicated Resident 2 had been admitted to SNF 1 on 5/5/13 and had resided at the facility until 3/13/15 when she was transferred to SNF 2, 38 miles away.Review of Resident 2's "Physician Orders" dated, 3/13/15, indicated, "May transfer to [SNF 2] with current orders and treatment." Review of Resident 2's "Transfer/Discharge Report" dated 3/13/15, had not contained documentation of the "Reason for transfer." Resident 2's "Interdisciplinary Discharge Summary" contained no documentation of the "Reason for discharge/discharge diagnosis(es)." On 5/19/15 at 9 a.m., during a concurrent interview and clinical record review, the SSD stated Resident 2's clinical record had no documented evidence of a social service note or a nursing progress note that indicated a reason for Resident 2's transfer. SSD stated, "No discharge planning care plan had been completed" for Resident 2. On 5/20/15 at 8:45 a.m., during a concurrent observation and interview in Resident 2's room at SNF 2, Resident 2 sat up in bed eating breakfast. Resident 2 stated she remembered being transferred to SNF 2.Resident 2 stated one morning a female employee had come to her in SNF 1 "very excited" and told her there was a bed available at SNF 2 and had stated it was a very nice place. Resident 2 stated she had not known anything about SNF 2. Resident 2 stated the employee told her she had to decide very quickly, within 15 minutes, if she wanted to transfer to SNF 2. Resident 2 stated it hadn't been her idea to transfer to SNF 2 but she had agreed to try it. Resident 2 stated the facility staff at SNF 1 packed her belongings immediately and within a couple of hours she was placed in the facility van with other residents and on her way to SNF 2. Resident 2 stated, "It was very fast! So quick I did not have time to call my friends to tell them I was leaving or where I was going." Resident 2 stated she had not had any visits from her friends since moving to SNF 2. Resident 2 stated she spoke with SSA 2 at SNF 2 to request returning to the previous SNF. Resident 2 was unaware of any medical justification for the transfer and stated SNF 1 had provided for her needs in a satisfactory manner; she had no complaints on her care and would have preferred to be permitted to stay at SNF 1.On 5/20/15 at 10 a.m., during an interview in the SNF 2 conference room, SSA 2 stated Resident 2 approached her on 5/19/15, two months after transfer to SNF 2, and had requested to return to SNF 1. SSA 2 stated Resident 2 had wanted to return to the area where her friends and her primary doctor resided. On 5/21/15 at 2:35 p.m., during a telephone interview, Resident 2's Geriatric Psychiatry Consultant (GPC) stated he had visited Resident 2 in the early morning hours of 5/20/15. The GPC stated the visit was scheduled at the request of [SNF 2]'s staff who reported Resident 2 had been generally upset. The GPC stated Resident 2 had discussed her desire to return to SNF 1 during the visit. The GPC stated a move had likely been distressing for Resident 2 due to her age and diagnosis. The GPC stated, "She is not a person who makes close attachments easily." 5. Review of Resident 7's clinical record indicated Resident 7 was admitted to SNF 1 on 12/5/13 and had resided in the facility until 3/17/15 when she was transferred to another skilled nursing facility (SNF 2) 38 miles away.Review of Resident 7's "Physician's Orders "dated, March 16, 2015, indicated, "May transfer to [SNF 2] with current orders and treatment." Review of Resident 7's "Transfer/Discharge Report" dated March 17, 2015, indicated Resident 7 was transferred on 3/17/15 with the reason for transfer documented, "Transfer to [SNF 2]." Review of Resident 7's "Social Service Progress Note" dated 3/16/15 indicated, "Spoke with resident about possible transfer to [SNF 2]. Resident is agreeing to transfer at this time. " Review of Resident 7's Minimum Data Set Assessment, dated 2/19/15 indicated a brief interview for mental status (BIMS) score of 3 (on a scale of 0 to 15, a score of 15 indicated there was no cognitive deficit, and a score below 7 indicated severe cognitive impairment). On 5/14/15 at 12 p.m., during a telephone interview, Resident Friend (RF) 1 stated she was a longtime friend of Resident 7. RF 1 stated she had visited Resident 7 two to three times per week at SNF 1. RF 1 stated she had gone to SNF 1 to visit Resident 7 one day in March [2015] and Resident 7 was gone. RF 1 stated she had taken clean clothes to Resident 7 two days before at SNF 1 and no one had said anything about a transfer at that time. RF 1 stated Resident 7 had completed a Durable Power of Attorney for Healthcare in the past naming her (RF 1) as the agent to speak for Resident 7 in the event she became unable to speak for herself. RF 1 stated she had been upset the facility had not called her prior to the transfer. RF 1 stated she talked to a SSA at SNF 1 and was told the SSA could not find documentation of a "Durable Power of Attorney for Healthcare" with her name on it, and therefore, they did not have to notify her or explain the transfer to her. RF 1 stated, "For some reason once [Resident 7] got to [SNF 2], the "Durable Power of Attorney for Healthcare" [document] turned up. Now they [SNF 2 staff] call me to sign consents." RF 1 stated she was not able to visit Resident 7 very often at SNF 2 due to health issues and the expense of travel to SNF 2. RF 1 stated when she had visited, shortly after the transfer to SNF 2, Resident 7 did not seem to understand why she had been transferred. RF 1 stated, "They just sent her. There was no warning. She was not prepared." RF 1 stated she was unaware of any medical justification for the transfer and as far as she was aware, Resident 7's needs were being met at SNF 1. On 5/20/15 at 12:05 p.m., during a concurrent observation and interview in the dining room at SNF 2, Resident 7 sat in a wheelchair at a dining table with three ladies, waiting for lunch to be served. When asked, Resident 7 was unable to state the name of the facility where she currently resided. When asked how she arrived at the facility, Resident 7 moved her legs back and forth and stated, "I walked."When asked in what city the facility was located, Resident 7 looked at her tablemates and asked, "Any of you girls know what city this is?" Resident 7 stated she had lived at SNF 2 for "a couple of hours." Review of Resident 7's clinical record, "Social Service Assessment" at SNF 2 dated 3/23/15, indicated, "Resident reported trouble sleeping and feeling tired at times due to new environment..." Review of Resident 7's clinical record, "Care Plan" from SNF 2, dated 5/1/15 indicated, "The resident has a psychosocial well-being problem r/t [related to] risk for isolation, risks of frustration as resident having episodes of perceiving current routine is very different from prior patterns." Review of Resident 7's clinical record, "Care Plan" from SNF 2, dated 5/4/15, indicated, "The resident has depression r/t verbalizing depression and frustration upon admission to facility. Resident had difficulties adjusting to environment and verbalized, "Things just aren't going right for me." Review of Resident 7's clinical record, "Power of Attorney for Healthcare" dated 12/5/14, contained documentation of Resident 7's notarized signature which appointed RF 1 as "My agent to make health care decisions for me..." 6. Review of Resident 1's clinical record indicated Resident 1 was admitted to SNF 1 on 9/14/2004 and had resided in the facility until 3/27/15 when she was transferred to another skilled nursing facility (SNF 2) located 38 miles away.Review of Resident 1's "Physician's Orders," dated March 27, 2015 indicated, "D/C [discharge] to [SNF 2]." Review of Resident 1's "Transfer/Discharge Report" dated 3/27/2015, (a report to be completed by the facility and the resident's physician upon transfer or discharge from the facility) indicated Resident 1 was transferred on 3/27/15 with the reason for transfer documented, "Res transferred to [SNF 2]." Review of Resident 1's "Interdisciplinary Discharge Summary," (form completed by the facility resident care team including social services, nursing, dietary, activities and therapy) contained no entry for, "Reason for discharge/discharge diagnosis(es)." On 4/28/15 at 10:55 a.m., during an interview in the facility conference room, Administrator (Adm) 1 stated Resident 1 did not have family who participated in her care. Adm 1 stated the facility's interdisciplinary team (IDT) was Resident 1's responsible party and could make healthcare decisions for Resident 1.On 4/28/15 at 11:10 a.m., during an interview in the facility conference room, SSA 1 stated Resident 1 was transferred to [SNF 2] on 3/27/15. SSA 1 stated the purpose of Resident 1's transfer was to "Free up more space for short term care" residents. SSA 1 stated the facility was focusing on admitting more residents from the acute care setting who needed short term rehabilitation. SSA 1 stated Resident 1 had been asked if "it was ok to transfer her and she said it was." Review of Resident 1's MDS assessment, dated 3/27/15 included a brief interview for mental status (BIMS) score of 0 (on a scale of 0 to 15) a score of 15 indicated no cognitive deficits and scores below 7 indicated severe cognitive impairment.Review of Resident 1's "Physician Orders" dated March 2015 indicated, "MD [medical doctor] determine that Resident does NOT have the Mental Capacity to make healthcare decisions..." On 4/28/15 at 2:30 p.m., during an interview in the hallway at SNF 1, licensed nurse (LN) 1 stated Resident 1 was unable to verbalize needs but staff could sometimes figure out what she needed by her expressions and gestures. LN 1 stated she did not think Resident 1 understood she was being transferred to another facility on 3/27/15 when she left in the facility van.On 4/29/15 at 9:20 a.m., during an observation in Resident 1's room at SNF 2, Resident 1 was sitting in a wheelchair. Resident 1's room contained a dollhouse size firehouse, two Barbie dolls, a fireman's hat, 2 toy firetrucks and several boxes stacked against the wall. Resident 1 stated, "fireman" and pointed at the toy firehouse. Resident 1 stated "baby" and produced a photo album with family pictures. Resident 1 nodded her head or responded "yes" to questions but was unable to respond in complete sentences.On 4/29/15 at 1 p.m., during an interview in the facility conference room, Adm 1 stated Resident 1 had not experienced a change of condition which would have necessitated a transfer from the facility. The Adm stated the facility IDT had not met to assess Resident 1's needs before the resident had been transferred to the receiving SNF. The Adm stated there was no documented assessment, discharge care plan, or IDT note, which would have indicated the transfer was done in the best interest of Resident 1.7. Review of Resident 5's clinical record indicated Resident 5 had been admitted to the facility on 6/26/08 and had resided at the facility until 3/17/15 when she was transferred to another skilled nursing facility (SNF 3) 35 miles away.Review of Resident 5's "Physician Orders" dated 3/17/15 indicated, "May transfer to [SNF 3] with current orders and treatment." Review of Resident 5's "Transfer/Discharge Report" dated 3/17/15, had not contained any documentation of "reason for transfer." Resident 5's, "Interdisciplinary Discharge Summary" indicated, "Reason for discharge/discharge diagnosis(es)" as "Transferred to [SNF 2]." On 5/19/15 at 9 a.m., during a concurrent interview and clinical record review, the SSD stated Resident 5's clinical record contained no documented evidence which indicated a reason for Resident 5's transfer had been determined. SSD stated no discharge planning care plan had been completed for Resident 5. Review of Resident 5's "Social Service Progress Note," dated 3/12/15 indicated, "Spoke with Resident regarding transfer to [SNF 3]. Resident agreed to transfer to [SNF 3]. Referral sent to [SNF 3]." Review of Resident 5's MDS assessment, dated 3/24/15 included a brief interview for mental status (BIMS) score of 5 (on a scale of 0 to 15).On 5/20/15 at 1:25 p.m., during an interview in the Director of Nurse's (DON) office at SNF 3, Resident 5 sat in a wheelchair. Resident 5 stated she had been at (SNF 3) for "a long time." Resident 5 stated she did not know why she was there, how she got there or where she was. On 5/21/15 at 2:35 p.m., during a telephone interview, Resident 5's Geriatric Psychiatry Consultant (GPC) stated he had met with Resident 5 on April 8, 2015. The GPC stated he would not consider Resident 5 able to make good decisions regarding her own healthcare.On 5/8/15 at 2:25 p.m., during an interview in the SNF 1 conference room, the Facility Medical Director (FMD) stated he had not been made aware seven long term care residents had transferred out of SNF 1 in March 2015. The FMD stated the transfers had not been discussed at the Quality Assurance Committee Meetings (committee of facility personnel that identify problems and seek solutions). On 5/19/15 at 3:25 p.m., during a telephone interview, MD 1 stated he had been the physician for Residents 1, 3, 4 and 7. MD 1 stated SNF 1 had sent a request for those residents to be transferred to another facility. MD 1 stated he had not attended any discharge planning meetings for Resident 1, 3, 4, or 7. MD 1 stated it was the responsibility of the facility to determine if a transfer was in the resident's best interest. MD 1 stated Residents 1, 3, 4 and 7 had been stable. MD 1 stated he had not been aware of any reason to deny the request to transfer.On 5/22/15 at 12 p.m., during an interview in the SNF 1 conference room, Adm 1 stated none of the residents (Resident 1, 2, 3, 4, 5, 6, or 7) had requested to transfer to another SNF. Adm 1 stated she had received a call in March 2015 from the Regional Director of Operations who had stated there were open long term care beds at another facility and if any resident wanted to transfer there were beds available. Adm 1 stated she had contacted the SNF 1 social services department to interview residents at SNF 1 to determine if any resident was interested in a transfer. Adm 1 stated there was no SSD employed at SNF 1 in March 2015. Adm 1 stated she had instructed two SSAs (SSA 1 and SSA 3) to speak with residents who were alert and oriented and could make their own decisions to determine if they were interested in a transfer. Adm 1 stated none of the residents (Residents 1, 2, 3, 4, 5, 6, or 7) had any medical condition that required a transfer to another Skilled Nursing Facility. Adm 1 stated, "We offered the transfers." Adm 1 stated there had not been any care conferences or discharge planning meeting in which the staff would discuss and determine if the transfers were necessary for the resident's welfare, and could meet the needs of Residents 1, 2, 3, 4, 5, 6 or 7. Adm 1 stated the two SSAs who arranged the transfers for the residents had not received adequate training in the facility in which to complete an appropriate transfer of the residents. Adm 1 stated she, as the administrator of SNF 1, should have provided oversight and supervision of the SSAs in the absence of a SSD. Seven of Seven Residents were not afforded the opportunity of a planned safe and orderly transfer away from the Skilled Nursing Facility in which they had resided in as their home. As a result of these unplanned transfers the residents exhibited signs and symptoms of sadness, depression, and confusion. This violation had a direct or immediate relationship to the residents health, safety, and security, and therefore constitutes a Class "B" Citation. |
| 100000026 |
Valley Subacute & Rehabilitation Center |
040012077 |
B |
16-Mar-16 |
FZRR11 |
17708 |
42 Code of Federal Regulations Section 483.12(a)(2) Transfer and discharge requirements:The facility must permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless- (i) The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility; (ii) The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility; (iii) The safety of individuals in the facility is endangered; (iv) The health of individuals in the facility would otherwise be endangered; (v) The resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at the facility. For a resident who becomes eligible for Medicaid after admission to a nursing facility, the nursing facility may charge a resident only allowable charges under Medicaid; or (vi) The facility ceases to operate.Title 22 Section 72527 Patients' Rights: (a) Patients have the rights numerated in this section and the facility shall ensure 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 any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (6) To be transferred or discharged only for medical reasons, or the patient's welfare or that of other patient's or for nonpayment for his or her stay and to be given reasonable advance notice to ensure orderly transfer or discharge. Such actions shall be documented in the patient's health record. Title 22 Section 72519 Patient Transfer: (a) The licensee shall maintain written transfer agreements with other nearby health facilities to make the services of those facilities accessible and to facilitate the transfer of patients. Complete and accurate patient information, in sufficient detail to provide for continuity of care shall be transferred with the patient at time of transfer. (b) When a patient is transferred to another facility, the following shall be entered in the patient health record: (1) The date, time, condition of the patient and a written statement of the reason for the transfer. (2) Informed written or telephone acknowledgement of the patient, patient's guardian or authorized representative except in an emergency or as provided in Section 72527(a)(5). On 12/9/15 at 9:40 a.m., an unannounced visit was made to the facility to investigate anonymous complaint CA00468198 regarding alleged violation of resident transfer and discharge rights. The facility failed to ensure Resident 11 was afforded the right to be transferred or discharged solely for medical reasons or for the resident's welfare, and to be given reasonable advance written notice to ensure a safe and orderly transfer or discharge. The facility transferred Resident 11 in order to accommodate the alleged plan of a potential new owner to convert the facility to a subacute setting (a specialized type of nursing service provided to residents who require complex care or rehabilitation). As a result, Resident 11 was displaced from her home and family and suffered significant psychological and emotional distress.Review of Resident 11's clinical record titled, "Face Sheet" indicated Resident 11 was admitted to the skilled nursing facility ( SNF)1 on 5/16/14 with diagnoses that included diabetes mellitus (disorder that affects blood sugar), anxiety disorder, impulse disorder, and dementia (memory loss that gets worse over time). Resident 11 was transferred to SNF 6 on 12/4/15.On 12/9/15 at 9:40 a.m., during a tour of SNF 1, no residents were observed in the hallways, resident rooms or dining area in the West Wing of the facility. Four residents were observed sitting in the East Wing main dining room watching television. During a concurrent interview with the facility Interim Administrator (IA) the IA stated the current facility census was seven of 70 available beds licensed for skilled nursing residents. The IA stated the West Wing was closed. The IA stated three of the seven remaining residents were scheduled to transfer out of the facility later that day, 12/9/15, due to a "Change of ownership" of the facility. On 12/9/15 at 12:15 p.m., during a staff interview in the East Wing hallway, Licensed Nurse (LN) 1 stated residents who resided in the facility were transferred out of the facility due to new ownership expected to take place in the near future. LN 1 stated all residents had to transfer out of the facility. LN 1 stated the new owner planned to run a facility that did not include long term care skilled nursing residents. LN 1 stated most residents that transferred were sad and did not want to leave as the facility was their home for a long time.On 12/9/15 at 1:30 p.m., during an interview with the Social Services Director (SSD) in the social services office, the SSD stated some of the residents who were transferred did not want to transfer to a different facility because they lived at SNF 1 for a long time. The SSD stated those residents were concerned prior to the transfer as to what would happen to them when the new owner took ownership of the facility.On 12/9/15 at 4:18 p.m., during an interview in the Administrator's office, the IA stated the facility had not provided any resident (including Resident 11) that was transferred since 6/1/15 a 30 day advance written notice that included the intent to transfer, the reason for the pending transfer or discharge or the right to appeal the transfer or discharge. The IA stated, "We didn't do those." Review of the facility's administrative policy titled, "California Standard Admission Agreement for Skilled Nursing Facilities and Intermediate Care Facilities" pages eight to nine, dated May 2011, provided to all SNF 1 residents on admission indicated, "VI. Transfers and Discharges...Our written notice of transfer to another facility or discharge against your wishes will be provided 30 days in advance...Our written notice will include the effective day, the location to which you will be transferred or discharged, and the reason the action is necessary. The only reason that we can transfer you to another facility or discharge you against your wishes are: 1) It is required to protect your well-being because your needs cannot be met in our facility; 2) It is appropriate because your health has improved enough that you no longer need the services of our Facility; 3) Your presence in our Facility endangers the health and safety of other individuals; 4) You have not paid for your stay in our Facility or have not arranged to have payment made under Medicare, Medi-Cal, or private insurance; 5) Our Facility ceases to operate; 6) Material or fraudulent misrepresentation of your finances to us... In our written notice, we will advise you that you have the right to appeal the transfer or discharge to the California Department of Health Care Services, and we will also provide the name, address and telephone number of the State Long-Term Care Ombudsman."On 12/16/15 at 3 p.m., during a staff interview, the SSD stated she had worked for SNF 1 for the past seven years. The SSD stated the facility process for discharging residents had begun to change in April 2015. The SSD stated she had been assigned the responsibility to coordinate the discharge of the residents in the facility. The SSD stated that responsibility had previously been a nursing service responsibility. The SSD stated in June 2015 the Clinical Nurse Liaison (CNL) began to assist her with the discharge of residents. She stated the CNL facilitated discharges of residents to other company-owned skilled nursing facilities. The SSD stated when approached by families or residents she had discussed the pending transition, and informed the residents or/and their families the residents could remain at the facility or seek placement before the transition was set to occur, but she could not speak to what would occur after the business was sold. The SSD stated families were given the instruction discharge of the residents was inevitable sooner or later as the type of patients accepted would change to those who required more complex care than was currently provided in SNF 1. The SSD stated the residents were "fast tracked" to discharge as part of the change in the process. She stated, "The majority of families wanted to seek placement out of fear, not knowing what was going to happen...how could they not be [fearful]? As an employee it was very difficult...they [the facility] were not communicating properly...I felt pressured...that's been very stressful."On 12/17/15 at 7:30 a.m., during an interview, the CNL stated her role at SNF 1 during the transition of ownership was to assist with the discharge of residents from the facility. The CNL stated she learned of an ownership transition in a staff meeting and received direction from the Regional Director of Operations (RDO) to discharge residents. She stated, "I wasn't aware of the regulations...I was stuck in between...it's been a nightmare." The CNL stated, "If they [the residents] asked [what would happen to them], we told them about the change of ownership...don't know when it's going to happen...there was the feeling of uncertainty." Review of Resident 11's clinical record titled, "MDS (Minimum Data Set) (an assessment tool to assess a resident's cognitive and physical functional abilities) 3.0 Assessment," dated 11/30/15, indicated Resident 11's cognitive (pertaining to comprehension, memory and reasoning ability) skills for daily decision making were, "Severely impaired - rarely/never made decisions" and her functional abilities were, "Totally dependent on staff" for mobility, eating, hygiene and bathing. Review of Resident 11's clinical record titled, "Transfer/Discharge Summary," dated 12/3/15, contained an area to document "Reason for Transfer/Discharge." A box indicating "Other, Please Explain" was the single box checked and "Long Term Care" was written on the line next to the box. There was no documented rationale for the transfer to SNF 6 indicated on the form.On 12/29/15 during an interview in the conference room at SNF 6 the Admissions Assistant (AA) stated Resident 11 was transferred to SNF 6 from SNF 1 on 12/4/15. The AA stated Resident 11 had resided at SNF 6 for about a week but her family was very unhappy about her placement and wanted her moved back to the town SNF 1 was located in. The AA stated Resident 11's family all lived in the same town as SNF 1 and they did not realize how far away SNF 6 was. The AA stated the family did not make a visit to SNF 6 prior to the transfer. The AA stated Resident 11's daughter had a broken leg and was unable to drive herself to see her mother. The daughter was worried about her mother because she did not speak English and no one at SNF 6 could speak her language. The AA stated Resident 11's daughter had said her mother seemed depressed because family was not visiting as often. The AA stated SNF 1 was part of the same company as SNF 6 and they provided the same level of care. She stated they were not providing any services to Resident 11 that were different from SNF 1. The AA stated Resident 11's daughter really wanted her back in the same town as SNF 1 because it was where the family lived and they could visit more often. The AA stated she was able to find placement and transfer Resident 11 to SNF 2 at the family's request. On 12/29/15 at 3:20 p.m., during an interview in the SNF 6 conference room, LN 5 stated she provided care for Resident 11 while she resided in SNF 6. LN 5 stated Resident 11 did not speak English; she was not sure what language she spoke but thought it was "Syrian." LN 5 stated, "No one here could speak it." LN 5 stated Resident 11's daughter had a broken leg and didn't visit daily but when she did visit she would speak in her native language and she would feed Resident 11. She stated Resident 11 would only eat for her daughter. LN 5 stated Resident 11 was served meals in her room and did not attend any of the scheduled activities. LN 5 stated Resident 11 had some behaviors especially refusing care from the certified nursing assistants (CNA). LN 5 stated, "She would claw or scratch at the CNAs when they gave care. She was not very trusting. Her family could get her to calm down but they were over an hour away. They couldn't pop over and help her calm herself. Personally, I don't understand why they would transfer her here when her entire family is in [previous town]. We couldn't communicate with her. I think it's good she went back to where her family is." On 12/30/15 at 11:10 a.m., during a concurrent interview and clinical record review with the SSD in the social services office at SNF 1, the SSD stated Resident 11's family had heard by "word of mouth" that the facility was being sold. The family was concerned and worried about what would happen. The SSD stated she first spoke with the family about placement at SNF 6 on 12/4/15 and Resident 11 was transferred the same day, 12/4/15. The SSD stated Resident 11's family would have preferred to have her stay in the same town as the facility but there had not been any beds available locally and they were fearful about what would happen when the facility changed owners, so they had agreed to SNF 6 as a "temporary placement." The SSD stated Resident 11 spoke Assyrian and the family would translate for staff. She stated SNF 1's Interdisciplinary Team (IDT) (a resident care team including nursing, dietary, social services and activity staff) had not met prior to the resident's transfer to discuss whether it was a safe and appropriate transfer and the discharge care plan was not updated to plan for the transfer to SNF 6. The SSD stated a 30 day notice of transfer that included the reason for transfer, the date of the transfer, the location of the transfer, the right to appeal the transfer and the name and phone number of the state ombudsman was not provided to Resident 11 or her Responsible Party. On 12/30/15 at 11:40 a.m., during a staff interview in the hallway at SNF 1, LN 6 stated she worked with Resident 11 when she resided at SNF 1. LN 6 stated Resident 11's family visited often and brought home cooked foods and she seemed happy to see them. She stated Resident 11 attended activities at SNF 1 daily. She stated Resident 11 enjoyed going to the activity room and having a snack with other residents.On 12/30/15 at 1:25 p.m., during a staff interview in the SNF 2 conference room, the Admissions Coordinator (AC) 2 stated Resident 11 was transferred to SNF 2 on 12/14/15 at the family's request. AC 2 stated Resident 11 went from SNF 1 to SNF 6 but the family was not happy with the placement because they were not aware of how far away it was. AC 2 stated she was able to accept Resident 11 for placement at SNF 2, close to family. She stated, "She [Resident 11] is confused. She does better when family is there." On 12/30/15 at 4:40 p.m., during an observation in the hallway at SNF 2, Resident 11 was awake and alert, sitting up in a wheelchair dressed in pajamas and partly covered by a blanket. A nurse was attempting to administer medications mixed in applesauce. Resident 11 did not respond to the nurse's encouragement to swallow the medications and spit them out. Is there any information Res 11 was cooperative with med taking at SNF 1? On 1/5/16 at 5:30 p.m., during a telephone interview, Resident 11's Responsible Party (RP) 4, with the help of Family Member (FM) 3 serving as an interpreter, stated she visited Resident 11 at SNF 1 in November 2015 and a facility nurse told her the facility was sold and residents had to be discharged to other facilities. RP 4 stated she looked everywhere in a nearby facility for a place for Resident 11 but was not able to find a place for her to go. RP 11 stated she felt "stressed, pressured and desperate. RP 4 stated the SSD at SNF 1 had offered placement for Resident 11 at SNF 6. RP 4 stated she agreed to placement at SNF 6 because she was worried Resident 11 would not have a place to stay after the new owner took ownership. RP 4 stated there had not been a family meeting to discuss the transfer and no advance notice was given to the resident or the family. RP 4 stated she had not realized how far away SNF 6 was from SNF 1, and she was very unhappy with the move. RP 4 stated she was unable to drive and had to rely on family members for transportation and the cost of gas was a financial burden. FM 3 added, "We are low income." RP 4 stated as a result of the transfer, she was not able to see Resident 11 as often as she had at SNF 1. RP 4 stated the transfer caused disruption in the extended family as they blamed her for allowing the move. She stated, "They [SNF 1] didn't do the right thing. They put our family under pressure." RP 4 stated Resident 11 was upset after the transfer, "She was crying, very sad."Review of website "www.Mapquest.com" indicated SNF 6 was located 50 miles and one hour and twelve minutes driving time from SNF 1. Therefore, the facility failed to honor and protect Resident 11's transfer and discharge rights. Resident 11 was transferred 50 miles from her home and family without ensuring the necessity to meet her medical or welfare needs and without reasonable notice and as a result suffered significant emotional and psychological harm.These violations had a direct relationship to Resident 11's health, safety and security and thus constitute a Class B Citation. |
| 100000026 |
Valley Subacute & Rehabilitation Center |
040012078 |
B |
16-Mar-16 |
FZRR11 |
14543 |
42 Code of Federal Regulations Section 483.12(a)(2) Transfer and discharge requirements:The facility must permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless- (i) The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility; (ii) The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility; (iii) The safety of individuals in the facility is endangered; (iv) The health of individuals in the facility would otherwise be endangered; (v) The resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at the facility. For a resident who becomes eligible for Medicaid after admission to a nursing facility, the nursing facility may charge a resident only allowable charges under Medicaid; or (vi) The facility ceases to operate.Title 22 Section 72527 Patients' Rights: (a) Patients have the rights numerated in this section and the facility shall ensure 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 any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (6) To be transferred or discharged only for medical reasons, or the patient's welfare or that of other patient's or for nonpayment for his or her stay and to be given reasonable advance notice to ensure orderly transfer or discharge. Such actions shall be documented in the patient's health record. Title 22 Section 72519 Patient Transfer: (a) The licensee shall maintain written transfer agreements with other nearby health facilities to make the services of those facilities accessible and to facilitate the transfer of patients. Complete and accurate patient information, in sufficient detail to provide for continuity of care shall be transferred with the patient at time of transfer. (b) When a patient is transferred to another facility, the following shall be entered in the patient health record: (1) The date, time, condition of the patient and a written statement of the reason for the transfer. (2) Informed written or telephone acknowledgement of the patient, patient's guardian or authorized representative except in an emergency or as provided in Section 72527(a)(5).On 12/9/15 at 9:40 a.m., an unannounced visit was made to the facility to investigate anonymous complaint CA00468198 regarding the alleged violation of transfer and discharge rights. The facility failed to ensure Resident 12 was afforded the right to be transferred or discharged solely for medical reasons or for the resident's welfare, and to be given reasonable advance written notice to ensure a safe and orderly transfer or discharge. The facility transferred Resident 12 in order to accommodate the alleged plan of a potential new owner to convert the facility to a subacute setting (a specialized type of nursing service provided to Residents who require complex care or rehabilitation). As a result, Resident 12 was displaced from her home and suffered significant psychological and emotional distress.Review of Resident 12's clinical record titled, "Face Sheet" indicated Resident 12 was admitted to the skilled nursing facility (SNF) 1 on 3/29/07 with diagnoses that included major depressive disorder and heart disease. Resident 12 was transferred from SNF 1 to SNF 6 on 12/4/15.On 12/9/15 at 9:40 a.m., during a tour of SNF 1, no residents were observed in the hallways, resident rooms or dining area in the West Wing of the facility. Four residents were observed sitting in the East Wing main dining room watching television. During a concurrent interview with the facility Interim Administrator (IA) the IA stated the current facility census was seven of 70 available beds licensed for skilled nursing residents. The IA stated the West Wing was closed. The IA stated three of the seven remaining residents were scheduled to transfer out of the facility later that day, 12/9/15, due to a "Change of ownership" of the facility. On 12/9/15 at 12:15 p.m., during a staff interview in the East Wing hallway, Licensed Nurse (LN) 1 stated residents who resided in the facility were transferred out of the facility due to new ownership expected to take place in the near future. LN 1 stated all residents had to transfer out of the facility. LN 1 stated the new owner planned to run a facility that did not include long term care skilled nursing residents. LN 1 stated most residents that transferred were sad and did not want to leave as the facility had been their home for a long time.On 12/9/15 at 1:30 p.m., during an interview with the Social Services Director (SSD) in the social services office, the SSD stated some of the residents who were transferred did not want to transfer to a different facility because they lived at SNF 1 for a long time. The SSD stated those residents were concerned prior to the transfer as to what would happen to them when the new owner took ownership of the facility. On 12/9/15 at 4:18 p.m., during an interview in the Administrator's office, the IA stated the facility had not provided any resident (including Resident 12) that was transferred since 6/1/15 a 30 day advance written notice that included the intent to transfer, the reason for the pending transfer or discharge or the right to appeal the transfer or discharge. The IA stated, "We didn't do those." Review of the facility's administrative policy titled, "California Standard Admission Agreement for Skilled Nursing Facilities and Intermediate Care Facilities" pages eight to nine, dated May 2011 provided to all SNF 1 residents on admission indicated, "VI. Transfers and Discharges...Our written notice of transfer to another facility or discharge against your wishes will be provided 30 days in advance...Our written notice will include the effective day, the location to which you will be transferred or discharged, and the reason the action is necessary. The only reason that we can transfer you to another facility or discharge you against your wishes are: 1) It is required to protect your well-being because your needs cannot be met in our facility; 2) It is appropriate because your health has improved enough that you no longer need the services of our Facility; 3) Your presence in our Facility endangers the health and safety of other individuals; 4) You have not paid for your stay in our Facility or have not arranged to have payment made under Medicare, Medi-Cal, or private insurance; 5) Our Facility ceases to operate; 6) Material or fraudulent misrepresentation of your finances to us... In our written notice, we will advise you that you have the right to appeal the transfer or discharge to the California Department of Health Care Services, and we will also provide the name, address and telephone number of the State Long-Term Care Ombudsman."On 12/16/15 at 3 p.m., during a staff interview, the SSD stated she had worked for SNF 1 for the past seven years. The SSD stated the facility process for discharging residents had begun to change in April 2015. The SSD stated she had been assigned the responsibility to coordinate the discharge of the residents in the facility. The SSD stated that responsibility had previously been a nursing service responsibility. The SSD stated in June 2015 the Clinical Nurse Liaison (CNL) began to assist her with the discharge of residents. She stated the CNL facilitated discharges of residents to other company-owned skilled nursing facilities. The SSD stated when approached by families or residents she had discussed the pending transition, and informed the residents or/and their families the residents could remain at the facility or seek placement before the transition was set to occur, but she could not speak to what would occur after the business was sold. The SSD stated families were given the instruction discharge of the residents was inevitable sooner or later as the type of patients accepted would change to those who required more complex care than was provided in SNF 1. The SSD stated the residents were "fast tracked" to discharge as part of the change in the process. She stated, "The majority of families wanted to seek placement out of fear, not knowing what was going to happen...how could they not be [fearful]? As an employee it was very difficult...they [the facility] were not communicating properly...I felt pressured...that's been very stressful."On 12/17/15 at 7:30 a.m., during an interview, the CNL stated her role at SNF 1 during the transition of ownership was to assist with the discharge of residents from the facility. The CNL stated she learned of an ownership transition in a staff meeting and received direction from the Regional Director of Operations (RDO) to discharge residents. She stated, "I wasn't aware of the regulations...I was stuck in between...it's been a nightmare." The CNL stated, "If they [the residents] asked [what would happen to them], we told them about the change of ownership...don't know when it's going to happen...there was the feeling of uncertainty." Review of Resident 12's clinical record titled, "MDS (Minimum Data Set) (an assessment tool to assess a resident's cognitive and physical functional abilities) 3.0 Assessment," dated 10/12/15, indicated Resident 12's Brief Interview for Mental Status (BIMS) score was 15 on a scale of 0 to 15. A score of15 indicated Resident 12 was cognitively (pertaining to comprehension, memory and reasoning ability) intact. Resident 12's MDS assessment of functional ability indicated she required "Staff supervision" for bed mobility, transferring, dressing, and hygiene. Review of Resident 12's clinical record titled, "Transfer/Discharge Summary," dated 12/3/15, contained an area to document "Reason for Transfer/Discharge." A box which indicated, "Other, Please Explain" was the single box checked and "Long Term Care" was written on the line next to the box. There was no documented rationale for the transfer to SNF 6 indicated on the form.On 12/10/15 at 8:55 a.m., during a telephone interview, Resident 12's Responsible Party (RP) 5 stated she lived out of state and was responsible for Resident 12's financial affairs. RP 5 stated she received a telephone call from SNF 1's Social Services Director in November 2015 and was told another company bought the building and everyone had to transfer out of SNF 1 by December 1, 2015. RP 5 stated, "It was my understanding that she [Resident 12] could not stay [at SNF 1]." RP 5 stated the SSD had told her she [the SSD] would look for another placement for Resident 12, and if not, she didn't know what would happen to her. RP 5 stated Resident 12 had no one locally to look after her and there were no long term beds available, so she ended up going to SNF 6. RP 5 stated she had not received a written advance notice regarding the reason for the transfer or the right to appeal the decision to transfer Resident 12. On 12/29/15 at 1:45 p.m., during an observation and concurrent interview in the Resident's room in SNF 6, Resident 12 was sitting on the side of the bed looking across the room at her roommate's television. Resident 12 was quiet, at first refusing to talk and responded by shrugging her shoulders. After being asked about her reason for transferring to SNF 6, Resident 12 stated she did not ask to be transferred to SNF 6. Resident 12 stated a staff member at SNF 1 told her the building had been sold, there was a new owner, and everyone had to move out. Resident 12 stated, "We all had to go. I didn't have a choice. They said I had to go. I don't understand it. I don't want to rock the boat or upset anyone. Sometimes if you complain you don't get what you need. Sometimes if you complain they'll treat you bad. I don't want that. I don't understand why I'm here." Resident 12 stated her room at SNF 1 had a window that she enjoyed looking out and she missed that. She stated she never received any advanced written notice regarding the transfer to SNF 6. On 12/29/15 at 2:30 p.m., during a staff interview in the SNF 6 conference room, the Admissions Assistant (AA) stated she received an email from the RDO requesting information of the number of available beds in SNF 6 because he had residents to place. The AA stated she was able to place two residents from SNF 1 into SNF 6, including Resident 12. The AA stated SNF 1 was a "sister facility" owned by the same company and provided the same type of care as SNF 6.On 12/29/15 at 2:55 p.m., during a staff interview in the SNF 6 conference room, LN 7 stated Resident 12 was very quiet and she never actually heard her speak. LN 7 stated, "She [Resident 12] does not interact. She doesn't do anything to get into anyone's way." On 12/30/15 at 10:40 a.m., during a staff interview and concurrent clinical record review with the SSD in the social services office at SNF 1, the SSD stated Resident 12's RP had heard by "word of mouth" that something was going on at SNF 1. The SSD stated she told RP 5 that the building was sold and she did not know what would happen in the future. The SSD stated RP 5 was worried and concerned and agreed to transfer Resident 12 to SNF 6. The SSD stated the SNF 1 Interdisciplinary Team (IDT) (a resident care team including nursing, dietary, social services and activity staff) had not met prior to the resident's transfer to discuss whether it was a safe and appropriate transfer and the discharge care plan was not updated to plan for the transfer to SNF 6. The SSD stated a 30 day notice of transfer that included the reason for transfer, the date of transfer, the location of the transfer, the right to appeal the transfer and the name and phone number of the state ombudsman was not provided to Resident 12 or her Responsible Party. Therefore, the facility failed to honor and protect Resident 12's transfer and discharge rights. Resident 12 was transferred against her wishes, without ensuring the necessity to meet her medical or welfare needs and without reasonable notice. These violations resulted in significant emotional and psychological distress for Resident 12 exhibited by fear, confusion and anxiety. These violations had a direct relationship to Resident 12's health, safety and security and thus constitute a Class B Citation. |
| 100000026 |
Valley Subacute & Rehabilitation Center |
040012079 |
B |
16-Mar-16 |
FZRR11 |
13113 |
42 Code of Federal Regulations Section 483.12(a)(2) Transfer and discharge requirements:The facility must permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless- (i) The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility; (ii) The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility; (iii) The safety of individuals in the facility is endangered; (iv) The health of individuals in the facility would otherwise be endangered; (v) The resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at the facility. For a resident who becomes eligible for Medicaid after admission to a nursing facility, the nursing facility may charge a resident only allowable charges under Medicaid; or (vi) The facility ceases to operate.Title 22 Section 72527 Patients' Rights: (a) Patients have the rights numerated in this section and the facility shall ensure 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 any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (6) To be transferred or discharged only for medical reasons, or the patient's welfare or that of other patient's or for nonpayment for his or her stay and to be given reasonable advance notice to ensure orderly transfer or discharge. Such actions shall be documented in the patient's health record. Title 22 Section 72519 Patient Transfer: (a) The licensee shall maintain written transfer agreements with other nearby health facilities to make the services of those facilities accessible and to facilitate the transfer of patients. Complete and accurate patient information, in sufficient detail to provide for continuity of care shall be transferred with the patient at time of transfer. (b) When a patient is transferred to another facility, the following shall be entered in the patient health record: (1) The date, time, condition of the patient and a written statement of the reason for the transfer. (2) Informed written or telephone acknowledgement of the patient, patient's guardian or authorized representative except in an emergency or as provided in Section 72527(a)(5). On 12/9/15 at 9:40 a.m., an unannounced visit was made to the facility to investigate anonymous complaint CA00468198 regarding alleged violation of resident transfer and discharge rights. The facility failed to ensure Resident 13 was afforded the right to be transferred or discharged solely for medical reasons or for the resident's welfare, and to be given reasonable advance written notice to ensure a safe and orderly transfer or discharge. The facility transferred Resident 13 in order to accommodate the alleged plan of a potential new owner to convert the facility to a subacute setting (a specialized type of nursing service provided to Residents who require complex care or rehabilitation). As a result, Resident 13 suffered periods of being upset, nervous and crying episodes. Review of Resident 13's clinical record titled, "Face Sheet" indicated Resident 13 was admitted to the skilled nursing facility (SNF) 1 on 4/17/15 with diagnoses that included cerebrovascular disease (stroke), atrial fibrillation (irregular heart beat), and muscle weakness. Resident 13 was transferred from SNF 1 to SNF 7 on 9/2/15.On 12/9/15 at 9:40 a.m., during a tour of SNF 1, no residents were observed in the hallways, resident rooms or dining area in the West Wing of the facility. Four residents were observed sitting in the East Wing main dining room watching television. During a concurrent interview with the facility Interim Administrator (IA) the IA stated the current facility census was seven of 70 available beds licensed for skilled nursing residents. The IA stated the West Wing was closed. The IA stated three of the seven remaining residents were scheduled to transfer out of the facility later that day, 12/9/15, due to a "Change of ownership" of the facility. On 12/9/15 at 12:15 p.m., during a staff interview in the East Wing hallway, Licensed Nurse (LN) 1 stated residents who resided in the facility were transferred out of the facility due to new ownership expected to take place in the near future. LN 1 stated all residents had to transfer out of the facility. LN 1 stated the new owner planned to run a facility that did not include long term care skilled nursing residents. LN 1 stated most residents that transferred were sad and did not want to leave as the facility had been their home for a long time.On 12/9/15 at 1:30 p.m., during an interview with the Social Services Director (SSD) in the social services office, the SSD stated some of the residents who were transferred did not want to transfer to a different facility because they lived at SNF 1 for a long time The SSD stated those residents were concerned prior to the transfer as to what would happen to them when the new owner took ownership of the facility. On 12/9/15 at 4:18 p.m., during an interview in the Administrator's office, the IA stated the facility had not provided any resident (including Resident 13) that was transferred since 6/1/15 a 30 day advance written notice that included the intent to transfer, the reason for the pending transfer or discharge or the right to appeal the transfer or discharge. The IA stated, "We didn't do those." Review of the facility's administrative policy titled "California Standard Admission Agreement for Skilled Nursing Facilities and Intermediate Care Facilities" pages eight to nine, dated May 2011 provided to all SNF 1 residents on admission indicated, "VI. Transfers and Discharges...Our written notice of transfer to another facility or discharge against your wishes will be provided 30 days in advance...Our written notice will include the effective day, the location to which you will be transferred or discharged, and the reason the action is necessary. The only reason that we can transfer you to another facility or discharge you against your wishes are: 1) It is required to protect your well-being because your needs cannot be met in our facility; 2) It is appropriate because your health has improved enough that you no longer need the services of our Facility; 3) Your presence in our Facility endangers the health and safety of other individuals; 4) You have not paid for your stay in our Facility or have not arranged to have payment made under Medicare, Medi-Cal, or private insurance; 5) Our Facility ceases to operate; 6) Material or fraudulent misrepresentation of your finances to us... In our written notice, we will advise you that you have the right to appeal the transfer or discharge to the California Department of Health Care Services, and we will also provide the name, address and telephone number of the State Long-Term Care Ombudsman."On 12/16/15 at 3 p.m., during a staff interview, the SSD stated she had worked for SNF 1 for the past seven years. The SSD stated the facility process for discharging residents had begun to change in April 2015. The SSD stated she had been assigned the responsibility to coordinate the discharge of the residents in the facility. The SSD stated that responsibility had previously been a nursing service responsibility. The SSD stated in June 2015 the Clinical Nurse Liaison (CNL) began to assist her with the discharge of residents. She stated the CNL facilitated discharges of residents to other company-owned skilled nursing facilities. The SSD stated when approached by families or residents she had discussed the pending transition, and informed the residents or/and their families the residents could remain at the facility or seek placement before the transition was set to occur, but she could not speak to what would occur after the business was sold. The SSD stated families were given the instruction discharge of the residents was inevitable sooner or later as the type of patients accepted would change to those who required more complex care than was provided in SNF 1. The SSD stated the residents were "fast tracked" to discharge as part of the change in the process. She stated, "The majority of families wanted to seek placement out of fear, not knowing what was going to happen...how could they not be [fearful]? As an employee it was very difficult...they [the facility] were not communicating properly...I felt pressured...that's been very stressful."On 12/17/15 at 7:30 a.m., during an interview, the CNL stated her role at SNF 1 during the transition of ownership was to assist with the discharge of residents from the facility. The CNL stated she learned of an ownership transition in a staff meeting and received direction from the Regional Director of Operations (RDO) to discharge residents. She stated, "I wasn't aware of the regulations...I was stuck in between...it's been a nightmare." The CNL stated, "If they [the residents] asked [what would happen to them], we told them about the change of ownership...don't know when it's going to happen...there was the feeling of uncertainty." Review of Resident 13's clinical record titled "MDS (Minimum Data Set) (a tool used to assess resident cognitive and physical abilities) 3.0 Assessment," dated 7/24/15, indicated Resident 13's Brief Interview for Mental Status (BIMS) score was 5 on a scale of 0 to 15. A score of 5 indicated severe cognitive (pertaining to comprehension, memory and reasoning ability) impairment. Resident 13's MDS assessment indicated Resident 13 required extensive assistance with f bed mobility, transferring, dressing, and bathing. Review of Resident 13's clinical record titled, "Transfer/Discharge Summary" dated 9/2/15, indicated "Reason for Transfer/Discharge - Family Request." On 12/31/15 at 11:05 a.m. during a staff interview in SNF 7's conference room, SNF 7's Admission's Director (AD) 1 stated she was contacted by Resident 13's Responsible Party (RP), RP 6 in August 2015 with an urgent request for placement of Resident 13. AD 1 stated RP 6 was worried and upset because she was told all of SNF 1's residents had to find placement elsewhere and move out. AD 1 stated RP 6 said she did not know what was going to happen and she was very stressed. RP 6 stated Resident 13 was also very nervous. AD 1 stated she found a place for Resident 13 in SNF 7 in response to RP 6's urgent request.On 12/21/15 at 11:40 a.m., during an observation and concurrent interview in Resident 13's room in SNF 7, Resident 13 was lying fully dressed in street clothes on top of her bed. Resident 13 stated she was really not sure why she was in SNF 7.On 1/8/16 at 11 a.m., during a telephone interview, RP 6 stated she had first heard SNF 1 was closing from Resident 13 but was unsure if it was true. RP 6 stated she then "Heard it through the grapevine" the facility was closing. RP 6 stated she asked a staff member if the facility was closing and was told SNF 1 was closing and her mother would need to go to another facility. RP 6 stated Resident 13 heard staff and other residents talking about the change of ownership and became increasingly nervous about what would happen to her. RP 6 stated Resident 13 was nervous, cried and was generally upset. RP 6 stated Resident 13 had friends at SNF 1 that she was no longer able to see, especially a gentleman friend and companion that she missed. RP 6 stated Resident 13 had a quilt given to her by her mother which had significant emotional and sentimental importance. RP 6 stated the quilt was lost in the move to SNF 7 and Resident 13 was sad about it.On 1/8/16 at 3:10 p.m., during a staff interview and concurrent clinical record review with the SSD in the SNF 1 social services office, the SSD stated the SNF 1 Interdisciplinary Team (IDT, a resident care team including nursing, dietary, social services and activity staff) had not met prior to Resident 13's transfer to discuss whether it was a safe and appropriate transfer and the discharge care plan was not updated to plan for the transfer to SNF 7. The SSD stated SNF 7 did not provide any services that were not available at SNF 1. The SSD stated a 30 day notice of transfer that included the reason for transfer, the date of transfer, the location of the transfer, the right to appeal the transfer and the name and phone number of the state ombudsman was not provided to Resident 13 or her RP. Therefore, the facility failed to honor and protect Resident 13's transfer and discharge rights. Resident 13 was transferred from her home and friends without ensuring the necessity to meet her medical or welfare needs and without reasonable notice and as a result experienced episodes of crying, being nervous and upset.These violations had a direct relationship to Resident 13's health, safety and security and thus constitute a Class B Citation. |
| 100000026 |
Valley Subacute & Rehabilitation Center |
040012081 |
B |
16-Mar-16 |
FZRR11 |
13249 |
42 Code of Federal Regulations Section 483.12(a)(2) Transfer and discharge requirements:The facility must permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless- (i) The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility; (ii) The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility; (iii) The safety of individuals in the facility is endangered; (iv) The health of individuals in the facility would otherwise be endangered; (v) The resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at the facility. For a resident who becomes eligible for Medicaid after admission to a nursing facility, the nursing facility may charge a resident only allowable charges under Medicaid; or (vi) The facility ceases to operate.Title 22 Section 72527 Patients' Rights: (a) Patients have the rights numerated in this section and the facility shall ensure 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 any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (6) To be transferred or discharged only for medical reasons, or the patient's welfare or that of other patient's or for nonpayment for his or her stay and to be given reasonable advance notice to ensure orderly transfer or discharge. Such actions shall be documented in the patient's health record. Title 22 Section 72519 Patient Transfer: (a) The licensee shall maintain written transfer agreements with other nearby health facilities to make the services of those facilities accessible and to facilitate the transfer of patients. Complete and accurate patient information, in sufficient detail to provide for continuity of care shall be transferred with the patient at time of transfer. (b) When a patient is transferred to another facility, the following shall be entered in the patient health record: (1) The date, time, condition of the patient and a written statement of the reason for the transfer. (2) Informed written or telephone acknowledgement of the patient, patient's guardian or authorized representative except in an emergency or as provided in Section 72527(a)(5). On 12/9/15 at 9:40 a.m., an unannounced visit was made to the facility to investigate anonymous complaint CA00468198 regarding alleged violation of resident transfer and discharge rights. The facility failed to ensure Resident 14 was afforded the right to be transferred or discharged solely for medical reasons or for the resident's welfare, and to be given reasonable advance written notice to ensure a safe and orderly transfer or discharge. The facility transferred Resident 14 in order to accommodate the alleged plan of a potential new owner to convert the facility to a subacute setting (a specialized type of nursing service provided to Residents who require complex care or rehabilitation). As a result, Resident 14 expressed feelings of confusion and helplessness.Review of Resident 14's clinical record titled, "Face Sheet" indicated Resident 14 was admitted to the skilled nursing facility (SNF) 1 on 12/11/12 with diagnoses that included dementia (memory loss), Alzheimer's disease (a type of progressive dementia), anxiety and muscle wasting. Resident 14 was transferred from SNF 1 to SNF 2 on 10/30/15. On 12/9/15 at 9:40 a.m., during a tour of SNF 1, no residents were observed in the hallways, resident rooms or dining area in the West Wing of the facility. Four residents were observed sitting in the East Wing main dining room watching television. During a concurrent interview with the facility Interim Administrator (IA) the IA stated the current facility census was seven of 70 available beds licensed for skilled nursing residents. The IA stated the West Wing was closed. The IA stated three of the seven remaining residents were scheduled to transfer out of the facility later that day, 12/9/15, due to a "Change of ownership" of the facility. On 12/9/15 at 12:15 p.m., during a staff interview in the East Wing hallway, Licensed Nurse (LN) 1 stated residents who resided in the facility were transferred out of the facility due to new ownership expected to take place in the near future. LN 1 stated all residents had to transfer out of the facility. LN 1 stated the new owner planned to run a facility that did not include long term care skilled nursing residents. LN 1 stated most residents that transferred were sad and did not want to leave as the facility had been their home for a long time.On 12/9/15 at 1:30 p.m., during an interview with the Social Services Director (SSD) in the social services office, the SSD stated some of the residents who were transferred did not want to transfer to a different facility because they lived at SNF 1 for a long time. The SSD stated those residents were concerned prior to the transfer as to what would happen to them when the new owner took ownership of the facility. On 12/9/15 at 4:18 p.m., during an interview in the Administrator's office, the IA stated the facility did not provide any resident (including Resident 14) that was transferred since 6/1/15 a 30 day advance written notice that included the intent to transfer, the reason for the pending transfer or discharge or the right to appeal the transfer or discharge. The IA stated, "We didn't do those." Review of the facility's administrative policy titled "California Standard Admission Agreement for Skilled Nursing Facilities and Intermediate Care Facilities" pages eight to nine, dated May 2011 provided to all SNF 1 residents on admission indicated, "VI. Transfers and Discharges...Our written notice of transfer to another facility or discharge against your wishes will be provided 30 days in advance...Our written notice will include the effective day, the location to which you will be transferred or discharged, and the reason the action is necessary. The only reason that we can transfer you to another facility or discharge you against your wishes are: 1) It is required to protect your well-being because your needs cannot be met in our facility; 2) It is appropriate because your health has improved enough that you no longer need the services of our Facility; 3) Your presence in our Facility endangers the health and safety of other individuals; 4) You have not paid for your stay in our Facility or have not arranged to have payment made under Medicare, Medi-Cal, or private insurance; 5) Our Facility ceases to operate; 6) Material or fraudulent misrepresentation of your finances to us... In our written notice, we will advise you that you have the right to appeal the transfer or discharge to the California Department of Health Care Services, and we will also provide the name, address and telephone number of the State Long-Term Care Ombudsman."On 12/16/15 at 3 p.m., during a staff interview, the SSD stated she had worked for SNF 1 for the past seven years. The SSD stated the facility process for discharging residents had begun to change in April 2015. The SSD stated she had been assigned the responsibility to coordinate the discharge of the residents in the facility. The SSD stated that responsibility had previously been a nursing service responsibility. The SSD stated in June 2015 the Clinical Nurse Liaison (CNL) began to assist her with the discharge of residents. She stated the CNL facilitated discharges of residents to other company-owned skilled nursing facilities. The SSD stated when approached by families or residents she had discussed the pending transition, and informed the residents or/and their families the residents could remain at the facility or seek placement before the transition was set to occur, but she could not speak to what would occur after the business was sold. The SSD stated families were given the instruction discharge of the residents was inevitable sooner or later as the type of patients accepted would change to those who required more complex care than was provided in SNF 1. The SSD stated the residents were "fast tracked" to discharge as part of the change in the process. She stated, "The majority of families wanted to seek placement out of fear, not knowing what was going to happen...how could they not be [fearful]? As an employee it was very difficult...they [the facility] were not communicating properly...I felt pressured...that's been very stressful."On 12/17/15 at 7:30 a.m., during an interview, the CNL stated her role at SNF 1 during the transition of ownership was to assist with the discharge of residents from the facility. The CNL stated she learned of an ownership transition in a staff meeting and received direction from the Regional Director of Operations (RDO) to discharge residents. She stated, "I wasn't aware of the regulations...I was stuck in between...it's been a nightmare." The CNL stated, "If they [the residents] asked [what would happen to them], we told them about the change of ownership...don't know when it's going to happen...there was the feeling of uncertainty." Review of Resident 14's clinical record titled "MDS 3.0 (Minimum Data Set) (an assessment tool to assess a residents cognitive and physical functional abilities) Assessment," dated 9/25/15, indicated Resident 14's Brief Interview for Mental Status (BIMS) score was 15 on a scale of 0 to 15 with 15 indicating the resident was cognitively (pertaining to comprehension, memory and reasoning ability) intact. Resident 14's MDS assessment of functional ability indicated he required "Extensive assistance" from staff for bed mobility, transferring, dressing, and hygiene. Review of Resident 14's clinical record titled, "Transfer/Discharge Summary" dated 10/30/15 contained an area to document "Reason for Transfer/Discharge." A box indicating "Other, Please Explain" was the single box checked and "Other Facility" was written on the line next to the box. There was no documented rationale for the transfer to SNF 2.On 12/30/15 at 3:40 p.m., during an observation and concurrent interview in Resident 14's room in SNF 2, Resident 14 was lying in bed, awake and alert, watching television. Resident 14 stated he transferred to SNF 2 because SNF 1 was sold and he was told he had to leave. Resident 14 stated he had liked living at SNF 1 and did not want to leave. Resident 14 stated, "I don't know what the benefit of moving was. I'm not crazy about being here, but I don't know what choice I have. I can hardly walk, so I'm pretty helpless." On 1/7/16 at 10:40 a.m., during a telephone interview, Resident 14's Responsible Party (RP) 7 stated he received a telephone call from SNF 1 in October 2015 notifying him the building was closing and everyone had to move out. RP 7 stated SNF 1 staff told him they found a room for Resident 14 at SNF 2 and they wanted to move him as soon as possible. RP 7 stated Resident 14 was moved the next day. RP 7 stated Resident 14 did not want to move. RP 7 stated Resident 14 had a hard time adjusting to the move during the first month after the transfer because he was put into a four bed room and he had come from a two bed room in SNF 1. Resident 14 also had a very noisy roommate at SNF 2 and the noise and commotion in the room were constant problems. RP 7 stated SNF 2 told him they would try to move Resident 14 into a two bed room but it would take about six weeks for one to become available. RP 14 stated he had not received any advance notice in any form regarding the transfer; he found out on 10/29/15, the day before the transfer to SNF 2. On 1/8/16 at 9:50 a.m., during a staff interview and concurrent clinical record review with the SSD in the social services office at SNF 1, the SSD stated her first social services note regarding Resident 14's transfer to SNF 2 was written on 10/29/15 and he was transferred on 10/30/15. The SSD stated the SNF 1 Interdisciplinary Team (IDT), (a resident care team including nursing, dietary, social services and activity staff) had not met prior to the resident's transfer to discuss whether it was a safe and appropriate transfer and the discharge care plan had not been updated to plan for the transfer to SNF 2. The SSD stated SNF 2 did not provide any services that could not be provided at SNF 1. The SSD stated a 30 day notice of transfer that included the reason for transfer, the date of transfer, the location of the transfer, the right to appeal the transfer and the name and phone number of the state ombudsman had not been provided to Resident 14 or his Responsible Party. Therefore, the facility failed to honor and protect Resident 14's transfer and discharge rights. Resident 14 was transferred without ensuring the necessity to meet his medical or welfare needs and without reasonable notice and as a result expressed feelings of helplessness.These violations had a direct relationship to Resident 14's health, safety and security and thus constitute a Class B Citation. |
| 100000026 |
Valley Subacute & Rehabilitation Center |
040012082 |
B |
16-Mar-16 |
FZRR11 |
14314 |
42 Code of Federal Regulations Section 483.12(a)(2) Transfer and discharge requirements:The facility must permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless- (i) The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility; (ii) The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility; (iii) The safety of individuals in the facility is endangered; (iv) The health of individuals in the facility would otherwise be endangered; (v) The resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at the facility. For a resident who becomes eligible for Medicaid after admission to a nursing facility, the nursing facility may charge a resident only allowable charges under Medicaid; or (vi) The facility ceases to operate.Title 22 Section 72527 Patients' Rights: (a) Patients have the rights numerated in this section and the facility shall ensure 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 any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (6) To be transferred or discharged only for medical reasons, or the patient's welfare or that of other patient's or for nonpayment for his or her stay and to be given reasonable advance notice to ensure orderly transfer or discharge. Such actions shall be documented in the patient's health record. Title 22 Section 72519 Patient Transfer: (a) The licensee shall maintain written transfer agreements with other nearby health facilities to make the services of those facilities accessible and to facilitate the transfer of patients. Complete and accurate patient information, in sufficient detail to provide for continuity of care shall be transferred with the patient at time of transfer. (b) When a patient is transferred to another facility, the following shall be entered in the patient health record: (1) The date, time, condition of the patient and a written statement of the reason for the transfer. (2) Informed written or telephone acknowledgement of the patient, patient's guardian or authorized representative except in an emergency or as provided in Section 72527(a)(5). On 12/9/15 at 9:40 a.m., an unannounced visit was made to the facility to investigate anonymous complaint CA00468198 regarding the alleged violation of resident transfer and discharge rights. The facility failed to ensure Resident 17 was afforded the right to be transferred or discharged solely for medical reasons or for the resident's welfare, and to be given reasonable advance written notice to ensure a safe and orderly transfer or discharge. The facility transferred Resident 17 in order to accommodate the alleged plan of a potential new owner to convert the facility to a subacute setting (a specialized type of nursing service provided to Residents who require complex care or rehabilitation). As a result, Resident 17 was displaced from his home without his consent.Review of Resident 17's clinical record titled, "Face Sheet" indicated Resident 17 was admitted to the skilled nursing facility (SNF) 1 on 12/31/09 with diagnoses that included multiple sclerosis (a neurological disease causing difficulty with movement and speech), cerebrovascular disease (disease of the blood vessels of the brain), cognitive communication deficit, and gastrostomy status (tube inserted through the abdominal wall into the stomach to supply food, fluids and medication). The "Face Sheet" indicated Resident 17 was responsible for his own medical and financial decisions. Resident 17 was transferred from SNF 1 to SNF 2 on 11/11/15. On 12/9/15 at 9:40 a.m., during a tour of SNF 1, no residents were observed in the hallways, resident rooms or dining area in the West Wing of the facility. Four residents were observed sitting in the East Wing main dining room watching television. During a concurrent interview with the facility Interim Administrator (IA) the IA stated the current facility census was seven of 70 available beds licensed for skilled nursing residents. The IA stated the West Wing was closed and did not house any residents. The IA stated three of the seven remaining residents were scheduled to transfer out of the facility later that day, 12/9/15, due to a "Change of ownership" of the facility. On 12/9/15 at 12:15 p.m., during a staff interview in the East Wing hallway, Licensed Nurse (LN) 1 stated residents who resided in the facility were transferred out of the facility due to new ownership expected to take place in the near future. LN 1 stated all residents had to transfer out of the facility. LN 1 stated the new owner planned to run a facility that did not include long term care skilled nursing residents. LN 1 stated most residents that transferred were sad and did not want to leave as the facility had been their home for a long time.On 12/9/15 at 1:30 p.m., during an interview with the Social Services Director (SSD) in the social services office, the SSD stated some of the residents who were transferred did not want to transfer to a different facility because they lived at SNF 1 for a long time. The SSD stated those residents were concerned prior to the transfer as to what would happen to them when the new owner took ownership of the facility. On 12/9/15 at 4:18 p.m., during an interview in the Administrator's office, the IA stated the facility did not provide any resident (including Resident 17) that was transferred since 6/1/15 a 30 day advance written notice that included the intent to transfer, the reason for the pending transfer or discharge or the right to appeal the transfer or discharge. The IA stated, "We didn't do those." Review of the facility's administrative policy titled, "California Standard Admission Agreement for Skilled Nursing Facilities and Intermediate Care Facilities" pages eight to nine, dated May 2011 provided to all SNF 1 residents on admission indicated, "VI. Transfers and Discharges...Our written notice of transfer to another facility or discharge against your wishes will be provided 30 days in advance...Our written notice will include the effective day, the location to which you will be transferred or discharged, and the reason the action is necessary. The only reason that we can transfer you to another facility or discharge you against your wishes are: 1) It is required to protect your well-being because your needs cannot be met in our facility; 2) It is appropriate because your health has improved enough that you no longer need the services of our Facility; 3) Your presence in our Facility endangers the health and safety of other individuals; 4) You have not paid for your stay in our Facility or have not arranged to have payment made under Medicare, Medi-Cal, or private insurance; 5) Our Facility ceases to operate; 6) Material or fraudulent misrepresentation of your finances to us... In our written notice, we will advise you that you have the right to appeal the transfer or discharge to the California Department of Health Care Services, and we will also provide the name, address and telephone number of the State Long-Term Care Ombudsman."On 12/16/15 at 3 p.m., during a staff interview, the SSD stated she had worked for SNF 1 for the past seven years. The SSD stated the facility process for discharging residents had begun to change in April 2015. The SSD stated she had been assigned the responsibility to coordinate the discharge of the residents in the facility. The SSD stated that responsibility had previously been a nursing service responsibility. The SSD stated in June 2015 the Clinical Nurse Liaison (CNL) began to assist her with the discharge of residents. She stated the CNL facilitated discharges of residents to other company-owned skilled nursing facilities. The SSD stated when approached by families or residents she had discussed the pending transition, and informed the residents or/and their families the residents could remain at the facility or seek placement before the transition was set to occur, but she could not speak to what would occur after the business was sold. The SSD stated families were given the instruction discharge of the residents was inevitable sooner or later as the type of patients accepted would change to those who required more complex care than was provided in SNF 1. The SSD stated the residents were "fast tracked" to discharge as part of the change in the process. She stated, "The majority of families wanted to seek placement out of fear, not knowing what was going to happen...how could they not be [fearful]? As an employee it was very difficult...they [the facility] were not communicating properly...I felt pressured...that's been very stressful."On 12/17/15 at 7:30 a.m., during an interview, the CNL stated her role at SNF 1 during the transition of ownership was to assist with the discharge of residents from the facility. The CNL stated she learned of an ownership transition in a staff meeting and received direction from the Regional Director of Operations (RDO) to discharge residents. She stated, "I wasn't aware of the regulations...I was stuck in between...it's been a nightmare." The CNL stated, "If they [the residents] asked [what would happen to them], we told them about the change of ownership...don't know when it's going to happen...there was the feeling of uncertainty." Review of Resident 17's clinical record titled, "MDS [Minimum Data Set] (a tool used to assess resident cognitive and functional abilities) 3.0 Assessment," dated 10/2/15, indicated Resident 17's cognitive (pertaining to comprehension, memory and reasoning ability) skills for daily decision making were "Moderately impaired-decisions poor; cues/supervision required." Resident 17's MDS assessment under the area of functional ability, the document indicated he was totally dependent on staff for transfers, dressing, eating, hygiene and bathing. Review of Resident 17's clinical record titled, "Physician Orders" dated November 2015, indicated, "Resident is capable of managing own finances; Resident is capable of participating in own plan of care; Resident is capable of understanding and exercising own rights." Review of Resident 17's SNF 1 clinical record titled, "Transfer/Discharge Summary" dated 11/11/15 contained an area to document "Reason for Transfer/Discharge." This area of the document was blank, and there was no documentation to justify of the reason for the transfer to another SNF.On 12/30/15 at 4:10 p.m., during an observation and concurrent interview in Resident 17's room in SNF 2, Resident 17 was sleeping in bed. Resident 17 awoke when his name was called. Resident 17 was unable to express himself verbally but nodded his head up and down to signify "yes" when asked if he remembered leaving SNF 1 and being transferred to SNF 2. When asked if he had wanted to move to SNF 2, Resident 17 closed his eyes and went back to sleep. On 12/30/15 at 4:20 p.m., during a staff interview in the hallway at SNF 2, Certified Nurse Assistant, (CNA) 2 stated Resident 17 required total care provided by staff including being fed by a tube placed into his stomach. CNA 2 stated Resident 17 was unable to speak but could communicate his needs and respond to staff by blinking his eyes or pointing toward letters on a spelling board. CNA 2 stated, "It depends on the day and his mood. Some days he doesn't respond to people." On 1/8/16 at 11:05 a.m., a staff interview and concurrent clinical record review with the SSD in the social services office in SNF 1 was conducted. The SSD stated Resident 17's Family Member (FM) 5 had told the SSD she had heard about the transition of the facility to a new owner. The SSD stated FM 5 was worried about what would happen when the facility changed owners. The SSD stated she found a bed at SNF 2 and FM 5 agreed to have Resident 17 transferred there. The SSD stated she did not recall meeting with Resident 17 prior to the transfer to discuss if he wanted to transfer, although Resident 17 was responsible for his own decision making. The SSD stated Resident 17 was able to communicate with staff by using a communication board. The SSD stated she was unable to find documentation of a meeting to discuss the proposed transfer with Resident 17 in the clinical record. The SSD stated she was not sure how Resident 17 had been made aware of the proposed transfer. The SSD stated there was no documentation of a meeting with Resident 17's family member prior to transfer. The SSD confirmed the sole reference in the clinical record to Resident 17's transfer was in the "Departmental Notes" dated 11/11/15 that indicated, "Social Service Discharge Note: Resident discharged on 11/11/15 to [SNF 2]." The SSD stated review of Resident 17's clinical record indicated the SNF 1 Interdisciplinary Team (IDT) (a resident care team including nursing, dietary, social services and activity staff) had not met prior to the transfer to discuss whether resident 17's planned transfer was a safe and appropriate transfer and the discharge care plan document was not updated to plan for the transfer to SNF 2. The SSD stated SNF 2 did not provide any additional services for Resident 17 that could not be provided at SNF 1. The SSD stated a 30 day notice of transfer that included the reason for transfer, the date of transfer, the location of the transfer, the right to appeal the transfer and the name and phone number of the state ombudsman was not provided to Resident 17, who was his own responsible party, or to FM 5. Therefore, the facility failed to honor and protect Resident 17's transfer and discharge rights. Resident 17 was transferred without ensuring the necessity to meet his medical or welfare needs, without reasonable notice, and without his consent, and as a result was deprived of his transfer/discharge rights.These violations had a direct relationship to Resident 17's health, safety and security and thus constitute a Class B Citation. |
| 100000026 |
Valley Subacute & Rehabilitation Center |
040012087 |
B |
16-Mar-16 |
FZRR11 |
13732 |
42 Code of Federal Regulations Section 483.12(a)(2) Transfer and discharge requirements:The facility must permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless- (i) The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility; (ii) The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility; (iii) The safety of individuals in the facility is endangered; (iv) The health of individuals in the facility would otherwise be endangered; (v) The resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at the facility. For a resident who becomes eligible for Medicaid after admission to a nursing facility, the nursing facility may charge a resident only allowable charges under Medicaid; or (vi) The facility ceases to operate.Title 22 Section 72527 Patients' Rights: (a) Patients have the rights numerated in this section and the facility shall ensure 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 any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (6) To be transferred or discharged only for medical reasons, or the patient's welfare or that of other patient's or for nonpayment for his or her stay and to be given reasonable advance notice to ensure orderly transfer or discharge. Such actions shall be documented in the patient's health record. Title 22 Section 72519 Patient Transfer: (a) The licensee shall maintain written transfer agreements with other nearby health facilities to make the services of those facilities accessible and to facilitate the transfer of patients. Complete and accurate patient information, in sufficient detail to provide for continuity of care shall be transferred with the patient at time of transfer. (b) When a patient is transferred to another facility, the following shall be entered in the patient health record: (1) The date, time, condition of the patient and a written statement of the reason for the transfer. (2) Informed written or telephone acknowledgement of the patient, patient's guardian or authorized representative except in an emergency or as provided in Section 72527(a)(5). On 12/9/15 at 9:40 a.m., an unannounced visit was made to the facility to investigate anonymous complaint CA00468198 regarding the alleged violation of resident transfer and discharge rights. The facility failed to ensure Resident 15 was afforded the right to be transferred or discharged solely for medical reasons or for the resident's welfare, and to be given reasonable advance written notice to ensure a safe and orderly transfer or discharge. The facility transferred Resident 15 in order to accommodate the alleged plan of a potential new owner to convert the facility to a subacute setting (a specialized type of nursing service provided to Residents who require complex care or rehabilitation). As a result, Resident 15 was displaced from his home and familiar staff and routines. Review of Resident 15's clinical record titled, "Face Sheet" indicated Resident 15 was admitted to the skilled nursing facility (SNF) 1 on 3/20/15 with diagnoses that included schizophrenia (a severe mental disorder) and gastrostomy tube status (a tube placed through the abdominal wall into the stomach for the purpose of supplying food, fluids and medication). Resident 15 was transferred from SNF 1 to SNF 2 on 8/24/15. On 12/9/15 at 9:40 a.m., during a tour of SNF 1, no residents were observed in the hallways, resident rooms or dining area in the West Wing of the facility. Four residents were observed sitting in the East Wing main dining room watching television. During a concurrent interview with the facility Interim Administrator (IA) the IA stated the current facility census was seven of 70 available beds licensed for skilled nursing residents. The IA stated the West Wing was closed. The IA stated three of the seven remaining residents were scheduled to transfer out of the facility later that day, 12/9/15, due to a "Change of ownership" of the facility. On 12/9/15 at 12:15 p.m., during a staff interview in the East Wing hallway, Licensed Nurse (LN) 1 stated residents who resided in the facility were transferred out of the facility due to new ownership expected to take place in the near future. LN 1 stated all residents had to transfer out of the facility. LN 1 stated the new owner planned to run a facility that did not include long term care skilled nursing residents. LN 1 stated most residents that transferred were sad and did not want to leave as the facility had been their home for a long time. On 12/9/15 at 1:30 p.m., during an interview with the Social Services Director (SSD) in the social services office, the SSD stated some of the residents who were transferred did not want to transfer to a different facility because they lived at SNF 1 for a long time. The SSD stated those residents were concerned prior to the transfer as to what would happen to them when the new owner took ownership of the facility. On 12/9/15 at 4:18 p.m., during an interview in the Administrator's office, the IA stated the facility did not provide any resident (including Resident 15) that was transferred since 6/1/15 a 30 day advance written notice that included the intent to transfer, the reason for the pending transfer or discharge or the right to appeal the transfer or discharge. The IA stated, "We didn't do those." Review of the facility's administrative policy titled "California Standard Admission Agreement for Skilled Nursing Facilities and Intermediate Care Facilities" pages eight to nine, dated May 2011 provided to all SNF 1 residents on admission indicated, "VI. Transfers and Discharges...Our written notice of transfer to another facility or discharge against your wishes will be provided 30 days in advance...Our written notice will include the effective day, the location to which you will be transferred or discharged, and the reason the action is necessary. The only reason that we can transfer you to another facility or discharge you against your wishes are: 1) It is required to protect your well-being because your needs cannot be met in our facility; 2) It is appropriate because your health has improved enough that you no longer need the services of our Facility; 3) Your presence in our Facility endangers the health and safety of other individuals; 4) You have not paid for your stay in our Facility or have not arranged to have payment made under Medicare, Medi-Cal, or private insurance; 5) Our Facility ceases to operate; 6) Material or fraudulent misrepresentation of your finances to us... In our written notice, we will advise you that you have the right to appeal the transfer or discharge to the California Department of Health Care Services, and we will also provide the name, address and telephone number of the State Long-Term Care Ombudsman."On 12/16/15 at 3 p.m., during a staff interview, the SSD stated she had worked for SNF 1 for the past seven years. The SSD stated the facility process for discharging residents had begun to change in April 2015. The SSD stated she had been assigned the responsibility to coordinate the discharge of the residents in the facility. The SSD stated that responsibility had previously been a nursing service responsibility. The SSD stated in June 2015 the Clinical Nurse Liaison (CNL) began to assist her with the discharge of residents. She stated the CNL facilitated discharges of residents to other company-owned skilled nursing facilities. The SSD stated when approached by families or residents she had discussed the pending transition, and informed the residents or/and their families the residents could remain at the facility or seek placement before the transition was set to occur, but she could not speak to what would occur after the business was sold. The SSD stated families were given the instruction discharge of the residents was inevitable sooner or later as the type of patients accepted would change to those who required more complex care than was provided in SNF 1. The SSD stated the residents were "fast tracked" to discharge as part of the change in the process. She stated, "The majority of families wanted to seek placement out of fear, not knowing what was going to happen...how could they not be [fearful]? As an employee it was very difficult...they [the facility] were not communicating properly...I felt pressured...that's been very stressful."On 12/17/15 at 7:30 a.m., during an interview, the CNL stated her role at SNF 1 during the transition of ownership was to assist with the discharge of residents from the facility. The CNL stated she learned of an ownership transition in a staff meeting and received direction from the Regional Director of Operations (RDO) to discharge residents. She stated, "I wasn't aware of the regulations...I was stuck in between...it's been a nightmare." The CNL stated, "If they [the residents] asked [what would happen to them], we told them about the change of ownership...don't know when it's going to happen...there was the feeling of uncertainty." Review of Resident 15's clinical record titled "MDS [Minimum Data Set] (a tool used to assess the residents cognitive and physical functional abilities) 3.0 Assessment," dated 8/31/15, indicated Resident 15's Brief Interview for Mental Status (BIMS) score was 0 on a scale of 0 to 15 with 0 indicating severe cognitive (pertaining to comprehension, memory and reasoning ability) impairment. Resident 15's MDS assessment of functional ability indicated he was totally dependent on staff for bed mobility, eating and hygiene. Review of Resident 15's clinical record titled, "Transfer/Discharge Summary" dated 8/24/15/15 contained an area to document "Reason for Transfer/Discharge." A box on the document indicated, "Resident needs SNF/Hospital [acute hospital] care" was checked. There was no documented rationale for the transfer to SNF 2 indicated on the form.On 12/30/15 at 2:25 p.m. during a staff interview in SNF 2 conference room, SNF 2's Admission Coordinator (AC) 2 stated Resident 15 was transferred from SNF 1 to SNF 2 on 8/24/15. AC 2 stated she received a fax (facsimile) from SNF 1 on 8/23/15 requesting placement for Resident 15. AC 2 stated she had been unable to admit him to SNF 2 on 8/24/15. AC 2 stated Resident 15 had no family and was represented by a public guardian.On 12/31/15 at 9:50 a.m., during a staff interview in SNF 2 hallway, Certified Nursing Assistant (CNA) 1 stated Resident 15 stayed in his room all day, had no visitors and did not attend any activities. CNA 1 stated, "He looks angry a lot. He is anxious and restless." CNA 1 stated Resident 15 required total assistance by staff for all his needs.On 12/31/15 at 10 a.m., during an observation in the resident's room at SNF 2, Resident 15 was lying in bed, the head of the bed was elevated 40 degrees, and a plastic bottle labeled "Fibersource" was attached to a feeding pump which was turned off. Resident 15 was not wearing a shirt and the lower half of his body was covered by a sheet. Resident 15's legs were hanging over the edge of the bed. His eyes were open but he did not respond to questions. On 1/8/16 at 9:45 a.m., during a telephone interview, Resident 15's Public Guardian (PG) 1 stated she received a call from the SNF 1 SSD on 8/20/15 informing her SNF 1 had been sold and she [the SSD] did not know what would happen to Resident 15 when the new owner took over the facility. The SSD informed her Resident 15 could transfer to their [SNF 1] sister facility at SNF 2. PG 1 stated she had not known what else to do so she approved the transfer. PG 1 stated she received a call on 8/21/15 that there was a bed available at SNF 2, and Resident 15 was transferred on 8/24/15.On 1/8/16 at 9:55 a.m., a staff interview and concurrent clinical record review with the SSD in the social services office at SNF 1 was conducted. The SSD stated PG 1 heard through the community SNF 1 had been sold and PG 1 was concerned. The SSD stated she suggested to PG 1 Resident 15 transfer to SNF 2, a sister facility of SNF 1, which provided the same level of care, and PG 1 agreed. The SSD stated she spoke to PG 1 on 8/20/15 and Resident 15 was transferred on 8/24/15. The SSD stated SNF 1's Interdisciplinary Team (IDT), (a resident care team including nursing, dietary, social services and activity staff) had not met prior to Resident 15's transfer to discuss whether it was a safe and appropriate transfer and the discharge care plan had not been updated with a plan to transfer Resident 15 to SNF 2. The SSD stated SNF 2 was not able to provide care for Resident 15 that SNF 1 could not provide. The SSD stated a 30 day notice of transfer that included the reason for transfer, the date of the transfer, the location of the transfer, the right to appeal the transfer and the name and phone number of the state ombudsman was not provided to Resident 15 or his Public Guardian. Therefore, the facility failed to honor and protect Resident 15's transfer and discharge rights. Resident 15 was transferred without ensuring the necessity to meet his medical or welfare needs and without reasonable notice and as a result experienced anger and anxiety.These violations had a direct relationship to Resident 15's health, safety and security and thus constitute a Class B Citation. |
| 100000026 |
Valley Subacute & Rehabilitation Center |
040012088 |
B |
16-Mar-16 |
FZRR11 |
13773 |
42 Code of Federal Regulations Section 483.12(a)(2) Transfer and discharge requirements:The facility must permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless- (i) The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility; (ii) The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility; (iii) The safety of individuals in the facility is endangered; (iv) The health of individuals in the facility would otherwise be endangered; (v) The resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at the facility. For a resident who becomes eligible for Medicaid after admission to a nursing facility, the nursing facility may charge a resident only allowable charges under Medicaid; or (vi) The facility ceases to operate.Title 22 Section 72527 Patients' Rights: (a) Patients have the rights numerated in this section and the facility shall ensure 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 any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (6) To be transferred or discharged only for medical reasons, or the patient's welfare or that of other patient's or for nonpayment for his or her stay and to be given reasonable advance notice to ensure orderly transfer or discharge. Such actions shall be documented in the patient's health record. Title 22 Section 72519 Patient Transfer: (a) The licensee shall maintain written transfer agreements with other nearby health facilities to make the services of those facilities accessible and to facilitate the transfer of patients. Complete and accurate patient information, in sufficient detail to provide for continuity of care shall be transferred with the patient at time of transfer. (b) When a patient is transferred to another facility, the following shall be entered in the patient health record: (1) The date, time, condition of the patient and a written statement of the reason for the transfer. (2) Informed written or telephone acknowledgement of the patient, patient's guardian or authorized representative except in an emergency or as provided in Section 72527(a)(5). On 12/9/15 at 9:40 a.m., an unannounced visit was made to the facility to investigate anonymous complaint CA00468198 regarding alleged violation of resident transfer and discharge rights. The facility failed to ensure Resident 16 was afforded the right to be transferred or discharged solely for medical reasons or for the resident's welfare, and to be given reasonable advance written notice to ensure a safe and orderly transfer or discharge. The facility transferred Resident 16 in order to accommodate the alleged plan of a potential new owner to convert the facility to a subacute setting (a specialized type of nursing service provided to Residents who require complex care or rehabilitation). As a result, Resident 16 was displaced from her usual place of residence and suffered psychological and emotional distress.Review of Resident 16's clinical record titled, "Face Sheet" indicated Resident 16 was admitted to the skilled nursing facility (SNF) 1 on 2/20/14 with diagnoses that included end stage renal disease (kidney failure) and dialysis (treatment for kidney failure using a mechanical artificial kidney). Resident 16 was transferred to the acute care hospital (Hosp) 2 on 9/7/15 and transferred from Hosp 2 to SNF 2 on 9/11/15.Review of Resident 16's clinical record titled, "Departmental Notes - Nurses Note" dated 9/8/15, indicated, "Received approval from RP (Responsible Party) for 7 days bed hold, bed hold form [form requesting facility hold the bed for seven days for the Resident during hospitalization] completed." On 12/9/15 at 9:40 a.m., during a tour of SNF 1, no residents were observed in the hallways, resident rooms or dining area in the West Wing of the facility. Four residents were observed sitting in the East Wing main dining room watching television. During a concurrent interview with the facility Interim Administrator (IA) the IA stated the current facility census was seven of 70 available beds licensed for skilled nursing residents. The IA stated the West Wing was closed. The IA stated three of the seven remaining residents were scheduled to transfer out of the facility later that day, 12/9/15, due to a "Change of ownership" of the facility. On 12/9/15 at 12:15 p.m., during a staff interview in the East Wing hallway, Licensed Nurse (LN) 1 stated residents who resided in the facility were transferred out of the facility due to new ownership expected to take place in the near future. LN 1 stated all residents had to transfer out of the facility. LN 1 stated the new owner planned to run a facility that did not include long term care skilled nursing residents. LN 1 stated most residents that transferred were sad and did not want to leave as the facility had been their home for a long time. On 12/9/15 at 1:30 p.m., during an interview with the Social Services Director (SSD) in the social services office, the SSD stated some of the residents who were transferred did not want to transfer to a different facility because they lived at SNF 1 for a long time. The SSD stated those residents were concerned prior to the transfer as to what would happen to them when the new owner took ownership of the facility. On 12/9/15 at 4:18 p.m., during an interview in the Administrator's office, the IA stated the facility did not provide any resident (including Resident 16 or the Responsible Party for Resident 16) that was transferred since 6/1/15 a 30 day advance written notice that included the intent to transfer, the reason for the pending transfer or discharge or the right to appeal the transfer or discharge. The IA stated, "We didn't do those." Review of the facility's administrative policy titled, "California Standard Admission Agreement for Skilled Nursing Facilities and Intermediate Care Facilities" pages eight to nine, dated May 2011 provided to all SNF 1 residents on admission indicated, "VI. Transfers and Discharges...Our written notice of transfer to another facility or discharge against your wishes will be provided 30 days in advance...Our written notice will include the effective day, the location to which you will be transferred or discharged, and the reason the action is necessary. The only reason that we can transfer you to another facility or discharge you against your wishes are: 1) It is required to protect your well-being because your needs cannot be met in our facility; 2) It is appropriate because your health has improved enough that you no longer need the services of our Facility; 3) Your presence in our Facility endangers the health and safety of other individuals; 4) You have not paid for your stay in our Facility or have not arranged to have payment made under Medicare, Medi-Cal, or private insurance; 5) Our Facility ceases to operate; 6) Material or fraudulent misrepresentation of your finances to us... In our written notice, we will advise you that you have the right to appeal the transfer or discharge to the California Department of Health Care Services, and we will also provide the name, address and telephone number of the State Long-Term Care Ombudsman."On 12/16/15 at 3 p.m., during a staff interview, the SSD stated she had worked for SNF 1 for the past seven years. The SSD stated the facility process for discharging residents had begun to change in April 2015. The SSD stated she had been assigned the responsibility to coordinate the discharge of the residents in the facility. The SSD stated that responsibility had previously been a nursing service responsibility. The SSD stated in June 2015 the Clinical Nurse Liaison (CNL) began to assist her with the discharge of residents. She stated the CNL facilitated discharges of residents to other company-owned skilled nursing facilities. The SSD stated when approached by families or residents she had discussed the pending transition, and informed the residents or/and their families the residents could remain at the facility or seek placement before the transition was set to occur, but she could not speak to what would occur after the business was sold. The SSD stated families were given the instruction discharge of the residents was inevitable sooner or later as the type of patients accepted would change to those who required more complex care than was provided in SNF 1. The SSD stated the residents were "fast tracked" to discharge as part of the change in the process. She stated, "The majority of families wanted to seek placement out of fear, not knowing what was going to happen...how could they not be [fearful]? As an employee it was very difficult...they [the facility] were not communicating properly...I felt pressured...that's been very stressful."On 12/17/15 at 7:30 a.m., during an interview, the CNL stated her role at SNF 1 during the transition of ownership was to assist with the discharge of residents from the facility. The CNL stated she learned of an ownership transition in a staff meeting and received direction from the Regional Director of Operations (RDO) to discharge residents. She stated, "I wasn't aware of the regulations...I was stuck in between...it's been a nightmare." The CNL stated, "If they [the residents] asked [what would happen to them], we told them about the change of ownership...don't know when it's going to happen...there was the feeling of uncertainty." Review of Resident 16's clinical record titled, "MDS (Minimum Data Set) (an assessment tool to assess resident cognitive and physical function abilities) 3.0 Assessment," dated 10/2/15, indicated Resident 16's Brief Interview for Mental Status (BIMS) score was 13 on a scale of 0 to 15 with 13 indicating the resident was cognitively (pertaining to comprehension, memory and reasoning ability) intact. Resident 16's MDS assessment of functional ability indicated she required extensive assistance from staff for bed mobility, transferring, dressing, and hygiene. On 12/30/15 at 4 p.m., during an observation and concurrent interview in Resident 16's room in SNF 2, Resident 16 was sitting in a wheelchair next to her bed crocheting. Resident 16 indicated she spoke Spanish only. Family Member (FM) 4 entered the room and translated the conversation. Resident 16 stated she was at SNF 1, transferred to the acute hospital for treatment for four days, and then was transferred from the acute hospital to SNF 2. Resident 16 stated SNF 1 staff talked to her Responsible Party, RP 8, regarding the transfer to SNF 2 when Resident 16 had not returned to SNF 1. RP 8 stated the transfer had not been discussed with her.On 12/30/15 at 4:05 p.m., during an interview in Resident 16's room in SNF 2, FM 4 stated Resident 16 had some difficulty adjusting to the new facility. FM 4 stated Resident 16 liked her old room at SNF 1 better and she did not like the change in locations. FM 4 stated, "She [Resident 16] doesn't like change. At first she stayed in her room and wouldn't talk to anyone." On 1/7/16 at 11 a.m., during a telephone interview, RP 8 stated Resident 16 was sent from SNF 1 to the acute care hospital on 9/7/15. RP 8 stated prior to Resident 16's discharge from the acute hospital on 9/11/15 he received a call from staff at SNF 1 notifying him Resident 16 would not return to SNF 1, but instead they had found a room for her at SNF 2. RP 8 stated he was told the facility had been sold and all residents had to move out. RP 8 stated he had not planned on transferring Resident 16 out of SNF 1 because her husband was elderly and SNF 1 was closer for him to visit. RP 8 stated he was told, "You can have the room [at SNF 2] now or you can take your chances later." RP 8 stated he was worried what would happen to Resident 16 and agreed to transfer Resident 16 to SNF 2. He stated Resident 16 had difficulty adjusting for the first three to four weeks as she was used to SNF 1's staff and routines.On 1/8/15 at 10:35 a.m., during a staff interview and concurrent clinical record review with the SSD in the social services office at SNF 1, the SSD stated Resident 16 was transferred to the acute care hospital for treatment on 9/7/15. The SSD stated RP 8 had signed a form requesting SNF 1 hold Resident 16's bed for seven days. The SSD stated Resident 16 had not returned to SNF 1 after four days in the acute hospital but instead was transferred to SNF 2. The SSD stated she did not know why Resident 16 had not returned to SNF 1. The SSD stated she could not find any documentation in Resident 16's clinical record that explained why the Resident did not return to SNF 1. The SSD was unable to locate the written bed hold request in the record. The SSD stated SNF 2 did not provide any additional services for Resident 16 that could not be provided at SNF 1. Therefore, the facility failed to honor and protect Resident 16's transfer and discharge rights. Resident 16 and her RP agreed to the transfer to SNF 2 due to fear of what would happen if they declined. Resident 16 was transferred without ensuring the necessity to meet her medical or welfare needs and without reasonable notice. As a result, Resident 16 experienced emotional and psychological distress and exhibited isolation behaviors.These violations had a direct relationship to Resident 16's health, safety and security and thus constitute a Class B Citation. |
| 100000026 |
Valley Subacute & Rehabilitation Center |
040012089 |
B |
16-Mar-16 |
FZRR11 |
15947 |
42 Code of Federal Regulations Section 483.12(a)(2) Transfer and discharge requirements:The facility must permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless- (i) The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility; (ii) The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility; (iii) The safety of individuals in the facility is endangered; (iv) The health of individuals in the facility would otherwise be endangered; (v) The resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at the facility. For a resident who becomes eligible for Medicaid after admission to a nursing facility, the nursing facility may charge a resident only allowable charges under Medicaid; or (vi) The facility ceases to operate.Title 22 Section 72527 Patients' Rights: (a) Patients have the rights numerated in this section and the facility shall ensure 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 any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (6) To be transferred or discharged only for medical reasons, or the patient's welfare or that of other patient's or for nonpayment for his or her stay and to be given reasonable advance notice to ensure orderly transfer or discharge. Such actions shall be documented in the patient's health record. Title 22 Section 72519 Patient Transfer: (a) The licensee shall maintain written transfer agreements with other nearby health facilities to make the services of those facilities accessible and to facilitate the transfer of patients. Complete and accurate patient information, in sufficient detail to provide for continuity of care shall be transferred with the patient at time of transfer. (b) When a patient is transferred to another facility, the following shall be entered in the patient health record: (1) The date, time, condition of the patient and a written statement of the reason for the transfer. (2) Informed written or telephone acknowledgement of the patient, patient's guardian or authorized representative except in an emergency or as provided in Section 72527(a)(5). On 12/9/15 at 9:40 a.m., an unannounced visit was made to the facility to investigate anonymous complaint CA00468198 regarding the alleged violation of transfer and discharge rights. The facility failed to ensure Resident 18 was afforded the right to be transferred or discharged solely for medical reasons or for the resident's welfare, and to be given reasonable advance written notice to ensure a safe and orderly transfer or discharge. The facility transferred Resident 18 in order to accommodate the alleged plan of a potential new owner to convert the facility to a subacute setting (a specialized type of nursing service provided to Residents who require complex care or rehabilitation). As a result, Resident 18 was displaced from his home and family and suffered psychological and emotional harm.Review of Resident 18's clinical record titled, "Face Sheet" indicated Resident 18 was admitted to the skilled nursing facility (SNF) 1 on 2/20/14 with diagnoses that included diabetes mellitus (disorder that affects blood sugar), paraplegia (inability to move the legs), and Stage IV pressure ulcer (skin ulcer caused by pressure involving deep tissue damage). Resident 18 was transferred to the acute care hospital (Hosp) 1 on 6/18/15 for treatment and from Hosp 1 to SNF 11 on 7/14/15. On 12/9/15 at 9:40 a.m., during a tour of SNF 1, no residents were observed in the hallways, resident rooms or dining area in the West Wing of the facility. Four residents were observed sitting in the East Wing main dining room watching television. During a concurrent interview with the facility Interim Administrator (IA) the IA stated the current facility census was seven of 70 available beds licensed for skilled nursing residents. The IA stated the West Wing was closed. The IA stated three of the seven remaining residents were scheduled to transfer out of the facility later that day, 12/9/15, due to a "Change of ownership" of the facility. On 12/9/15 at 12:15 p.m., during a staff interview in the East Wing hallway, Licensed Nurse (LN) 1 stated residents who resided in the facility were transferred out of the facility due to new ownership expected to take place in the near future. LN 1 stated all residents had to transfer out of the facility. LN 1 stated the new owner planned to run a facility that did not include long term care skilled nursing residents. LN 1 stated most residents that transferred were sad and did not want to leave as the facility had been their home for a long time.On 12/9/15 at 1:30 p.m., during an interview with the Social Services Director (SSD) in the social services office, the SSD stated some of the residents who were transferred did not want to transfer to a different facility because they lived at SNF 1 for a long time. The SSD stated those residents were concerned prior to the transfer as to what would happen to them when the new owner took ownership of the facility. On 12/9/15 at 4:18 p.m., during an interview in the Administrator's office, the IA stated the facility had not provided any resident (including Resident 18) that was transferred since 6/1/15 a 30 day advance written notice that included the intent to transfer, the reason for the pending transfer or discharge or the right to appeal the transfer or discharge. The IA stated, "We didn't do those." Review of the facility's administrative policy titled, "California Standard Admission Agreement for Skilled Nursing Facilities and Intermediate Care Facilities" pages eight to nine, dated May 2011, provided to all SNF 1 residents on admission indicated, "VI. Transfers and Discharges...Our written notice of transfer to another facility or discharge against your wishes will be provided 30 days in advance...Our written notice will include the effective day, the location to which you will be transferred or discharged, and the reason the action is necessary. The only reason that we can transfer you to another facility or discharge you against your wishes are: 1) It is required to protect your well-being because your needs cannot be met in our facility; 2) It is appropriate because your health has improved enough that you no longer need the services of our Facility; 3) Your presence in our Facility endangers the health and safety of other individuals; 4) You have not paid for your stay in our Facility or have not arranged to have payment made under Medicare, Medi-Cal, or private insurance; 5) Our Facility ceases to operate; 6) Material or fraudulent misrepresentation of your finances to us... In our written notice, we will advise you that you have the right to appeal the transfer or discharge to the California Department of Health Care Services, and we will also provide the name, address and telephone number of the State Long-Term Care Ombudsman."On 12/16/15 at 3 p.m., during a staff interview, the SSD stated she had worked for SNF 1 for the past seven years. The SSD stated the facility process for discharging residents had begun to change in April 2015. The SSD stated she had been assigned the responsibility to coordinate the discharge of the residents in the facility. The SSD stated that responsibility had previously been a nursing service responsibility. The SSD stated in June 2015 the Clinical Nurse Liaison (CNL) began to assist her with the discharge of residents. She stated the CNL facilitated discharges of residents to other company-owned skilled nursing facilities. The SSD stated when approached by families or residents she had discussed the pending transition, and informed the residents or/and their families the residents could remain at the facility or seek placement before the transition was set to occur, but she could not speak to what would occur after the business was sold. The SSD stated families were given the instruction discharge of the residents was inevitable sooner or later as the type of patients accepted would change to those who required more complex care than was provided in SNF 1. The SSD stated the residents were "fast tracked" to discharge as part of the change in the process. She stated, "The majority of families wanted to seek placement out of fear, not knowing what was going to happen...how could they not be [fearful]? As an employee it was very difficult...they [the facility] were not communicating properly...I felt pressured...that's been very stressful."On 12/17/15 at 7:30 a.m., during an interview, the CNL stated her role at SNF 1 during the transition of ownership was to assist with the discharge of residents from the facility. The CNL stated she learned of an ownership transition in a staff meeting and received direction from the Regional Director of Operations (RDO) to discharge residents. She stated, "I wasn't aware of the regulations...I was stuck in between...it's been a nightmare." The CNL stated, "If they [the residents] asked [what would happen to them], we told them about the change of ownership...don't know when it's going to happen...there was the feeling of uncertainty." Resident 18's clinical record titled, "MDS (Minimum Data Set) (an assessment tool to assess a residents cognitive and physical functional abilities) 3.0 Assessment," dated 4/24/15, indicated under "Cognitive [pertaining to comprehension, memory and reasoning ability] Patterns," a summary score of 15/15, which indicated he had no cognitive deficits. Under "Functional Status," his bed mobility and transfer ability score was 4/3, which indicated total dependence, and extensive assistance required by at least two persons. Under "Walk," he scored 8/8, which indicated he did not walk. Under "Skin Conditions," the assessment indicated a risk for development of pressure ulcers, with one Stage II (a sore caused by pressure that involves loss of the upper layer of skin causing a shallow ulcer) and one Stage IV (skin ulcer caused by pressure involving deep tissue damage) pressure ulcer present on admission.Resident 18's SNF 1 Nurses Notes dated 6/18/15 at 7:10 p.m., indicated, "Resident taken to [Hospital 1] for treatment of pressure ulcers to buttocks...Resident is alert and oriented to person, time and place..." Resident 18's Transfer/Discharge Summary-Post Discharge Plan of Care dated 6/18/15, indicated under Skin Assessment, "Stage IV wound buttocks, paraplegia." Social Service Note dated 6/22/15, indicated, "Resident was transferred to [Hosp 1] for wound managemen[t] on 6/18/15. Resident is...spanish speaking...alert and oriented, capable of making his needs be known...Resident discharge is anticipated long term care...Staff will monitor for any changes and meet all resident needs." On 12/18/15 at 11:20 a.m., during an interview at Hosp 1, Resident 18's case management and discharge records were requested from the Director of Medical Records (DMR). On 12/18/15 at 11:40 a.m., during an interview, the DMR stated she was unable to produce Resident 18's case management notes, and further stated she had called Case Manager 1 (CM 1) and the Hosp1 Social Services Designee (HSSD) to help locate the case management notes.On 12/18/15 at 11:45 a.m., during an interview, CM 1 and HSSD stated they were unable to produce any case management notes for Resident 18. On inquiry regarding why he was transferred to SNF 11, CM 1 stated she could not find her notes. The HSSD stated she could not remember. CM 1 and HSSD were unable to produce any written documentation for Resident 18's transfer to SNF 11, or any written documentation of family involvement in his discharge planning process.Review of Resident 18's undated Hosp 1 Discharge Planning Communication Form indicated under Anticipated Discharge Destination, "Please have pt [patient] return to [SNF 1]. Anticipated Discharge date/time: 7/11/15 at 12 p.m." Resident 18's Hospital Physician Order Sheet dated 7/14/15 at 3:33 p.m., indicated, "1. D/C [discharge] pt [patient] on 7/14/15 to [SNF 11]." The telephone physician order was signed by CM 1. On 12/23/15 at 1:20 p.m., during a concurrent interview with Resident 18's Interpreter (INT), 1 INT 1, Resident 18 stated he was transferred to Hosp 1 from SNF 1 for surgery, and planned to return to SNF 1, because it was located closer to his family. INT 1stated Resident 18 was told by Hosp 1 staff the resident could not return to SNF 1 because there was no available bed. Resident 18's INT 1 stated he was sent to SNF 11, a distance of 30 miles from SNF 1. On 1/6/16 at 3 p.m., during a telephone interview, Family member (FM) 6 stated when Resident 18 was ready for discharge from Hosp 1; a staff person informed her [FM 6] SNF 1 was no longer caring for long term residents. FM 6 stated Resident 18 was upset about the transfer and had difficulty adjusting to SNF 11 because it was unfamiliar to him and a lengthy distance from his family.On 1/8/16 at 2 p.m., during a staff interview with the SSD at SNF 1, the SSD stated Resident 18 was transferred to Hosp 1 on 6/18/15. The SSD stated Resident 18 should have a signed Bed Hold Notice (written notice required to be provided to residents informing them they have the right to request the facility hold their bed for seven days if they need acute hospital care and the right to the first available bed if the hospital stay is longer than seven days) in his clinical record, but she was unable to locate the notice. The SSD stated she did not know why Resident 18 was not transferred back to SNF 1 after receiving treatment at Hosp 1.On 1/11/16 at 2:30 p.m., during a telephone interview with the SSD, Resident 18's Bed Hold Notice was again requested. On 1/12/16 at 8:30 a.m., during an interview, the Administrator-in- Training (AIT) stated SNF 1 was unable to provide written evidence of the required Bed Hold Notice for Resident 18.On 1/12/16 at 11:30 a.m., during a telephone interview, FM 7 stated Resident 18 was upset and sad when discharged from Hosp 1 and transferred to SNF 11 because it was 30 miles away from his family who lived near SNF 1. FM 7 stated Resident 18 wanted to be close to family. FM 7 further stated Resident 18 had difficulty adjusting to the new facility because he was worried his family would have to travel an extended distance to visit. 1/12/16 at 4 p.m., during an interview, the Clinical Nurse Liaison (CNL) stated Resident 18 did not return to SNF 1 because he had a wound vac [vacuum] (medical device which utilizes negative pressure to heal wounds) when discharged from Hosp 1, which necessitated care by licensed nursing staff. She stated SNF 1 had fewer than usual licensed nurses on duty able to handle care of the wound vac treatment, unnecessary, so SNF 1's Director of Nursing made the decision to transfer Resident 18 to another facility. On 1/14/16 at 3:30 p.m., during an interview, SNF 11's Director of Staff Development (DSD) stated Resident 18 did not have a pressure ulcer wound vac on admission to SNF 11. Therefore, the facility failed to honor and protect Resident 18's transfer and discharge rights. Resident 18 was transferred to SNF 11 without ensuring the necessity to meet his medical or welfare needs, without reasonable notice, and without being readmitted to the first available bed at SNF 1. As a result Resident 18 was displaced a significant distance from his family and experienced emotional and psychological distress.These violations had a direct relationship to Resident 18's health, safety and security and thus constitute a Class B Citation. |
| 100000026 |
Valley Subacute & Rehabilitation Center |
040012090 |
B |
16-Mar-16 |
FZRR11 |
15104 |
42 Code of Federal Regulations Section 483.12(a)(2) Transfer and discharge requirements:The facility must permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless- (i) The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility; (ii) The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility; (iii) The safety of individuals in the facility is endangered; (iv) The health of individuals in the facility would otherwise be endangered; (v) The resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at the facility. For a resident who becomes eligible for Medicaid after admission to a nursing facility, the nursing facility may charge a resident only allowable charges under Medicaid; or (vi) The facility ceases to operate.Title 22 Section 72527 Patients' Rights: (a) Patients have the rights numerated in this section and the facility shall ensure 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 any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (6) To be transferred or discharged only for medical reasons, or the patient's welfare or that of other patient's or for nonpayment for his or her stay and to be given reasonable advance notice to ensure orderly transfer or discharge. Such actions shall be documented in the patient's health record. Title 22 Section 72519 Patient Transfer: (a) The licensee shall maintain written transfer agreements with other nearby health facilities to make the services of those facilities accessible and to facilitate the transfer of patients. Complete and accurate patient information, in sufficient detail to provide for continuity of care shall be transferred with the patient at time of transfer. (b) When a patient is transferred to another facility, the following shall be entered in the patient health record: (1) The date, time, condition of the patient and a written statement of the reason for the transfer. (2) Informed written or telephone acknowledgement of the patient, patient's guardian or authorized representative except in an emergency or as provided in Section 72527(a)(5). On 12/9/15 at 9:40 a.m., an unannounced visit was made to the facility to investigate anonymous complaint CA00468198 regarding the alleged violation of transfer and discharge rights. The facility failed to ensure Resident 19 was afforded the right to be transferred or discharged solely for medical reasons or for the resident's welfare, and to be given reasonable advance written notice to ensure a safe and orderly transfer or discharge. The facility transferred Resident 19 inorder to accommodate the alleged plan of a potential new owner to convert the facility to a subacute setting (a specialized type of nursing service provided to Residents who require complex care or rehabilitation). As a result, Resident 19 was displaced from her home and suffered emotional distress.Review of Resident 19's clinical record titled, "Face Sheet" indicated Resident 19 was admitted to the skilled nursing facility (SNF) 1 on 11/20/14 with a diagnosis of dementia (memory loss). Resident 19 was transferred from SNF 1 to SNF 2 on 12/8/15.On 12/9/15 at 9:40 a.m., during a tour of SNF 1, no residents were observed in the hallways, resident rooms or dining area in the West Wing of the facility. Four residents were observed sitting in the East Wing main dining room watching television. During a concurrent interview with the facility Interim Administrator (IA) the IA stated the current facility census was seven of 70 available beds licensed for skilled nursing residents. The IA stated the West Wing was closed. The IA stated three of the seven remaining residents were scheduled to transfer out of the facility later that day, 12/9/15, due to a "Change of ownership" of the facility. On 12/9/15 at 12:15 p.m., during a staff interview in the East Wing hallway, Licensed Nurse (LN) 1 stated residents who resided in the facility were transferred out of the facility due to new ownership expected to take place in the near future. LN 1 stated all residents had to transfer out of the facility. LN 1 stated the new owner planned to run a facility that did not include long term care skilled nursing residents. LN 1 stated most residents that transferred were sad and did not want to leave as the facility had been their home for a long time. On 12/9/15 at 1:30 p.m., during an interview with the Social Services Director (SSD) in the social services office, the SSD stated some of the residents who were transferred did not want to transfer to a different facility because they lived at SNF 1 for a long time. The SSD stated those residents were concerned prior to the transfer as to what would happen to them when the new owner took ownership of the facility. On 12/9/15 at 4:18 p.m., during an interview in the Administrator's office, the IA stated the facility did not provide any resident (including Resident 19) that was transferred since 6/1/15 a 30 day advance written notice that included the intent to transfer, the reason for the pending transfer or discharge or the right to appeal the transfer or discharge. The IA stated, "We didn't do those." Review of the facility's administrative policy titled "California Standard Admission Agreement for Skilled Nursing Facilities and Intermediate Care Facilities" pages eight to nine, dated May 2011 provided to all SNF 1 residents on admission indicated, "VI. Transfers and Discharges...Our written notice of transfer to another facility or discharge against your wishes will be provided 30 days in advance...Our written notice will include the effective day, the location to which you will be transferred or discharged, and the reason the action is necessary. The only reason that we can transfer you to another facility or discharge you against your wishes are: 1) It is required to protect your well-being because your needs cannot be met in our facility; 2) It is appropriate because your health has improved enough that you no longer need the services of our Facility; 3) Your presence in our Facility endangers the health and safety of other individuals; 4) You have not paid for your stay in our Facility or have not arranged to have payment made under Medicare, Medi-Cal, or private insurance; 5) Our Facility ceases to operate; 6) Material or fraudulent misrepresentation of your finances to us... In our written notice, we will advise you that you have the right to appeal the transfer or discharge to the California Department of Health Care Services, and we will also provide the name, address and telephone number of the State Long-Term Care Ombudsman."On 12/16/15 at 3 p.m., during a staff interview, the SSD stated she had worked for SNF 1 for the past seven years. The SSD stated the facility process for discharging residents had begun to change in April 2015. The SSD stated she had been assigned the responsibility to coordinate the discharge of the residents in the facility. The SSD stated that responsibility had previously been a nursing service responsibility. The SSD stated in June 2015 the Clinical Nurse Liaison (CNL) began to assist her with the discharge of residents. She stated the CNL facilitated discharges of residents to other company-owned skilled nursing facilities. The SSD stated when approached by families or residents she had discussed the pending transition, and informed the residents or/and their families the residents could remain at the facility or seek placement before the transition was set to occur, but she could not speak to what would occur after the business was sold. The SSD stated families were given the instruction discharge of the residents was inevitable sooner or later as the type of patients accepted would change to those who required more complex care than was provided in SNF 1. The SSD stated the residents were "fast tracked" to discharge as part of the change in the process. She stated, "The majority of families wanted to seek placement out of fear, not knowing what was going to happen...how could they not be [fearful]? As an employee it was very difficult...they [the facility] were not communicating properly...I felt pressured...that's been very stressful."On 12/17/15 at 7:30 a.m., during an interview, the CNL stated her role at SNF 1 during the transition of ownership was to assist with the discharge of residents from the facility. The CNL stated she learned of an ownership transition in a staff meeting and received direction from the Regional Director of Operations (RDO) to discharge residents. She stated, "I wasn't aware of the regulations...I was stuck in between...it's been a nightmare." The CNL stated, "If they [the residents] asked [what would happen to them], we told them about the change of ownership...don't know when it's going to happen...there was the feeling of uncertainty." Resident 19's clinical record titled, "MDS (Minimum Data Set) (a resident assessment tool that measures resident cognitive and physical functional abilities) 3.0 Assessment," dated 10/15/15, indicated under Cognitive (pertaining to comprehension, memory and reasoning ability) Patterns the summary score of 3/15, which indicated severe cognitive impairment. Resident 19's MDS assessment indicated Resident 19 was unable to state the correct month, day, or year, and had no recall ability. Resident 19's Interdisciplinary Team (IDT) (a resident care team including nursing, dietary, social services and activity staff) Care Plan Conference Review notes dated 10/23/15, indicated, "...Resident son [Responsible Party (RP) 9] asked IDT about facility upcoming transition. Son stated he heard about it from a relative that works in the medical field/community. Son requested to start actively seeking discharge." The note was signed by the Social Services Director (SSD). Quarterly Social Services Discharge Planning Note dated 10/23/15 indicated under Discharge Plans or Discharge Barriers Reviewed with Resident [19], "No.Under Discharge Imminent? the note indicated, "No." The note was signed by the SSD on 10/29/15. Review of Resident 19's clinical record titled, "Transfer/Discharge Summary," dated 12/8/15, contained an area to document, "Reason for Transfer/Discharge." A box indicated, "Other, Please Explain" was the single box checked, and "Long term" was written on the line next to the box. There was no documented rationale for the transfer to SNF 2 indicated on the form.Resident 19's Social Service Note dated 12/8/15, indicated, "Resident discharged on 12/8/15 to [SNF 2]...Resident discharged with sons by car..." SNF 2 Nurses Note dated 12/11/15 at 3:54 p.m., indicated,"... [Resident 19] Responsive and alert, with confusion, oriented X [times] 1 [person only]. Cooperative with care, able to verbalize her needs to staff.....Needs minimal assistance with transfers...self- sufficient when in wheelchair...able to feed self..." A SNF 1 Social Services Note dated 12/16/15, (8 days after discharge) indicated, "...SSD spoke with RP [Responsible Party]...stated resident is adjusting well at [SNF 2]. Resident was getting a room change today due to not liking [residing in the]center bed. Resident has been recognizing some of our staff that are now working there. RP had no concerns. RP and spouse by phone very thankful for all SSD help and stated this was a good move..." On 12/20/15 at 2 p.m., during an interview, SNF 2 Admissions Coordinator (AC) 2 stated SNF 1 sent Resident 19's admission request information to SNF 2 on 12/6/15, and she was admitted 12/8/15 at 10 a.m. She stated the family transported the resident in a personal vehicle.On 12/29/15 at 4 p.m., during an interview, SNF 2 Certified Nurse Assistant (CNA) 3 stated she had provided care to Resident 19. On inquiry, she stated, "She's a very nice lady but is very confused...she keeps to herself...eats in her room...doesn't participate in activities...she can't even get to the shower." On 1/5/16 at 4:30 p.m., during an interview, RP 9 stated he was notified by SNF 1 staff the facility had been sold and Resident 19 had to move. RP 9 stated he was unhappy; Resident 19 was comfortable at SNF 1, and felt she had been "Kicked out." RP 9 stated he asked the SNF 1 SSD "What do we do now?" RP 9 stated he was initially informed Resident 19 was to transfer to SNF 3 which was over 50 miles away from SNF 1. RP 9 stated he refused that transfer and was worried where Resident 19 would go. RP 9 stated he was notified of the transfer to SNF 2 on 12/7/15 and Resident 19 was transferred on 12/8/15, within 24 hours. RP 9 stated when SNF 1 attempted to transport Resident 19 by ambulance to SNF 2; she was upset and refused to go. RP 9 stated he transported Resident 19 in his personal vehicle because she would not go without him. When asked how the resident had adjusted to SNF 2, he stated, "All in all [Resident 19] is doing much worse, and is more mentally distressed since the transfer." He stated during a recent holiday visit, the resident told him SNF 2 was not her home, and she wanted to go home. RP 9 stated Resident 19 referred to SNF 1 as her home. He further stated, "It's sad the way they treat the elderly...at [SNF 1] she was able to have her stuff out...but now she doesn't have the space." RP 9 further stated Resident 19 is more confused, no longer watches television, an activity she liked to do at SNF 1, and stated she didn't seem content.On 1/7/16 at 3:40 p.m., during an interview, SNF 1 SSD stated RP 9 had expressed concern regarding the sale of SNF 1 and what type of facility it would become. The SSD stated she told RP 9 what she knew, that it would be a post- acute facility. She stated, "That worried him." The SSD stated the SNF 1IDT had not met prior to Resident 19's transfer to discuss whether it was a safe and appropriate transfer and the discharge care plan was not updated for the transfer to SNF 2. The SSD stated SNF 2 did not provide any additional services to Resident 19 that could not be provided at SNF 1. The SSD stated a 30 day notice of transfer that included the reason for transfer, the date of transfer, the location of the transfer, the right to appeal the transfer and the name and phone number of the state ombudsman had not been provided to Resident 19 or to RP 9. Therefore, the facility failed to honor and protect Resident 19's transfer and discharge rights. Resident 19 was transferred without ensuring the necessity to meet her medical or welfare needs and without reasonable notice and as a result experienced emotional and psychological stress.These violations had a direct relationship to Resident 19's health, safety and security and thus constitute a Class B Citation. |
| 100000026 |
Valley Subacute & Rehabilitation Center |
040012091 |
B |
16-Mar-16 |
FZRR11 |
14506 |
42 Code of Federal Regulations Section 483.12(a)(2) Transfer and discharge requirements:The facility must permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless- (i) The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility; (ii) The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility; (iii) The safety of individuals in the facility is endangered; (iv) The health of individuals in the facility would otherwise be endangered; (v) The resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at the facility. For a resident who becomes eligible for Medicaid after admission to a nursing facility, the nursing facility may charge a resident only allowable charges under Medicaid; or (vi) The facility ceases to operate.Title 22 Section 72527 Patients' Rights: (a) Patients have the rights numerated in this section and the facility shall ensure 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 any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (6) To be transferred or discharged only for medical reasons, or the patient's welfare or that of other patient's or for nonpayment for his or her stay and to be given reasonable advance notice to ensure orderly transfer or discharge. Such actions shall be documented in the patient's health record. Title 22 Section 72519 Patient Transfer: (a) The licensee shall maintain written transfer agreements with other nearby health facilities to make the services of those facilities accessible and to facilitate the transfer of patients. Complete and accurate patient information, in sufficient detail to provide for continuity of care shall be transferred with the patient at time of transfer. (b) When a patient is transferred to another facility, the following shall be entered in the patient health record: (1) The date, time, condition of the patient and a written statement of the reason for the transfer. (2) Informed written or telephone acknowledgement of the patient, patient's guardian or authorized representative except in an emergency or as provided in Section 72527(a)(5). On 12/9/15 at 9:40 a.m., an unannounced visit was made to the facility to investigate anonymous complaint CA00468198 regarding the alleged violation of transfer and discharge rights. The facility failed to ensure Resident 20 was afforded the right to be transferred or discharged solely for medical reasons or for the resident's welfare, and to be given reasonable advance written notice to ensure a safe and orderly transfer or discharge. The facility transferred Resident 20 in order to accommodate the alleged plan of a potential new owner to convert the facility to a subacute setting (a specialized type of nursing service provided to Residents who require complex care or rehabilitation).As a result, Resident 20 suffered psychological and emotional distress.Review of Resident 20's clinical record titled, "Face Sheet" indicated Resident 20 was admitted to the skilled nursing facility (SNF) 1 on 3/25/09 with diagnoses of chronic obstructive pulmonary disease (lung disease), heart disease, and anxiety. Resident 20 was transferred from SNF 1 to SNF 9 on 9/25/15.On 12/9/15 at 9:40 a.m., during a tour of SNF 1, no residents were observed in the hallways, resident rooms or dining area in the West Wing of the facility. Four residents were observed sitting in the East Wing main dining room watching television. During a concurrent interview with the facility Interim Administrator (IA) the IA stated the current facility census was seven of 70 available beds licensed for skilled nursing residents. The IA stated the West Wing was closed. The IA stated three of the seven remaining residents were scheduled to transfer out of the facility later that day, 12/9/15, due to a "Change of ownership" of the facility. On 12/9/15 at 12:15 p.m., during a staff interview in the East Wing hallway, Licensed Nurse (LN) 1 stated residents who resided in the facility were transferred out of the facility due to new ownership expected to take place in the near future. LN 1 stated all residents had to transfer out of the facility. LN 1 stated the new owner planned to run a facility that did not include long term care skilled nursing residents. LN 1 stated most residents that transferred were sad and did not want to leave as the facility had been their home for a long time.On 12/9/15 at 1:30 p.m., during an interview with the Social Services Director (SSD) in the social services office, the SSD stated some of the residents who were transferred did not want to transfer to a different facility because they lived at SNF 1 for a long time. The SSD stated those residents were concerned prior to the transfer as to what would happen to them when the new owner took ownership of the facility. On 12/9/15 at 4:18 p.m., during an interview in the Administrator's office, the IA stated the facility had not provided any resident (including Resident 20) that was transferred since 6/1/15 a 30 day advance written notice that included the intent to transfer, the reason for the pending transfer or discharge or the right to appeal the transfer or discharge. The IA stated, "We didn't do those." Review of the facility's administrative policy titled "California Standard Admission Agreement for Skilled Nursing Facilities and Intermediate Care Facilities" pages eight to nine, dated May 2011 provided to all SNF 1 residents on admission indicated, "VI. Transfers and Discharges...Our written notice of transfer to another facility or discharge against your wishes will be provided 30 days in advance...Our written notice will include the effective day, the location to which you will be transferred or discharged, and the reason the action is necessary. The only reason that we can transfer you to another facility or discharge you against your wishes are: 1) It is required to protect your well-being because your needs cannot be met in our facility; 2) It is appropriate because your health has improved enough that you no longer need the services of our Facility; 3) Your presence in our Facility endangers the health and safety of other individuals; 4) You have not paid for your stay in our Facility or have not arranged to have payment made under Medicare, Medi-Cal, or private insurance; 5) Our Facility ceases to operate; 6) Material or fraudulent misrepresentation of your finances to us... In our written notice, we will advise you that you have the right to appeal the transfer or discharge to the California Department of Health Care Services, and we will also provide the name, address and telephone number of the State Long-Term Care Ombudsman."On 12/16/15 at 3 p.m., during a staff interview, the SSD stated she had worked for SNF 1 for the past seven years. The SSD stated the facility process for discharging residents had begun to change in April 2015. The SSD stated she had been assigned the responsibility to coordinate the discharge of the residents in the facility. The SSD stated that responsibility had previously been a nursing service responsibility. The SSD stated in June 2015 the Clinical Nurse Liaison (CNL) began to assist her with the discharge of residents. She stated the CNL facilitated discharges of residents to other company-owned skilled nursing facilities. The SSD stated when approached by families or residents she had discussed the pending transition, and informed the residents or/and their families the residents could remain at the facility or seek placement before the transition was set to occur, but she could not speak to what would occur after the business was sold. The SSD stated families were given the instruction discharge of the residents was inevitable sooner or later as the type of patients accepted would change to those who required more complex care than was provided in SNF 1. The SSD stated the residents were "fast tracked" to discharge as part of the change in the process. She stated, "The majority of families wanted to seek placement out of fear, not knowing what was going to happen...how could they not be [fearful]? As an employee it was very difficult...they [the facility] were not communicating properly...I felt pressured...that's been very stressful."On 12/17/15 at 7:30 a.m., during an interview, the CNL stated her role at SNF 1 during the transition of ownership was to assist with the discharge of residents from the facility. The CNL stated she learned of an ownership transition in a staff meeting and received direction from the Regional Director of Operations (RDO) to discharge residents. She stated, "I wasn't aware of the regulations...I was stuck in between...it's been a nightmare." The CNL stated, "If they [the residents] asked [what would happen to them], we told them about the change of ownership...don't know when it's going to happen...there was the feeling of uncertainty." Resident 20's SNF 1 Nurses Note dated 9/16/15 at 11:07 p.m., indicated, "Resident [20] c/o [complaining of] chest pain and SOB [shortness of breath].....resident was sent to [Hosp 2] at [8:05p.m.] for evaluation....Bed hold in place." Resident 20's Quarterly Social Services (SS) Discharge Planning Note dated 9/22/15, (the day of readmission), indicated under Discharge Plans or Discharge Barriers Reviewed with Resident, it indicated, "Yes." Under Discharge Imminent it indicated, "No."A SNF 1 SS Note dated 9/23/15 at 2:07 p.m., indicated, "Social Services re-admit note: Resident was re-admitted to [SNF 1] on 9/22/15....Resident discharge plan is anticipated long term care. Resident is incapable of living independently at home. Resident is her own responsible party..."A SNF 1 SS Note dated 9/24/15 at 4:46 p.m., indicated, "Social Service pre-discharge note: Resident was made aware in Acute Hospital of [SNF 1] changes and wishe[s] to be transfer[red] to [SNF 9] due to having availability for long term care bed. SSD left son a message to inform him....Discharge is anticipated on 9/25/15 at 10 am... [Vendor] transport setup. All staff notified." Resident 20's SNF 1 Physician Communication Fax (facsimile) Request dated 9/24/15, indicated under Request, "Resident discharging on 9/25/15 to [SNF 9]." Under MD (Medical Doctor) Response it indicated, "Approved." The document was signed and dated 9/25/15 by MD 1. Resident 20's SNF 1 Transfer/Discharge Summary-Post Discharge Plan of Care dated 9/25/15 indicated a hand entered pen stroke next to "Resident needs SMF [skilled medical facility]/Hospital care," indicating the reason for Transfer/Discharge. There was no documented rationale for the transfer to SNF 9 on the form. A SNF 1 SS Note dated 9/28/15 at 12:18 p.m., indicated, "Social Service discharge note: Resident was discharged on 9/25/15 to [SNF 9]....[SNF 1] assisted resident by delivering her belongings to new facility due to son unable to do it..." Resident 20's SNF 1 SS Note dated 9/28/15 at 12:27 p.m., indicated, "...Resident is adjusting well to new facility. No concerns at this time."Resident 20's SNF 9 admission "MDS (Minimum Data Set) (an assessment tool to assess a residents cognitive and physical functional abilities) 3.0 Assessment" dated 10/2/15, indicated under Cognitive (pertaining to comprehension, memory and reasoning ability) Patterns the summary score of 15 of 15 possible, which indicated she was cognitively intact. On 12/31/15 at 11:25 a.m., during an interview in SNF 9, Resident 20 stated, "They [SNF 1] told us we had to leave...everybody was up in the air for two months...nobody knew what was going on...nobody could tell us anything." Resident 20 stated she was notified of her transfer by the SNF 1 SSD, and stated, "They came to me in my room. They needed to move all long term residents out. They sold it [SNF 1] and was shutting down...I had to sign a paper that I agreed, but everyone knew we were going to have to leave." On inquiry regarding whether she had visited SNF 9 prior to discharge, she stated, "No, it was too fast." When asked if she wanted to return to SNF 1 she stated, "In a heartbeat. I had 6 years- worth of friends there...staying there would have been nice." On inquiry regarding her personal items, she stated she lost her wheelchair in the move, "Someone mislabeled it...it wasn't on the inventory."On 12/31/15 at 11:45 a.m., during an interview, the SNF 9 Nursing Supervisor (NS) 1 stated Resident 20 did not participate in SNF 9 activities, and ate all meals in her room. NS 1 stated the resident had expressed concern about her missing wheelchair. On 1/8/16 at 10:45 a.m., during an interview, SNF 1 SSD stated, "[Resident 20] called me to her room. I told her they were selling the building and [Hosp 1] was taking over...we didn't know when...what their process would be...I didn't know so I couldn't tell her...she was anxious about it..." On inquiry why the resident's concerns were not documented in the clinical record, she stated she was not sure why. The SSD stated the SNF 1 Interdisciplinary Team (IDT) (a resident care team including nursing, dietary, social services and activity staff) had not met prior to Resident 20's transfer to discuss whether it was a safe and appropriate transfer and the discharge care plan was not updated to plan for the transfer to SNF 9. The SSD stated SNF 9 did not provide any care for Resident 20 that SNF 1 could not provide. The SSD stated a 30 day notice of transfer that included the reason for transfer, the date of transfer, the location of the transfer, the right to appeal the transfer and the name and phone number of the state ombudsman was not provided to Resident 20. Therefore, the facility failed to honor and protect Resident 20's transfer and discharge rights. Resident 20 was transferred to SNF 9 without ensuring the necessity to meet her medical or welfare needs and without reasonable notice and as a result Resident 20 experienced loss of friendships and emotional and psychological distress.These violations had a direct relationship to Resident 20's health, safety and security and thus constitute a Class B Citation. |
| 100000026 |
Valley Subacute & Rehabilitation Center |
040012092 |
B |
16-Mar-16 |
FZRR11 |
13608 |
42 Code of Federal Regulations Section 483.12(a)(2) Transfer and discharge requirements:The facility must permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless- (i) The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility; (ii) The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility; (iii) The safety of individuals in the facility is endangered; (iv) The health of individuals in the facility would otherwise be endangered; (v) The resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at the facility. For a resident who becomes eligible for Medicaid after admission to a nursing facility, the nursing facility may charge a resident only allowable charges under Medicaid; or (vi) The facility ceases to operate.Title 22 Section 72527 Patients' Rights: (a) Patients have the rights numerated in this section and the facility shall ensure 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 any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (6) To be transferred or discharged only for medical reasons, or the patient's welfare or that of other patient's or for nonpayment for his or her stay and to be given reasonable advance notice to ensure orderly transfer or discharge. Such actions shall be documented in the patient's health record. Title 22 Section 72519 Patient Transfer: (a) The licensee shall maintain written transfer agreements with other nearby health facilities to make the services of those facilities accessible and to facilitate the transfer of patients. Complete and accurate patient information, in sufficient detail to provide for continuity of care shall be transferred with the patient at time of transfer. (b) When a patient is transferred to another facility, the following shall be entered in the patient health record: (1) The date, time, condition of the patient and a written statement of the reason for the transfer. (2) Informed written or telephone acknowledgement of the patient, patient's guardian or authorized representative except in an emergency or as provided in Section 72527(a)(5). On 12/9/15 at 9:40 a.m., an unannounced visit was made to the facility to investigate anonymous complaint CA00468198 regarding the alleged violation of transfer and discharge rights. The facility failed to ensure Resident 21 was afforded the right to be transferred or discharged solely for medical reasons or for the resident's welfare, and to be given reasonable advance written notice to ensure a safe and orderly transfer or discharge. The facility transferred Resident 21 in order to accommodate the alleged plan of a potential new owner to convert the facility to a subacute setting (a specialized type of nursing service provided to residents who require complex care or rehabilitation). As a result, Resident 21 suffered loneliness, and emotional and psychological distress.Review of Resident 21's clinical record titled, "Face Sheet" indicated Resident 21 was admitted to the skilled nursing facility (SNF) 1 on 6/5/14, with diagnoses of dementia (memory loss), enterocolitis (inflammation of the small and large intestine), kidney disease, chronic obstructive pulmonary disease (lung disease) and malignant neoplasm (cancerous tumor). Resident 21 was transferred to SNF 2 on 11/11/15. On 12/9/15 at 9:40 a.m., during a tour of SNF 1, no residents were observed in the hallways, resident rooms or dining area in the West Wing of the facility. Four residents were observed sitting in the East Wing main dining room watching television. During a concurrent interview with the facility Interim Administrator (IA) the IA stated the current facility census was seven of 70 available beds licensed for skilled nursing residents. The IA stated the West Wing was closed. The IA stated three of the seven remaining residents were scheduled to transfer out of the facility later that day, 12/9/15, due to a "Change of ownership" of the facility. On 12/9/15 at 12:15 p.m., during a staff interview in the East Wing hallway, Licensed Nurse (LN) 1 stated residents who resided in the facility were transferred out of the facility due to new ownership expected to take place in the near future. LN 1 stated all residents had to transfer out of the facility. LN 1 stated the new owner planned to run a facility that did not include long term care skilled nursing residents. LN 1 stated most residents that transferred were sad and did not want to leave as the facility had been their home for a long time.On 12/9/15 at 1:30 p.m., during an interview with the Social Services Director (SSD) in the social services office, the SSD stated some of the residents who were transferred did not want to transfer to a different facility because they lived at SNF 1 for a long time. The SSD stated those residents were concerned prior to the transfer as to what would happen to them when the new owner took ownership of the facility.On 12/9/15 at 4:18 p.m., during an interview in the Administrator's office, the IA stated the facility had not provided any resident (including Resident 21or his Responsible Party) that was transferred since 6/1/15 a 30 day advance written notice that included the intent to transfer, the reason for the pending transfer or discharge or the right to appeal the transfer or discharge. The IA stated, "We didn't do those." Review of the facility's administrative policy titled, "California Standard Admission Agreement for Skilled Nursing Facilities and Intermediate Care Facilities" pages eight to nine, dated May 2011, provided to all SNF 1 residents on admission indicated, "VI. Transfers and Discharges...Our written notice of transfer to another facility or discharge against your wishes will be provided 30 days in advance...Our written notice will include the effective day, the location to which you will be transferred or discharged, and the reason the action is necessary. The only reason that we can transfer you to another facility or discharge you against your wishes are: 1) It is required to protect your well-being because your needs cannot be met in our facility; 2) It is appropriate because your health has improved enough that you no longer need the services of our Facility; 3) Your presence in our Facility endangers the health and safety of other individuals; 4) You have not paid for your stay in our Facility or have not arranged to have payment made under Medicare, Medi-Cal, or private insurance; 5) Our Facility ceases to operate; 6) Material or fraudulent misrepresentation of your finances to us... In our written notice, we will advise you that you have the right to appeal the transfer or discharge to the California Department of Health Care Services, and we will also provide the name, address and telephone number of the State Long-Term Care Ombudsman."On 12/16/15 at 3 p.m., during a staff interview, the SSD stated she had worked for SNF 1 for the past seven years. The SSD stated the facility process for discharging residents had begun to change in April 2015. The SSD stated she had been assigned the responsibility to coordinate the discharge of the residents in the facility. The SSD stated that responsibility had previously been a nursing service responsibility. The SSD stated in June 2015 the Clinical Nurse Liaison (CNL) began to assist her with the discharge of residents. She stated the CNL facilitated discharges of residents to other company-owned skilled nursing facilities. The SSD stated when approached by families or residents she had discussed the pending transition, and informed the residents or/and their families the residents could remain at the facility or seek placement before the transition was set to occur, but she could not speak to what would occur after the business was sold. The SSD stated families were given the instruction discharge of the residents was inevitable sooner or later as the type of patients accepted would change to those who required more complex care than was currently provided in SNF 1. The SSD stated the residents were "fast tracked" to discharge as part of the change in the process. She stated, "The majority of families wanted to seek placement out of fear, not knowing what was going to happen...how could they not be [fearful]? As an employee it was very difficult...they [the facility] were not communicating properly...I felt pressured...that's been very stressful."On 12/17/15 at 7:30 a.m., during an interview, the CNL stated her role at SNF 1 during the transition of ownership was to assist with the discharge of residents from the facility. The CNL stated she learned of an ownership transition in a staff meeting and received direction from the Regional Director of Operations (RDO) to discharge residents. She stated, "I wasn't aware of the regulations...I was stuck in between...it's been a nightmare." The CNL stated, "If they [the residents] asked [what would happen to them], we told them about the change of ownership...don't know when it's going to happen...there was the feeling of uncertainty." Resident 21's clinical record titled "MDS (Minimum Data Set) (an assessment tool to assess a residents cognitive and physical functional abilities) 3.0 Assessment," dated 5/29/15, indicated under Cognitive (pertaining to comprehension, memory and reasoning ability) Patterns the summary score of 5 of 15 possible, which indicated severely impaired cognition. Resident 21's Quarterly Social Services Discharge Planning Note dated 7/4/14, indicated under Barriers to Discharge Goals, "Resident is incapable of living independently." Under Discharge Imminent, it was marked, "No." Resident 21's Social Service (SS) Note dated 11/11/15 at 3:40 p.m., indicated, "...Resident discharged on 11/11/15 to [SNF 2], transport setup belongings delivered to [SNF 2] by SNF 1 staff. Family visited [SNF 2] prior to discharge...." Review of Resident 21's SNF 1 clinical record titled, "Transfer/Discharge Summary" dated 11/11/15 contained an area to document "Reason for Transfer/Discharge" which was left blank. No rationale for the transfer to SNF 2 was provided in the summary.Resident 212's SS Note dated 11/16/15 at 8:56 a.m., indicated, "Social Services discharge follow up note: Resident is adjusting well at [SNF 2]. No concerns at this time." Resident 21's SNF 2 Nurses Note dated 11/12/15 at 6:37 p.m., indicated, "Resident [21].....A&O x 3 [alert and oriented to person, place and time]. Able to verbalize needs...."On 12/30/15 at 2:15 p.m., during an interview, the SNF 2 Admissions Coordinator (AC) 2 stated Resident 21's clinical admission information was faxed to SNF 2 on 10/26/15, and he arrived on 11/11/15 by ambulance. On 1/5/16 at 8:30 a.m., during an interview, Resident 21's Responsible Party (RP) 10 stated she was told by SNF 1 staff that the facility was sold and all residents needed to find a new placement. RP 10 stated she began making phone calls to secure another home for Resident 21. RP 10 further stated she came to SNF 1 on several occasions, worried about what would transpire for Resident 21. RP 10 stated she understood a new company would be caring for a different type of resident, and the facility needed to remodel. She stated when Resident 21 was transferred to SNF 2 she accompanied the resident, but the transfer scared the resident. RP 10 stated after Resident 21's transfer, he lost track of time, he was lonely, and missed his friends. RP 10 stated Resident 21 received physical therapy at SNF 1, but at SNF 2 he was no longer receptive to therapy, and became weaker since admission.On 1/8/16 at 8:20 a.m., during a concurrent staff interview and clinical record review with the SSD in the social services office at SNF 1, the SSD stated the SNF 1 Interdisciplinary Team (IDT) (a resident care team including nursing, dietary, social services and activity staff) had not met prior to Resident 21's transfer to SNF 2 to discuss whether it was a safe and appropriate transfer, and the discharge care plan was not updated to plan for the transfer to SNF 2. The SSD produced the Social Services Note dated 11/11/15, and stated no other transfer related notes were present in Resident 21's clinical record. On inquiry regarding the reason for Resident 21's transfer, the SSD stated the resident's family was concerned about the SNF 1 transition, and requested assistance in transferring him elsewhere. The SSD stated SNF 2 did not offer Resident 21 any services that could not be provided at SNF 1. The SSD stated a 30 day notice of transfer that included the reason for transfer, the date of the transfer, the location of the transfer, the right to appeal the transfer and the name and phone number of the state ombudsman was not provided to Resident 21 or to RP 10. Therefore, the facility failed to honor and protect Resident 21's transfer and discharge rights. Resident 21 was transferred without ensuring the necessity to meet his medical or welfare needs and without reasonable notice and as a result suffered loneliness and emotional and psychological harm.These violations had a direct relationship to Resident 21's health, safety and security and thus constitute a Class B Citation. |
| 100000026 |
Valley Subacute & Rehabilitation Center |
040012094 |
B |
16-Mar-16 |
FZRR11 |
15858 |
42 Code of Federal Regulations Section 483.12(a)(2) Transfer and discharge requirements:The facility must permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless- (i) The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility; (ii) The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility; (iii) The safety of individuals in the facility is endangered; (iv) The health of individuals in the facility would otherwise be endangered; (v) The resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at the facility. For a resident who becomes eligible for Medicaid after admission to a nursing facility, the nursing facility may charge a resident only allowable charges under Medicaid; or (vi) The facility ceases to operate.Title 22 Section 72527 Patients' Rights: (a) Patients have the rights numerated in this section and the facility shall ensure 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 any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (6) To be transferred or discharged only for medical reasons, or the patient's welfare or that of other patient's or for nonpayment for his or her stay and to be given reasonable advance notice to ensure orderly transfer or discharge. Such actions shall be documented in the patient's health record. Title 22 Section 72519 Patient Transfer: (a) The licensee shall maintain written transfer agreements with other nearby health facilities to make the services of those facilities accessible and to facilitate the transfer of patients. Complete and accurate patient information, in sufficient detail to provide for continuity of care shall be transferred with the patient at time of transfer. (b) When a patient is transferred to another facility, the following shall be entered in the patient health record: (1) The date, time, condition of the patient and a written statement of the reason for the transfer. (2) Informed written or telephone acknowledgement of the patient, patient's guardian or authorized representative except in an emergency or as provided in Section 72527(a)(5). On 12/9/15 at 9:40 a.m., an unannounced visit was made to the facility to investigate anonymous complaint CA00468198 regarding the alleged violation of transfer and discharge rights. The facility failed to ensure Resident 22 was afforded the right to be transferred or discharged solely for medical reasons or for the resident's welfare, and to be given reasonable advance written notice to ensure a safe and orderly transfer or discharge. The facility transferred Resident 22 in order to accommodate the alleged plan of a potential new owner to convert the facility to a subacute setting (a specialized type of nursing service provided to Residents who require complex care or rehabilitation). As a result, Resident 22 suffered psychological and emotional distress.Review of Resident 22's clinical record titled, "Face Sheet" indicated Resident 22 was admitted to the skilled nursing facility (SNF) 1 on 9/3/09, with diagnoses of heart disease, arthritis, acute embolism (a blocked artery, usually by blood clot or air bubble) and depression. Resident 22 was transferred to SNF12 on 10/23/15. On 12/9/15 at 9:40 a.m., during a tour of SNF 1, no residents were observed in the hallways, resident rooms or dining area in the West Wing of the facility. Four residents were observed sitting in the East Wing main dining room watching television. During a concurrent interview with the facility Interim Administrator (IA) the IA stated the current facility census was seven of 70 available beds licensed for skilled nursing residents. The IA stated the West Wing was closed. The IA stated three of the seven remaining residents were scheduled to transfer out of the facility later that day, 12/9/15, due to a "Change of ownership" of the facility. On 12/9/15 at 12:15 p.m., during a staff interview in the East Wing hallway, Licensed Nurse (LN) 1 stated residents who resided in the facility were transferred out of the facility due to new ownership expected to take place in the near future. LN 1 stated all residents had to transfer out of the facility. LN 1 stated the new owner planned to run a facility that did not include long term care skilled nursing residents. LN 1 stated most residents that transferred were sad and did not want to leave as the facility had been their home for a long time.On 12/9/15 at 1:30 p.m., during an interview with the Social Services Director (SSD) in the social services office, the SSD stated some of the residents who were transferred did not want to transfer to a different facility because they lived at SNF 1 for a long time. The SSD stated those residents were concerned prior to the transfer as to what would happen to them when the new owner took ownership of the facility. On 12/9/15 at 4:18 p.m., during an interview in the Administrator's office, the IA stated the facility had not provided any resident (including Resident 22 or his Responsible Party) that was transferred since 6/1/15 a 30 day advance written notice that included the intent to transfer, the reason for the pending transfer or discharge or the right to appeal the transfer or discharge. The IA stated, "We didn't do those." Review of the facility's administrative policy titled "California Standard Admission Agreement for Skilled Nursing Facilities and Intermediate Care Facilities" pages eight to nine, dated May 2011 provided to all SNF 1 residents on admission indicated, "VI. Transfers and Discharges...Our written notice of transfer to another facility or discharge against your wishes will be provided 30 days in advance...Our written notice will include the effective day, the location to which you will be transferred or discharged, and the reason the action is necessary. The only reason that we can transfer you to another facility or discharge you against your wishes are: 1) It is required to protect your well-being because your needs cannot be met in our facility; 2) It is appropriate because your health has improved enough that you no longer need the services of our Facility; 3) Your presence in our Facility endangers the health and safety of other individuals; 4) You have not paid for your stay in our Facility or have not arranged to have payment made under Medicare, Medi-Cal, or private insurance; 5) Our Facility ceases to operate; 6) Material or fraudulent misrepresentation of your finances to us... In our written notice, we will advise you that you have the right to appeal the transfer or discharge to the California Department of Health Care Services, and we will also provide the name, address and telephone number of the State Long-Term Care Ombudsman."On 12/16/15 at 3 p.m., during a staff interview, the SSD stated she had worked for SNF 1 for the past seven years. The SSD stated the facility process for discharging residents had begun to change in April 2015. The SSD stated she had been assigned the responsibility to coordinate the discharge of the residents in the facility. The SSD stated that responsibility had previously been a nursing service responsibility. The SSD stated in June 2015 the Clinical Nurse Liaison (CNL) began to assist her with the discharge of residents. She stated the CNL facilitated discharges of residents to other company-owned skilled nursing facilities. The SSD stated when approached by families or residents she had discussed the pending transition, and informed the residents or/and their families the residents could remain at the facility or seek placement before the transition was set to occur, but she could not speak to what would occur after the business was sold. The SSD stated families were given the instruction discharge of the residents was inevitable sooner or later as the type of patients accepted would change to those who required more complex care than was currently provided in SNF 1. The SSD stated the residents were "fast tracked" to discharge as part of the change in the process. She stated, "The majority of families wanted to seek placement out of fear, not knowing what was going to happen...how could they not be [fearful]? As an employee it was very difficult...they [the facility] were not communicating properly...I felt pressured...that's been very stressful."On 12/17/15 at 7:30 a.m., during an interview, the CNL stated her role at SNF 1 during the transition of ownership was to assist with the discharge of residents from the facility. The CNL stated she learned of an ownership transition in a staff meeting and received direction from the Regional Director of Operations (RDO) to discharge residents. She stated, "I wasn't aware of the regulations...I was stuck in between...it's been a nightmare." The CNL stated, "If they [the residents] asked [what would happen to them], we told them about the change of ownership...don't know when it's going to happen...there was the feeling of uncertainty." Resident 22's clinical record titled, "MDS (Minimum Data Set) (an assessment tool to assess a residents cognitive and physical functional abilities) 3.0 Assessment," dated 9/22/15, indicated under Cognitive (pertaining to comprehension, memory and reasoning ability) Patterns a summary score of 8 out of 15 possible, which indicated he was moderately impaired, oriented to the day of the week only, with limited recall. Under Mood, his PHQ-9 (a validated interview that screens for symptoms of depression) Severity score was 8 out of 27 possible, which indicated he was mildly depressed. Under Functional Status it indicated he required assistance to transfer and walk in his room, and required extensive assistance to dress, and for personal hygiene. Under Bathing it indicated he was totally dependent, and required one person physical assistance.Resident 22's Social Service (SS) Note dated 8/24/15 at 3:54p.m, indicated "Resident discharge plan is anticipated Long Term Care. Resident is incapable of living independently. Resident is alert and oriented with episodes of confusion, capable of making his needs known, speech clear, understands...Resident feeling tired or having little energy, having poor appetite...had persistent anger with self or others. Staff re-direct when behaviors [occur]. Resident has trouble sleeping or sleeps too much...Resident resists care at times..." An Interdisciplinary Team (IDT) Care Plan Conference Review dated 9/1/15, indicated, "...Resident attends some activities and continue[s] to preach on Sundays..." A Quarterly SS Discharge Planning Note dated 9/18/15, indicated under Discharge Imminent? "No." SS Note dated 10/20/15 at 4:46 p.m., indicated, "...Resident son [FM 8] met with SSD [Social Services Director] that he is actively seeking placement. [FM 8] is aware of transition of [SNF 1] and wants resident relocated. [FM 8] requested a nursing home list. SSD provided him with a list. FM requested for resident inquiry to be faxed to [7 SNF facilities]." The Physician Communication Fax (facsimile) Request dated 10/22/15, indicated under Request, "Resident discharge to [SNF 12] on 10/23/15."Resident 22's Transfer/Discharge Summary-Post Discharge Plan of Care, dated 10/23/15, indicated under Reason For Transfer/Discharge, "Resident/Family Request." Under Skin Assessment Comments it indicated, "Periorbital Cellulitis [infection of the eyelid and soft tissues with swelling and redness)." Under Patient/Responsible Party signature line it stated, "Verbal consent per RP [Responsible Party] [name]."Resident 22's Nurse's Notes dated 10/23/15 at 12:09 p.m., indicated, "...Resident discharged on 10/23/15 to [SNF 12]." Resident 22's Nurse's Notes dated 10/23/15 at 12:22 p.m., indicated, "Resident left [SNF 1] via [vendor] transportation w/c [wheelchair] with all his belongings, no s/s [signs/symptoms] of distress." SNF 2 SS Note dated 10/26/15 at 8:30 a.m., indicated, "...SSD spoke with resident son [FM 8]. [FM 8] stated resident is adjusting to placement but doing well."On 12/29/15 at 1 p.m., during an observation and concurrent interview in Resident 22's room at SNF 12, Resident 22 was lying in bed, blankets pulled up to under his neck, watching television. Resident 22 stated he was informed by a Certified Nurse Assistant at SNF 1 that he had to leave because the facility was being sold. He stated he didn't like the situation but had no choice. He further stated he missed an eye appointment and a dental appointment during the transfer, and lost his razor cord. Resident 22 stated he moved to three different rooms since his transfer to SNF 12.On 12/29/15 at 1:20 p.m., during a staff interview at SNF 12, LN 9 stated she had provided care for Resident 22 during his stay at SNF 12. LN 9 stated Resident 22 did not socialize with other residents much, did not attend activities and ate all his meals in his room. LN 9 stated Resident 22 was confused at times and wandered around SNF 12.On 1/6/16 at 10 a.m., during an interview, Resident 22's Responsible Party (RP) 11 stated she was told by SNF 1 staff the facility was sold and they didn't want any long term residents there anymore. When asked who initiated the transfer, RP 11 stated it was not the family; the family was notified by SNF 1 staff that the resident had to leave. She stated SNF 1 provided a list of potential places, but the family located a facility for transfer.On 1/6/16 at 10:30 a.m., during a telephone interview, FM 8 stated the reason for Resident 22's discharge was to make way for a different kind of patient. FM 8 stated SNF 1 had been sold, and SNF 1 was moving all the residents out. FM 8 stated the family was given a deadline of September, then it was October, and then November, "The move was very disconcerting, not only for [Resident 22], but to the whole family...he was happy where he was [at SNF 1]." FM 8 stated the transfer to SNF 12 had been stressful for Resident 22. FM 8 further stated Resident 22 had access to a phone that he used when at SNF 1, and stated now it was a lot harder to find a phone for him. SNF 1 SS Note dated 1/6/16 at 3:22 P.M., indicated, "Nursing found resident's hearing aids that were in med cart. SSD drove over to [SNF 12] and delivered hearing aids and gave them to front desk on 1/5/16." On 1/8/16 at 11:35 a.m., during an interview and concurrent record review, the SNF 1 SSD stated the SNF 1 Interdisciplinary Team ( IDT) (a resident care team including nursing, dietary, social services and activity staff) had not met prior to Resident 22's transfer to assess if it was a safe and appropriate transfer. The SSD stated Resident 22's discharge care plan was not updated for the transfer to SNF 12. The SSD stated SNF 12 did not offer Resident 22 any services that could not be provided at SNF 1. The SSD stated a 30 day notice of transfer that included the reason for transfer, the date of transfer, the location transferring to, the right to appeal the transfer and the name and phone number of the state ombudsman was not provided to Resident 22 or to RP 11.Therefore, the facility failed to honor and protect Resident 22's transfer and discharge rights. Resident 22 was transferred without ensuring the necessity to meet his medical or welfare needs and without reasonable notice and as a result experienced emotional and psychological distress.These violations had a direct relationship to Resident 22's health, safety and security and thus constitute a Class B Citation. |
| 100000026 |
Valley Subacute & Rehabilitation Center |
040012095 |
B |
16-Mar-16 |
FZRR11 |
12690 |
42 Code of Federal Regulations Section 483.12(a)(2) Transfer and discharge requirements:The facility must permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless- (i) The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility; (ii) The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility; (iii) The safety of individuals in the facility is endangered; (iv) The health of individuals in the facility would otherwise be endangered; (v) The resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at the facility. For a resident who becomes eligible for Medicaid after admission to a nursing facility, the nursing facility may charge a resident only allowable charges under Medicaid; or (vi) The facility ceases to operate.Title 22 Section 72527 Patients' Rights: (a) Patients have the rights numerated in this section and the facility shall ensure 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 any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (6) To be transferred or discharged only for medical reasons, or the patient's welfare or that of other patient's or for nonpayment for his or her stay and to be given reasonable advance notice to ensure orderly transfer or discharge. Such actions shall be documented in the patient's health record. Title 22 Section 72519 Patient Transfer: (a) The licensee shall maintain written transfer agreements with other nearby health facilities to make the services of those facilities accessible and to facilitate the transfer of patients. Complete and accurate patient information, in sufficient detail to provide for continuity of care shall be transferred with the patient at time of transfer. (b) When a patient is transferred to another facility, the following shall be entered in the patient health record: (1) The date, time, condition of the patient and a written statement of the reason for the transfer. (2) Informed written or telephone acknowledgement of the patient, patient's guardian or authorized representative except in an emergency or as provided in Section 72527(a)(5). On 12/9/15 at 9:40 a.m., an unannounced visit was made to the facility to investigate anonymous complaint CA00468198 regarding the alleged violation of transfer and discharge rights. The facility failed to ensure Resident 23 was afforded the right to be transferred or discharged solely for medical reasons or for the resident's welfare, and to be given reasonable advance written notice to ensure a safe and orderly transfer or discharge. The facility transferred Resident 23 in order to accommodate the alleged plan of a potential new owner to convert the facility to a subacute setting (a specialized type of nursing service provided to residents who require complex care or rehabilitation). As a result, Resident 23 was transferred without adequate reason or advanced notice.Review of Resident 23's clinical record titled, "Face Sheet" indicated Resident 23 was admitted to the skilled nursing facility (SNF) 1 on 1/6/15 with diagnoses of depression, pneumonia, and chronic pain. Resident 23 was transferred to SNF 9 on 9/10/15. On 12/9/15 at 9:40 a.m., during a tour of SNF 1, no residents were observed in the hallways, resident rooms or dining area in the West Wing of the facility. Four residents were observed sitting in the East Wing main dining room watching television. During a concurrent interview with the facility Interim Administrator (IA) the IA stated the current facility census was seven of 70 available beds licensed for skilled nursing residents. The IA stated the West Wing was closed. The IA stated three of the seven remaining residents were scheduled to transfer out of the facility later that day, 12/9/15, due to a "Change of ownership" of the facility. On 12/9/15 at 12:15 p.m., during a staff interview in the East Wing hallway, Licensed Nurse (LN) 1 stated residents who resided in the facility were transferred out of the facility due to new ownership expected to take place in the near future. LN 1 stated all residents had to transfer out of the facility. LN 1 stated the new owner planned to run a facility that did not include long term care skilled nursing residents. LN 1 stated most residents that transferred were sad and did not want to leave as the facility was their home for a long time.On 12/9/15 at 1:30 p.m., during an interview with the Social Services Director (SSD) in the social services office, the SSD stated some of the residents who were transferred did not want to transfer to a different facility because they lived at SNF 1 for a long time. The SSD stated those residents were concerned prior to the transfer as to what would happen to them when the new owner took ownership of the facility.On 12/9/15 at 4:18 p.m., during an interview in the Administrator's office, the IA stated the facility had not provided any resident (including Resident 23) that was transferred since 6/1/15 a 30 day advance written notice that included the intent to transfer, the reason for the pending transfer or discharge or the right to appeal the transfer or discharge. The IA stated, "We didn't do those." Review of the facility's administrative policy titled, "California Standard Admission Agreement for Skilled Nursing Facilities and Intermediate Care Facilities" pages eight to nine, dated May 2011, provided to all SNF 1 residents on admission indicated, "VI. Transfers and Discharges...Our written notice of transfer to another facility or discharge against your wishes will be provided 30 days in advance...Our written notice will include the effective day, the location to which you will be transferred or discharged, and the reason the action is necessary. The only reason that we can transfer you to another facility or discharge you against your wishes are: 1) It is required to protect your well-being because your needs cannot be met in our facility; 2) It is appropriate because your health has improved enough that you no longer need the services of our Facility; 3) Your presence in our Facility endangers the health and safety of other individuals; 4) You have not paid for your stay in our Facility or have not arranged to have payment made under Medicare, Medi-Cal, or private insurance; 5) Our Facility ceases to operate; 6) Material or fraudulent misrepresentation of your finances to us... In our written notice, we will advise you that you have the right to appeal the transfer or discharge to the California Department of Health Care Services, and we will also provide the name, address and telephone number of the State Long-Term Care Ombudsman."On 12/16/15 at 3 p.m., during a staff interview, the SSD stated she had worked for SNF 1 for the past seven years. The SSD stated the facility process for discharging residents had begun to change in April 2011. The SSD stated she had been assigned the responsibility to coordinate the discharge of the residents in the facility. The SSD stated that responsibility had previously been a nursing service responsibility. The SSD stated in June 2011 the Clinical Nurse Liaison (CNL) began to assist her with the discharge of residents. She stated the CNL facilitated discharges of residents to other company-owned skilled nursing facilities. The SSD stated when approached by families or residents she had discussed the pending transition, and informed the residents or/and their families the residents could remain at the facility or seek placement before the transition was set to occur, but she could not speak to what would occur after the business was sold. The SSD stated families were given the instruction discharge of the residents was inevitable sooner or later as the type of patients accepted would change to those who required more complex care than was currently provided in SNF 1. The SSD stated the residents were "fast tracked" to discharge as part of the change in the process. She stated, "The majority of families wanted to seek placement out of fear, not knowing what was going to happen...how could they not be [fearful]? As an employee it was very difficult...they [the facility] were not communicating properly...I felt pressured...that's been very stressful."On 12/17/15 at 7:30 a.m., during an interview, the CNL stated her role at SNF 1 during the transition of ownership was to assist with the discharge of residents from the facility. The CNL stated she learned of an ownership transition in a staff meeting and received direction from the Regional Director of Operations (RDO) to discharge residents. She stated, "I wasn't aware of the regulations...I was stuck in between...it's been a nightmare." The CNL stated, "If they [the residents] asked [what would happen to them], we told them about the change of ownership...don't know when it's going to happen...there was the feeling of uncertainty." Resident 23's clinical record titled, "MDS (Minimum Data Set) (an assessment tool to assess a residents cognitive and physical functional abilities) 3.0 Assessment," dated 7/9/15, indicated under Cognitive (pertaining to comprehension, memory and reasoning ability) Patterns a summary score of 15 out of 15, which indicated she was cognitively intact. Under Functional Status, it indicated transfer and walking activity did not occur. Resident 23's Physician Communication Fax Request dated 6/9/15, indicated under Request; "Resident discharge on 9/10/15 to [SNF 9]." The request was signed by MD 1.Resident 23's Social Service (SS) Note dated 9/9/15 at 11:30 a.m., indicated, "Daughter/resident has requested for resident to discharge to [SNF 13 or SNF 9]......Resident excited to go." Resident 23's SS Note 9/10/15 at 2:20 p.m., indicated, "Resident discharged on 9/10/15 at 9 am with [vendor] transport to [SNF 9]...." On 12/31/15 at 11 a.m., during an interview at SNF 9, Resident 23 stated she was told by the SNF 1 SSD the facility was going to be shut down in order to bring it up to code, and SNF 1 would find a place for her to move to. When asked how this made Resident 23 feel, she stated, "Good and bad, good because the place was filthy with cockroaches, bad because some people couldn't speak up for themselves." Resident 23 stated residents were not given information regarding what was happening at the facility, and stated, "It was all up in the air. They didn't even tell the staff much of anything. They didn't know if they were going to have a job." When asked about her transfer, Resident 23 stated, "I was told I was leaving one day, and the same night the CNA [Certified Nurse Assistant] packed my belongings, and I was gone the day after I was told. It was boom...boom!" Resident 23 stated she did not receive any advance written notice regarding the transfer to SNF 9. On 12/31/15 at 11:30 a.m., during an interview, SNF 9 Nursing Supervisor (NS) 1 stated Resident 23 was adjusting, and staff was attempting to get the resident involved with activities, but she preferred to remain in bed. NS 1 stated Resident 23 did not participate in dining, and ate in her room. On 1/8/16 at 10:55 a.m., during a staff interview and concurrent clinical record review, the SNF 1 SSD stated the SNF 1 Interdisciplinary Team (IDT) (a resident care team including nursing, dietary, social services and activity staff) had not met prior to Resident 23's transfer to discuss whether it was a safe and appropriate transfer and the discharge care plan was not updated to plan for the transfer to SNF 9. The SSD stated SNF 9 was not able to provide any care for Resident 23 that SNF 1 could not provide. The SSD stated a 30 day notice of transfer that included the reason for transfer, the date of transfer, the location of the transfer, the right to appeal the transfer and the name and phone number of the state ombudsman was not provided to Resident 23 prior to her transfer. Therefore, the facility failed to honor and protect Resident 23's transfer and discharge rights. Resident 23 was transferred without ensuring the necessity to meet her medical or welfare needs and without reasonable notice and as a result was denied her transfer and discharge rights.These violations had a direct relationship to Resident 23's health, safety and security and thus constitute a Class B Citation. |
| 100000026 |
Valley Subacute & Rehabilitation Center |
040012097 |
B |
16-Mar-16 |
FZRR11 |
14485 |
42 Code of Federal Regulations Section 483.12(a)(2) Transfer and discharge requirements:The facility must permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless- (i) The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility; (ii) The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility; (iii) The safety of individuals in the facility is endangered; (iv) The health of individuals in the facility would otherwise be endangered; (v) The resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at the facility. For a resident who becomes eligible for Medicaid after admission to a nursing facility, the nursing facility may charge a resident only allowable charges under Medicaid; or (vi) The facility ceases to operate.Title 22 Section 72527 Patients' Rights: (a) Patients have the rights numerated in this section and the facility shall ensure 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 any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (6) To be transferred or discharged only for medical reasons, or the patient's welfare or that of other patient's or for nonpayment for his or her stay and to be given reasonable advance notice to ensure orderly transfer or discharge. Such actions shall be documented in the patient's health record. Title 22 Section 72519 Patient Transfer: (a) The licensee shall maintain written transfer agreements with other nearby health facilities to make the services of those facilities accessible and to facilitate the transfer of patients. Complete and accurate patient information, in sufficient detail to provide for continuity of care shall be transferred with the patient at time of transfer. (b) When a patient is transferred to another facility, the following shall be entered in the patient health record: (1) The date, time, condition of the patient and a written statement of the reason for the transfer. (2) Informed written or telephone acknowledgement of the patient, patient's guardian or authorized representative except in an emergency or as provided in Section 72527(a)(5). On 12/9/15 at 9:40 a.m., an unannounced visit was made to the facility to investigate anonymous complaint CA00468198 regarding the alleged violation of transfer and discharge rights. The facility failed to ensure Resident 24 was afforded the right to be transferred or discharged solely for medical reasons or for the resident's welfare, and to be given reasonable advance written notice to ensure a safe and orderly transfer or discharge. The facility transferred Resident 24 in order to accommodate the alleged plan of a potential new owner to convert the facility to a subacute setting (a specialized type of nursing service provided to residents who require complex care or rehabilitation). As a result, Resident 24 was transferred without adequate reason or advanced notice and suffered fear, confusion and emotional and psychological harm.Review of Resident 24's clinical record titled, "Face Sheet" indicated Resident 24 was admitted to the skilled nursing facility (SNF) 1 on 5/19/14 with diagnoses of dementia (memory loss), Alzheimer's disease (disease causing progressive dementia), and dysphagia (difficulty swallowing). Resident 24 was transferred to SNF 2 on 10/29/15. On 12/9/15 at 9:40 a.m., during a tour of SNF 1, no residents were observed in the hallways, resident rooms or dining area in the West Wing of the facility. Four residents were observed sitting in the East Wing main dining room watching television. During a concurrent interview with the facility Interim Administrator (IA) the IA stated the current facility census was seven of 70 available beds licensed for skilled nursing residents. The IA stated the West Wing was closed. The IA stated three of the seven remaining residents were scheduled to transfer out of the facility later that day, 12/9/15, due to a "Change of ownership" of the facility. On 12/9/15 at 12:15 p.m., during a staff interview in the East Wing hallway, Licensed Nurse (LN) 1 stated residents who resided in the facility were transferred out of the facility due to new ownership expected to take place in the near future. LN 1 stated all residents had to transfer out of the facility. LN 1 stated the new owner planned to run a facility that did not include long term care skilled nursing residents. LN 1 stated most residents that transferred were sad and did not want to leave as the facility had been their home for a long time.On 12/9/15 at 1:30 p.m., during an interview with the Social Services Director (SSD) in the social services office, the SSD stated some of the residents who were transferred did not want to transfer to a different facility because they lived at SNF 1 for a long time. The SSD stated those residents were concerned prior to the transfer as to what would happen to them when the new owner took ownership of the facility.On 12/9/15 at 4:18 p.m., during an interview in the Administrator's office, the IA stated the facility had not provided any resident (including Resident 24 or her Responsible Party) that was transferred since 6/1/15 a 30 day advance written notice that included the intent to transfer, the reason for the pending transfer or discharge or the right to appeal the transfer or discharge. The IA stated, "We didn't do those." Review of the facility's administrative policy titled, "California Standard Admission Agreement for Skilled Nursing Facilities and Intermediate Care Facilities" pages eight to nine, dated May 2011, provided to all SNF 1 residents on admission indicated, "VI. Transfers and Discharges...Our written notice of transfer to another facility or discharge against your wishes will be provided 30 days in advance...Our written notice will include the effective day, the location to which you will be transferred or discharged, and the reason the action is necessary. The only reason that we can transfer you to another facility or discharge you against your wishes are: 1) It is required to protect your well-being because your needs cannot be met in our facility; 2) It is appropriate because your health has improved enough that you no longer need the services of our Facility; 3) Your presence in our Facility endangers the health and safety of other individuals; 4) You have not paid for your stay in our Facility or have not arranged to have payment made under Medicare, Medi-Cal, or private insurance; 5) Our Facility ceases to operate; 6) Material or fraudulent misrepresentation of your finances to us... In our written notice, we will advise you that you have the right to appeal the transfer or discharge to the California Department of Health Care Services, and we will also provide the name, address and telephone number of the State Long-Term Care Ombudsman."On 12/16/15 at 3 p.m., during a staff interview, the SSD stated she had worked for SNF 1 for the past seven years. The SSD stated the facility process for discharging residents had begun to change in April 2015. The SSD stated she had been assigned the responsibility to coordinate the discharge of the residents in the facility. The SSD stated that responsibility had previously been a nursing service responsibility. The SSD stated in June 2015 the Clinical Nurse Liaison (CNL) began to assist her with the discharge of residents. She stated the CNL facilitated discharges of residents to other company-owned skilled nursing facilities. The SSD stated when approached by families or residents she had discussed the pending transition, and informed the residents or/and their families the residents could remain at the facility or seek placement before the transition was set to occur, but she could not speak to what would occur after the business was sold. The SSD stated families were given the instruction discharge of the residents was inevitable sooner or later as the type of patients accepted would change to those who required more complex care than was currently provided in SNF 1. The SSD stated the residents were "fast tracked" to discharge as part of the change in the process. She stated, "The majority of families wanted to seek placement out of fear, not knowing what was going to happen...how could they not be [fearful]? As an employee it was very difficult...they [the facility] were not communicating properly...I felt pressured...that's been very stressful."On 12/17/15 at 7:30 a.m., during an interview, the CNL stated her role at SNF 1 during the transition of ownership was to assist with the discharge of residents from the facility. The CNL stated she learned of an ownership transition in a staff meeting and received direction from the Regional Director of Operations (RDO) to discharge residents. She stated, "I wasn't aware of the regulations...I was stuck in between...it's been a nightmare." The CNL stated, "If they [the residents] asked [what would happen to them], we told them about the change of ownership...don't know when it's going to happen...there was the feeling of uncertainty." Resident 24's clinical record titled, "MDS (Minimum Data Set) (a tool used to assess residents cognitive and physical abilities) 3.0 Assessment," dated 8/13/15, indicated under Cognitive (pertaining to comprehension, memory and reasoning ability) Patterns, a summary score of 3 out of 15 possible, which indicated severe cognitive impairment, with no orientation to month, day, or year, and no recall. Resident 24's Interdisciplinary (IDT) Team Care Plan Conference Review dated 8/25/15, indicated, "IDT conducted a care plan conference by phone with RP [name]...Resident attends activities regularly, propels herself to and from activities in dining room. Resident discharge long term care...son has no concerns." Resident 24's Quarterly Social Services (SS) Discharge Planning Note dated 8/25/15, indicated under Discharge Plans or Discharge Barriers Reviewed with Resident, "No." Under Discharge Imminent, it indicated, "No." Resident 24's SS Note dated 8/25/15, indicated, "...Resident son is her responsible party [RP]. Resident son is very involved in residents care. Resident is capable of making her needs be known, speech clear, understands...Resident discharge plan is anticipated long term care due to needing higher level of care and inability to care for herself...Resident attends activities regularly..." Resident 24's SS Note dated 10/28/15 at 4:24 p.m., indicated, "Resident discharge on 10/29/15 to [SNF 2], Family has been seeking placement and [SNF 2] had availability..." Resident 24's SS Note dated 11/2/15 at 8:45 a.m., indicated, "...Resident is adjusting well at [SNF 2]. Son has no concerns." Resident 24's Transfer/Discharge Summary-Post Discharge Plan of Care, dated 10/29/15, indicated under Reason For Transfer/Discharge, "Other, Please Explain: [left blank]." No rationale for the transfer to SNF 2 was documented.On 12/29/15 at 2 p.m., during an interview at SNF 2, Certified Nurse Assistant (CNA) 4 stated she provided care for Resident 24. CNA 4 stated Resident 24 was confused at times and looking for her room. CNA 4 stated Resident 24's roommate was hard of hearing and played the television volume up, so Resident 24 often stayed outside her room because the noise bothered her.On 1/4/16 at 4:40 p.m., during an interview, Resident 23's Responsible Party (RP) 12 stated Resident 24 was transferred to SNF 2 because SNF 1 was going out of business, and was bought by Hospital 1. RP 12 stated he was surprised Resident 24 had to move so quickly, and recalled it as a scary situation because he did not know what would happen to Resident 24. RP 12 stated Resident 24 was scared when she first arrived at SNF 2 and had a hard time adjusting to the transfer. RP 12 stated Resident 24 had dementia, was moved out of her home, SNF 1, and didn't know the staff at SNF 2. RP 12 stated Resident 24 physically resisted care provided by the staff at SNF 2 by striking out at them. RP 12 stated, "She was scared to death of her roommate, who yelled all the time. They finally moved her to another room." RP 12 stated he was called by SNF 2 because Resident 24 was fighting with the staff when they attempted to give her a shower. RP 12 stated he told the staff at SNF 2 to give Resident 24 some juice and a cookie, that this calmed her, and further stated he didn't know why SNF 1 did not pass this information to SNF 2. When asked if he would return Resident 24 to SNF 1 if given the opportunity, RP 12 stated, "Never, they burned their bridge." On 1/7/16 at 3:10 p.m., during a staff interview and concurrent clinical record review, the SNF 1 SSD stated the SNF 1 Interdisciplinary Team (IDT) (a resident care team including nursing, dietary, social services and activity staff) did not meet prior to Resident 24's discharge to discuss whether it was a safe and appropriate transfer and the discharge care plan was not updated to plan for the transfer to SNF 2. The SSD stated SNF 2 was not able to provide any care for Resident 24 that SNF 1 could not provide. The SSD stated a 30 day notice of transfer that included the reason for transfer, the date of transfer, the location of the transfer, the right to appeal the transfer and the name and phone number of the state ombudsman was not provided to Resident 24 or to RP 12 prior to transfer. When asked why Resident 24's family sought placement at another facility, the SSD stated the family was concerned about the SNF 1's transition, and the uncertainty of what was going to happen to Resident 24. Therefore, the facility failed to honor and protect Resident 24's transfer and discharge rights. Resident 24 was transferred without ensuring the necessity to meet her medical or welfare needs and without reasonable notice. Resident 24 was transferred to SNF 2, an unfamiliar environment with unfamiliar staff and routines and as a result suffered fear, confusion and emotional and psychological harm.These violations had a direct relationship to Resident 24's health, safety and security and thus constitute a Class B Citation. |
| 100000026 |
Valley Subacute & Rehabilitation Center |
040012098 |
B |
16-Mar-16 |
FZRR11 |
13779 |
42 Code of Federal Regulations Section 483.12(a)(2) Transfer and discharge requirements:The facility must permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless- (i) The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility; (ii) The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility; (iii) The safety of individuals in the facility is endangered; (iv) The health of individuals in the facility would otherwise be endangered; (v) The resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at the facility. For a resident who becomes eligible for Medicaid after admission to a nursing facility, the nursing facility may charge a resident only allowable charges under Medicaid; or (vi) The facility ceases to operate.Title 22 Section 72527 Patients' Rights: (a) Patients have the rights numerated in this section and the facility shall ensure 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 any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (6) To be transferred or discharged only for medical reasons, or the patient's welfare or that of other patient's or for nonpayment for his or her stay and to be given reasonable advance notice to ensure orderly transfer or discharge. Such actions shall be documented in the patient's health record. Title 22 Section 72519 Patient Transfer: (a) The licensee shall maintain written transfer agreements with other nearby health facilities to make the services of those facilities accessible and to facilitate the transfer of patients. Complete and accurate patient information, in sufficient detail to provide for continuity of care shall be transferred with the patient at time of transfer. (b) When a patient is transferred to another facility, the following shall be entered in the patient health record: (1) The date, time, condition of the patient and a written statement of the reason for the transfer. (2) Informed written or telephone acknowledgement of the patient, patient's guardian or authorized representative except in an emergency or as provided in Section 72527(a)(5). On 12/9/15 at 9:40 a.m., an unannounced visit was made to the facility to investigate anonymous complaint CA00468198 regarding the alleged violation of transfer and discharge rights. The facility failed to ensure Resident 25 was afforded the right to be transferred or discharged solely for medical reasons or for the resident's welfare, and to be given reasonable advance written notice to ensure a safe and orderly transfer or discharge. The facility transferred Resident 25 in order to accommodate the alleged plan of a potential new owner to convert the facility to a subacute setting (a specialized type of nursing service provided to Residents who require complex care or rehabilitation). As a result, Resident 25 was displaced from her home and suffered anxiety and psychological and emotional distress.Review of Resident 25's clinical record titled, "Face Sheet" indicated Resident 25 was admitted to the skilled nursing facility (SNF) 1 on 4/3/14 with diagnoses that included encephalopathy (brain disease, damage, or malfunction), anxiety, chronic obstructive pulmonary disease (lung disease) and dysphagia (difficulty swallowing). Resident 25 was transferred to SNF 12 on 10/23/15. The "Face Sheet" indicated Resident 25 was responsible for her own financial and medical affairs. On 12/9/15 at 9:40 a.m., during a tour of SNF 1, no residents were observed in the hallways, resident rooms or dining area in the West Wing of the facility. Four residents were observed sitting in the East Wing main dining room watching television. During a concurrent interview with the facility Interim Administrator (IA) the IA stated the current facility census was seven of 70 available beds licensed for skilled nursing residents. The IA stated the West Wing was closed. The IA stated three of the seven remaining residents were scheduled to transfer out of the facility later that day, 12/9/15, due to a "Change of ownership" of the facility. On 12/9/15 at 12:15 p.m., during a staff interview in the East Wing hallway, Licensed Nurse (LN) 1 stated residents who resided in the facility were transferred out of the facility due to new ownership expected to take place in the near future. LN 1 stated all residents had to transfer out of the facility. LN 1 stated the new owner planned to run a facility that did not include long term care skilled nursing residents. LN 1 stated most residents that transferred were sad and did not want to leave as the facility had been their home for a long time.On 12/9/15 at 1:30 p.m., during an interview with the Social Services Director (SSD) in the social services office, the SSD stated some of the residents who were transferred did not want to transfer to a different facility because they lived at SNF 1 for a long time. The SSD stated those residents were concerned prior to the transfer as to what would happen to them when the new owner took ownership of the facility. On 12/9/15 at 4:18 p.m., during an interview in the Administrator's office, the IA stated the facility had not provided any resident (including Resident 25) that was transferred since 6/1/15 a 30 day advance written notice that included the intent to transfer, the reason for the pending transfer, the location of the transfer, or the right to appeal the transfer. The IA stated, "We didn't do those." Review of the facility's administrative policy titled, "California Standard Admission Agreement for Skilled Nursing Facilities and Intermediate Care Facilities" pages eight to nine, dated May 2011, provided to all SNF 1 residents on admission indicated, "VI. Transfers and Discharges...Our written notice of transfer to another facility or discharge against your wishes will be provided 30 days in advance...Our written notice will include the effective day, the location to which you will be transferred or discharged, and the reason the action is necessary. The only reason that we can transfer you to another facility or discharge you against your wishes are: 1) It is required to protect your well-being because your needs cannot be met in our facility; 2) It is appropriate because your health has improved enough that you no longer need the services of our Facility; 3) Your presence in our Facility endangers the health and safety of other individuals; 4) You have not paid for your stay in our Facility or have not arranged to have payment made under Medicare, Medi-Cal, or private insurance; 5) Our Facility ceases to operate; 6) Material or fraudulent misrepresentation of your finances to us... In our written notice, we will advise you that you have the right to appeal the transfer or discharge to the California Department of Health Care Services, and we will also provide the name, address and telephone number of the State Long-Term Care Ombudsman."On 12/16/15 at 3 p.m., during a staff interview, the SSD stated she had worked for SNF 1 for the past seven years. The SSD stated the facility process for discharging residents had begun to change in April 2015. The SSD stated she had been assigned the responsibility to coordinate the discharge of the residents in the facility. The SSD stated that responsibility had previously been a nursing service responsibility. The SSD stated in June 2015 the Clinical Nurse Liaison (CNL) began to assist her with the discharge of residents. She stated the CNL facilitated discharges of residents to other company-owned skilled nursing facilities. The SSD stated when approached by families or residents she had discussed the pending transition, and informed the residents or/and their families the residents could remain at the facility or seek placement before the transition was set to occur, but she could not speak to what would occur after the business was sold. The SSD stated families were given the instruction discharge of the residents was inevitable sooner or later as the type of patients accepted would change to those who required more complex care than was provided in SNF 1. The SSD stated the residents were "fast tracked" to discharge as part of the change in the process. She stated, "The majority of families wanted to seek placement out of fear, not knowing what was going to happen...how could they not be [fearful]? As an employee it was very difficult...they [the facility] were not communicating properly...I felt pressured...that's been very stressful."On 12/17/15 at 7:30 a.m., during an interview, the CNL stated her role at SNF 1 during the transition of ownership was to assist with the discharge of residents from the facility. The CNL stated she learned of an ownership transition in a staff meeting and received direction from the Regional Director of Operations (RDO) to discharge residents. She stated, "I wasn't aware of the regulations...I was stuck in between...it's been a nightmare." The CNL stated, "If they [the residents] asked [what would happen to them], we told them about the change of ownership...don't know when it's going to happen...there was the feeling of uncertainty." Resident 25's clinical record titled, "MDS [Minimum Data Set] (a tool used to assess residents cognitive and physical function abilities) 3.0 Assessment," dated 9/21/15, indicated under Cognitive (pertaining to comprehension, memory and reasoning ability) Patterns a summary score of 15 out of 15, which indicated she had no cognitive deficits. Under Functional Status, she scored 3/2 in the areas of transfer, eating, and dressing, which indicated she required extensive assistance of one person to complete the task. Under Walk she scored 8/8, which indicated she did not walk. Resident 25's Quarterly Social Services (SS) Discharge Planning Note dated 9/24/15, indicated under Barriers to Discharge Date: "Resident is incapable of living independently." Under Discharge Imminent, it indicated, "No." SNF 1 Social Service (SS) note dated 10/22/15 at 12:54 p.m., indicated, "...Resident care manager has been actively seeking placement for resident. SSD was informed that [SNF 12] has accepted resident. SSD informed case manager [name]." The Physician Communication Fax [facsimile] Request dated 10/22/15, indicated under Request; "Resident will be discharging to [SNF 12] on 10/23/15." The request was approved on 10/22/15 by MD 1. Resident 25's clinical record titled, "Transfer/Discharge Summary-Post Discharge Plan of Care" dated 10/23/15, was left blank under "Reason for Transfer/Discharge." No rationale for the transfer to SNF 12 was documented. Resident 25's SNF 1 SS note dated 10/23/15 at 12:18 p.m., indicated, "Resident discharged today at 10:30 a.m., all docs [documents] including transfer/discharge form, copies given to transportation..." On 12/29/15 at 3:30 p.m., during a resident interview at SNF 12, Resident 25 was found sitting in her wheelchair, dressed, and at her bedside. Resident 25 stated she was informed by the SNF 1 SSD and Director of Nursing (DON) that she had to transfer out of SNF 1 because it was changing, and would be used for patients who had a tracheotomy (a surgical hole in the neck to breathe). Resident 25 stated she was not happy at SNF 12 and wanted to move to somewhere else. On 1/8/16 at 9:05 a.m., during a staff interview, the SNF 1 SSD stated when Resident 25 learned of the SNF 1 transition, she became upset, started yelling out more often, and would frequently ask staff if they were leaving. The SSD further stated Resident 25's caseworker heard about the transfer, and asked what was going on. Once informed, the caseworker assisted the SSD in looking for a placement. The SSD stated Resident 25's last Interdisciplinary Team (IDT) (a resident care team including nursing, dietary, social services and activity staff) meeting was held on 10/1/15, but no discharge plan was initiated at that time, nor was it initiated when the SNF 12 transfer was confirmed. The SSD further stated there was no written documentation of Resident 25's pending transfer until 10/22/15, just prior to discharge on 10/23/15. The SSD stated SNF 12 was not able to provide any care for Resident 25 that SNF 1 could not provide. The SSD stated a 30 day notice of transfer that included the reason for transfer, the date of transfer, the location of the transfer, the right to appeal the transfer and the name and phone number of the state ombudsman was not provided to Resident 25 prior to transfer.On 1/26/16 at 4 p.m., during an interview, Privacy Officer (PO) 1 stated documentation in Resident 25's caseworker file indicated Resident 25 had called on 10/22/15 concerned regarding her pending transfer scheduled for the following day, 10/23/15. Review of caseworker notes indicated Resident 25 was very anxious regarding the move. PO 1 stated there was no evidence of a caseworker request for resident transfer found in Resident 25's file.Therefore, the facility failed to honor and protect Resident 25's transfer and discharge rights. Resident 25 was transferred without ensuring the necessity to meet her medical or welfare needs and without reasonable notice. These violations resulted in anxiety and emotional and psychological distress for Resident 25. These violations had a direct relationship to Resident 25's health, safety and security and thus constitute a Class B Citation. |
| 100000026 |
Valley Subacute & Rehabilitation Center |
040012099 |
B |
16-Mar-16 |
FZRR11 |
14789 |
42 Code of Federal Regulations Section 483.12(a)(2) Transfer and discharge requirements:The facility must permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless- (i) The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility; (ii) The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility; (iii) The safety of individuals in the facility is endangered; (iv) The health of individuals in the facility would otherwise be endangered; (v) The resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at the facility. For a resident who becomes eligible for Medicaid after admission to a nursing facility, the nursing facility may charge a resident only allowable charges under Medicaid; or (vi) The facility ceases to operate.Title 22 Section 72527 Patients' Rights: (a) Patients have the rights numerated in this section and the facility shall ensure 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 any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (6) To be transferred or discharged only for medical reasons, or the patient's welfare or that of other patient's or for nonpayment for his or her stay and to be given reasonable advance notice to ensure orderly transfer or discharge. Such actions shall be documented in the patient's health record. Title 22 Section 72519 Patient Transfer: (a) The licensee shall maintain written transfer agreements with other nearby health facilities to make the services of those facilities accessible and to facilitate the transfer of patients. Complete and accurate patient information, in sufficient detail to provide for continuity of care shall be transferred with the patient at time of transfer. (b) When a patient is transferred to another facility, the following shall be entered in the patient health record: (1) The date, time, condition of the patient and a written statement of the reason for the transfer. (2) Informed written or telephone acknowledgement of the patient, patient's guardian or authorized representative except in an emergency or as provided in Section 72527(a)(5). On 12/9/15 at 9:40 a.m., an unannounced visit was made to the facility to investigate anonymous complaint CA00468198 regarding the alleged violation of transfer and discharge rights. The facility failed to ensure Resident 26 was afforded the right to be transferred or discharged solely for medical reasons or for the resident's welfare, and to be given reasonable advance written notice to ensure a safe and orderly transfer or discharge. The facility transferred Resident 26 in order to accommodate the alleged plan of a potential new owner to convert the facility to a subacute setting (a specialized type of nursing service provided to Residents who require complex care or rehabilitation). As a result, Resident 26 was displaced from his home and family and suffered psychological and emotional distress.Review of Resident 26's clinical record titled, "Face Sheet" indicated Resident 26 was admitted to the skilled nursing facility (SNF) 1 on 12/28/12 with diagnoses that included schizophreniform disorder (disorder of thought with disorganized speech and behavior), depression, Parkinson's disease (a progressive disease of the nervous system), dysphagia (difficulty swallowing), and muscle weakness. On 12/9/15 at 9:40 a.m., during a tour of SNF 1, no residents were observed in the hallways, resident rooms or dining area in the West Wing of the facility. Four residents were observed sitting in the East Wing main dining room watching television. During a concurrent interview with the facility Interim Administrator (IA) the IA stated the current facility census was seven of 70 available beds licensed for skilled nursing residents. The IA stated the West Wing was closed. The IA stated three of the seven remaining residents were scheduled to transfer out of the facility later that day, 12/9/15, due to a "Change of ownership" of the facility. On 12/9/15 at 12:15 p.m., during a staff interview in the East Wing hallway, Licensed Nurse (LN) 1 stated residents who resided in the facility were transferred out of the facility due to new ownership expected to take place in the near future. LN 1 stated all residents had to transfer out of the facility. LN 1 stated the new owner planned to run a facility that did not include long term care skilled nursing residents. LN 1 stated most residents that transferred were sad and did not want to leave as the facility had been their home for a long time.On 12/9/15 at 1:30 p.m., during an interview with the Social Services Director (SSD) in the social services office, the SSD stated some of the residents who were transferred did not want to transfer to a different facility because they lived at SNF 1 for a long time. The SSD stated those residents were concerned prior to the transfer as to what would happen to them when the new owner took ownership of the facility. On 12/9/15 at 4:18 p.m., during an interview in the Administrator's office, the IA stated the facility had not provided any resident (including Resident 26 or his Responsible Party) that was transferred since 6/1/15 a 30 day advance written notice that included the intent to transfer, the reason for the pending transfer or discharge or the right to appeal the transfer or discharge. The IA stated, "We didn't do those." Review of the facility's administrative policy titled, "California Standard Admission Agreement for Skilled Nursing Facilities and Intermediate Care Facilities" pages eight to nine, dated May 2011 provided to all SNF 1 residents on admission indicated, "VI. Transfers and Discharges...Our written notice of transfer to another facility or discharge against your wishes will be provided 30 days in advance...Our written notice will include the effective day, the location to which you will be transferred or discharged, and the reason the action is necessary. The only reason that we can transfer you to another facility or discharge you against your wishes are: 1) It is required to protect your well-being because your needs cannot be met in our facility; 2) It is appropriate because your health has improved enough that you no longer need the services of our Facility; 3) Your presence in our Facility endangers the health and safety of other individuals; 4) You have not paid for your stay in our Facility or have not arranged to have payment made under Medicare, Medi-Cal, or private insurance; 5) Our Facility ceases to operate; 6) Material or fraudulent misrepresentation of your finances to us... In our written notice, we will advise you that you have the right to appeal the transfer or discharge to the California Department of Health Care Services, and we will also provide the name, address and telephone number of the State Long-Term Care Ombudsman."On 12/16/15 at 3 p.m., during a staff interview, the SSD stated she had worked for SNF 1 for the past seven years. The SSD stated the facility process for discharging residents had begun to change in April 2015. The SSD stated she had been assigned the responsibility to coordinate the discharge of the residents in the facility. The SSD stated that responsibility had previously been a nursing service responsibility. The SSD stated in June 2015 the Clinical Nurse Liaison (CNL) began to assist her with the discharge of residents. She stated the CNL facilitated discharges of residents to other company-owned skilled nursing facilities. The SSD stated when approached by families or residents she had discussed the pending transition, and informed the residents or/and their families the residents could remain at the facility or seek placement before the transition was set to occur, but she could not speak to what would occur after the business was sold. The SSD stated families were given the information the discharge of the residents was inevitable sooner or later as the type of patients accepted would change to those who required more complex care than was currently provided in SNF 1. The SSD stated the residents were "fast tracked" to discharge as part of the change in the process. She stated, "The majority of families wanted to seek placement out of fear, not knowing what was going to happen...how could they not be [fearful]? As an employee it was very difficult...they [the facility] were not communicating properly...I felt pressured...that's been very stressful."On 12/17/15 at 7:30 a.m., during an interview, the CNL stated her role at SNF 1 during the transition of ownership was to assist with the discharge of residents from the facility. The CNL stated she learned of an ownership transition in a staff meeting and received direction from the Regional Director of Operations (RDO) to discharge residents. She stated, "I wasn't aware of the regulations...I was stuck in between...it's been a nightmare." The CNL stated, "If they [the residents] asked [what would happen to them], we told them about the change of ownership...don't know when it's going to happen...there was the feeling of uncertainty." Resident 26's clinical record titled, "MDS [Minimum Data Set](a tool to assess residents cognitive and physical abilities) 3.0 Assessment," dated 8/17/15, indicated under Cognitive (pertaining to comprehension, memory and reasoning ability) Patterns a summary score of 7 out of 15, which indicated severe cognitive impairment, with inability to correctly state the year, month, or day. Under Mood, it indicated a PHQ-9 (a validated interview to screen for depression) Total Severity score of 9 of 27 possible, which indicated mild depression. Under Functional Status, it indicated Resident 26 required extensive assistance, with one person physical assistance for transfer, and was totally dependent for dressing and bathing. Under Walk, Resident 26 scored 8/8, which indicated he did not walk. Resident 26's Quarterly Social Services (SS) Discharge Planning Note dated 8/26/15, indicated under Barriers to Discharge Goals: "Resident is incapable of living independently." Under Discharge Plans or Discharge Barriers Reviewed with Resident, it indicated, "No." Under Discharge Imminent, it indicated, "No." Resident 26's SS Note dated 10/2/15 at 1:13 p.m., indicated, "...On 10-1-15 SSD received a call from resident sister-in-law. She mentioned family/RP [Responsible Party] concerns with hearing in the community about the upcoming changes with facility. SSD reassured family resident isn't asked to leave and is welcome to stay here at this facility. Sister-in-law stated they don't want to wait and would like for discharge and to start seeking placement and would like [SNF 11 area] due to having family there they visit regularly." Resident 26's SS Note dated 10/2/15 at 1:23 p.m., indicated, "..."SSD informed RP that [SNF 11] had a male bed available..." Resident 26's SS Note dated 10/6/15 at 11:53 a.m., indicated, "...SSD received a call from RP that [SNF 11] will accept resident today 10-6-15 at noon. SSD spoke with resident and he was aware of relocating per family talking to him over the weekend..." Resident 26's Transfer/Discharge Summary-Post Discharge Plan of Care dated 10/6/15, indicated under Reason for Transfer/Discharge, "Resident needs SMF [Skilled Medical Facility]/Hospital care." SS Note dated 10/15/15 at 10:48 a.m., indicated, "Resident [26] discharged on 10-6-15 to [SNF 11] per family/resident request..." On 12/23/15 at 12 p.m., during an interview, Resident 26 stated he was transferred from SNF 1 in October 2015. He stated, "Leaving [SNF 1] upset me," and became tearful. Resident 26 further stated, "They wanted to send me to [SNF 5]...then they found this place [SNF 11]...I'm scared...This was the only place my family could find for me." Resident 26 restated, "I'm scared" four times during the interview. He further stated he wanted to be close to family, who live in the town where SNF 1 is located. He stated, "I want to be back near my mom....I love her so much." When asked if he wanted to return to SNF 1, he stated, "I don't want this place to get in trouble." On 1/6/16 at 9:30 a.m., during a telephone interview, Resident 26's Responsible Party (RP) 13 stated SNF 1 staff told him the facility was sold and was to be converted for rehabilitation of post-operative patients and that RP 13 needed to look for a place for Resident 26. He further stated SNF 1 contacted him at a later date to advise him SNF 5 had an available bed. RP 13 declined the bed due to its excessive distance, and RP 13 arranged to transfer him to SNF 11. When asked how Resident 26 is doing at SNF 11, RP 13 stated he seemed to be happy at first, but in the last month he has changed and is not the same. RP 13 placed Resident 26 on a waiting list for SNF 2, because family wanted him closer, and it was difficult for his mother to visit Resident 26. RP 13 stated it was a burden to drive to see Resident 26, and the number of visits they have made has decreased.Review of www.Mapquest.com, an Internet navigation tool, indicated SNF 11 was located 29 miles from SNF 1. On 1/8/16 at 11:55 a.m., during an interview with the SSD at SNF 1, the SSD stated Resident 26's last Interdisciplinary Team (IDT) (a resident care team including nursing, dietary, social services and activity staff) meeting was held on 8/26/15. The SSD stated no discharge care plan had been initiated for the transfer to SNF 11. The SSD further stated the IDT team had not met to determine if the transfer was safe and appropriate for Resident 26. The SSD stated SNF 11 did not provide any care for Resident 26 that SNF 1 could not provide. The SSD stated a 30 day notice of transfer that included the reason for transfer, the date of transfer, the location of the transfer, the right to appeal the transfer and the name and phone number of the state ombudsman was not provided to Resident 26 or RP 13 prior to the transfer.Therefore, the facility failed to honor and protect Resident 26's transfer and discharge rights. Resident 26 was transferred away from his home and family without ensuring the necessity to meet his medical or welfare needs and without reasonable notice. As a result, Resident 26 suffered fear and emotional and psychological distress. These violations had a direct relationship to Resident 26's health, safety and security and thus constitute a Class B Citation. |
| 100000026 |
Valley Subacute & Rehabilitation Center |
040012103 |
B |
16-Mar-16 |
FZRR11 |
15015 |
42 Code of Federal Regulations Section 483.12(a)(2) Transfer and discharge requirements:The facility must permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless- (i) The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility; (ii) The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility; (iii) The safety of individuals in the facility is endangered; (iv) The health of individuals in the facility would otherwise be endangered; (v) The resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at the facility. For a resident who becomes eligible for Medicaid after admission to a nursing facility, the nursing facility may charge a resident only allowable charges under Medicaid; or (vi) The facility ceases to operate.Title 22 Section 72527 Patients' Rights: (a) Patients have the rights numerated in this section and the facility shall ensure 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 any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (6) To be transferred or discharged only for medical reasons, or the patient's welfare or that of other patient's or for nonpayment for his or her stay and to be given reasonable advance notice to ensure orderly transfer or discharge. Such actions shall be documented in the patient's health record. Title 22 Section 72519 Patient Transfer: (a) The licensee shall maintain written transfer agreements with other nearby health facilities to make the services of those facilities accessible and to facilitate the transfer of patients. Complete and accurate patient information, in sufficient detail to provide for continuity of care shall be transferred with the patient at time of transfer. (b) When a patient is transferred to another facility, the following shall be entered in the patient health record: (1) The date, time, condition of the patient and a written statement of the reason for the transfer. (2) Informed written or telephone acknowledgement of the patient, patient's guardian or authorized representative except in an emergency or as provided in Section 72527(a)(5). On 12/9/15 at 9:40 a.m., an unannounced visit was made to the facility to investigate anonymous complaint CA00468198 regarding the alleged violation of transfer and discharge rights. The facility failed to ensure Resident 27 was afforded the right to be transferred or discharged solely for medical reasons or for the resident's welfare, and to be given reasonable advance written notice to ensure a safe and orderly transfer or discharge. The facility transferred Resident 27 in order to accommodate the alleged plan of a potential new owner to convert the facility to a subacute setting (a specialized type of nursing service provided to Residents who require complex care or rehabilitation). As a result, Resident 27 was transferred from her home to an unfamiliar location and suffered fear and psychological and emotional distress.Review of Resident 27's clinical record titled, "Face Sheet" indicated Resident 27 was admitted to the skilled nursing facility (SNF) 1 on 1/21/14 with diagnoses that included schizophrenia (a mental illness characterized by disorder of thought, disorganized speech and behavior, and hallucinations), major depression and cognitive (pertaining to comprehension, memory and reasoning ability) impairment. Resident 27 was transferred to SNF 11 on 10/28/15. On 12/9/15 at 9:40 a.m., during a tour of SNF 1, no residents were observed in the hallways, resident rooms or dining area in the West Wing of the facility. Four residents were observed sitting in the East Wing main dining room watching television. During a concurrent interview with the facility Interim Administrator (IA) the IA stated the current facility census was seven of 70 available beds licensed for skilled nursing residents. The IA stated the West Wing was closed. The IA stated three of the seven remaining residents were scheduled to transfer out of the facility later that day, 12/9/15, due to a "Change of ownership" of the facility. On 12/9/15 at 12:15 p.m., during a staff interview in the East Wing hallway, Licensed Nurse (LN) 1 stated residents who resided in the facility were transferred out of the facility due to new ownership expected to take place in the near future. LN 1 stated all residents had to transfer out of the facility. LN 1 stated the new owner planned to run a facility that did not include long term care skilled nursing residents. LN 1 stated most residents that transferred were sad and did not want to leave as the facility had been their home for a long time.On 12/9/15 at 1:30 p.m., during an interview with the Social Services Director (SSD) in the social services office, the SSD stated some of the residents who were transferred did not want to transfer to a different facility because they lived at SNF 1 for a long time. The SSD stated those residents were concerned prior to the transfer as to what would happen to them when the new owner took ownership of the facility. On 12/9/15 at 4:18 p.m., during an interview in the Administrator's office, the IA stated the facility had not provided any resident (including Resident 27 or her Responsible Party) that was transferred since 6/1/15 a 30 day advance written notice that included the intent to transfer, the reason for the pending transfer or discharge or the right to appeal the transfer or discharge. The IA stated, "We didn't do those." Review of the facility's administrative policy titled, "California Standard Admission Agreement for Skilled Nursing Facilities and Intermediate Care Facilities" pages eight to nine, dated May 2011, provided to all SNF 1 residents on admission indicated, "VI. Transfers and Discharges...Our written notice of transfer to another facility or discharge against your wishes will be provided 30 days in advance...Our written notice will include the effective day, the location to which you will be transferred or discharged, and the reason the action is necessary. The only reason that we can transfer you to another facility or discharge you against your wishes are: 1) It is required to protect your well-being because your needs cannot be met in our facility; 2) It is appropriate because your health has improved enough that you no longer need the services of our Facility; 3) Your presence in our Facility endangers the health and safety of other individuals; 4) You have not paid for your stay in our Facility or have not arranged to have payment made under Medicare, Medi-Cal, or private insurance; 5) Our Facility ceases to operate; 6) Material or fraudulent misrepresentation of your finances to us... In our written notice, we will advise you that you have the right to appeal the transfer or discharge to the California Department of Health Care Services, and we will also provide the name, address and telephone number of the State Long-Term Care Ombudsman."On 12/16/15 at 3 p.m., during a staff interview, the SSD stated she had worked for SNF 1 for the past seven years. The SSD stated the facility process for discharging residents had begun to change in April 2015. The SSD stated she had been assigned the responsibility to coordinate the discharge of the residents in the facility. The SSD stated that responsibility had previously been a nursing service responsibility. The SSD stated in June 2015 the Clinical Nurse Liaison (CNL) began to assist her with the discharge of residents. She stated the CNL facilitated discharges of residents to other company-owned skilled nursing facilities. The SSD stated when approached by families or residents she had discussed the pending transition, and informed the residents or/and their families the residents could remain at the facility or seek placement before the transition was set to occur, but she could not speak to what would occur after the business was sold. The SSD stated families were given the instruction discharge of the residents was inevitable sooner or later as the type of patients accepted would change to those who required more complex care than was provided in SNF 1. The SSD stated the residents were "fast tracked" to discharge as part of the change in the process. She stated, "The majority of families wanted to seek placement out of fear, not knowing what was going to happen...how could they not be [fearful]? As an employee it was very difficult...they [the facility] were not communicating properly...I felt pressured...that's been very stressful."On 12/17/15 at 7:30 a.m., during an interview, the CNL stated her role at SNF 1 during the transition of ownership was to assist with the discharge of residents from the facility. The CNL stated she learned of an ownership transition in a staff meeting and received direction from the Regional Director of Operations (RDO) to discharge residents. She stated, "I wasn't aware of the regulations...I was stuck in between...it's been a nightmare." The CNL stated, "If they [the residents] asked [what would happen to them], we told them about the change of ownership...don't know when it's going to happen...there was the feeling of uncertainty." Resident 27's Social Service Note dated 10/2/15 at 2:44 p.m., indicated, "Resident is a prior resident from [vendor] Guest Home, Resident has a public guardian that is her responsible party...Resident discharge plan is anticipated long term care...incapable of living independently." Resident 27's Social Service Note dated 10/2/15 at 4:18 p.m., indicated, "...SSD received a call from resident guardian [Public Guardian PG 2] regarding facility transition. SSD reassured [PG 2] resident isn't being placed. [PG 2] didn't know that we had been seeking other placement due to resident request and behaviors and seeking appropriate facility...SSD continue seeking placement. SSD reassured [PG 2] resident is capable of remaining in facility and not being asked to leave."Resident 27's clinical record titled, "MDS (Minimum Data Set) (resident assessment tool to assess cognitive and physical functional abilities) 3.0 Assessment," dated 10/7/15, indicated a Brief Interview for Mental Status (BIMS) score of 15 out of 15 possible, which indicated she was cognitively intact. Under Mood, it indicated a PHQ-9 (a validated interview to screen for depression) Total Severity score of 6 of 27 possible, which indicated mild depression. Under Functional Status, it indicated Resident 27 required limited assistance for transfers, eating and bathing. Resident 27's Physician Communication Fax Request dated 10/28/15, indicated under Request, "Resident discharge to [SNF 11] on 10/28/15." The document was approved and signed by MD 1 on 10/28/15. Social Service Note dated 10/28/15 at 1:59 p.m., indicated, "...Resident discharged on 10-28-15 to [SNF 11]. Resident was excited to go and stating I'll be closer to my brother..." The Transfer/Discharge Summary-Post Discharge Plan of Care dated 10/28/15, indicated under Reason for Transfer/Discharge, "Resident needs SMF [skilled medical facility]/Hospital Care" and "Needs SNF."SS Note dated 11/2/15 at 8:43 a.m., indicated, "...Resident is adjusting well to placement to [SNF 11]. SSD spoke with resident Public Guardian [PG 2] on 10/29/15. [PG 2] was pleased with placement and resident is closer to her brother. No concerns." On 12/23/15 at 12:30 p.m., during an interview at SNF 11, Resident 27 stated she wanted to transfer to San Luis Obispo to be near her brother. Resident 27 stated she had not requested to transfer to SNF 11 which was located in a small town 196 miles from San Luis Obispo. Resident 27 stated she had never heard of the town [SNF 11's location] prior to the transfer, didn't know where it was located, and had no family or friends there. Resident 27 stated she was asleep in her room in SNF 1 on 10/28/15 at 10 a.m. when a staff person woke her up. Resident 27 stated the SNF 1 staff person told her to get dressed; she would be leaving in less than an hour. Resident 27 stated the staff person helped her pack and she was transferred to SNF 11 within the hour. Resident 27 stated she was scared and didn't have a choice about where she was going. Resident 27 stated she had not participated in any planning to transfer to SNF 11, which was not near San Luis Obispo and not where she wanted to live.On 1/6/16 at 9:45 a.m., during an interview, Public Guardian (PG) 2 stated Resident 27 was transferred from SNF 1 because it was closing and could no longer accommodate the resident's needs. PG 2 stated she was informed by the SNF 1 SSD in June to July 2015, that within three months all residents were going to have to leave the facility. PG 2 stated she was involved with Resident 27's transfer only from PG 2's interest in transferring her closer to San Luis Obispo, as the resident wanted to be closer to family. PG 2 stated she was notified of Resident 27's transfer the day of the transfer and that she was being transferred to SNF 11, not San Luis Obispo. PG 2 stated Resident 27 wanted to be transferred to a skilled nursing facility in San Luis Obispo, and that didn't happen. PG 2 stated Resident 27 was transferred to meet the needs of SNF 1, not Resident 27. On 1/8/16 at 12:10 p.m., during an interview at SNF 1, the SSD stated PG 2 requested Resident 27's placement by phone. The SSD stated there was not a meeting held with Resident 27 to inform her of the pending transfer from SNF 1. The SSD stated the SNF 1 Interdisciplinary Team (IDT) (a resident care team including nursing, dietary, social services and activity staff) had not met prior toResident 27's transfer to SNF 11to discuss whether it was a safe and appropriate transfer and the discharge care plan was not updated to plan for the transfer to SNF 11. The SSD stated SNF 11 did not provide any care for Resident 27 that SNF 1 could not provide. The SSD stated a 30 day notice of transfer that included the reason for transfer, the date of transfer, the location transferring to, the right to appeal the transfer and the name and phone number of the state ombudsman was not provided to Resident 27 or her Public Guardian. Therefore, the facility failed to honor and protect Resident 27's transfer and discharge rights. Resident 27 was transferred to SNF 11 without her consent, without ensuring the necessity to meet her medical or welfare needs and without reasonable notice. These violations resulted in fear and emotional and psychological distress for Resident 27.These violations had a direct relationship to Resident 27's health, safety and security and thus constitute a Class B Citation. |
| 100000026 |
Valley Subacute & Rehabilitation Center |
040012104 |
B |
16-Mar-16 |
FZRR11 |
15367 |
42 Code of Federal Regulations Section 483.12(a)(2) Transfer and discharge requirements:The facility must permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless- (i) The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility; (ii) The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility; (iii) The safety of individuals in the facility is endangered; (iv) The health of individuals in the facility would otherwise be endangered; (v) The resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at the facility. For a resident who becomes eligible for Medicaid after admission to a nursing facility, the nursing facility may charge a resident only allowable charges under Medicaid; or (vi) The facility ceases to operate.Title 22 Section 72527 Patients' Rights: (a) Patients have the rights numerated in this section and the facility shall ensure 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 any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (6) To be transferred or discharged only for medical reasons, or the patient's welfare or that of other patient's or for nonpayment for his or her stay and to be given reasonable advance notice to ensure orderly transfer or discharge. Such actions shall be documented in the patient's health record. Title 22 Section 72519 Patient Transfer: (a) The licensee shall maintain written transfer agreements with other nearby health facilities to make the services of those facilities accessible and to facilitate the transfer of patients. Complete and accurate patient information, in sufficient detail to provide for continuity of care shall be transferred with the patient at time of transfer. (b) When a patient is transferred to another facility, the following shall be entered in the patient health record: (1) The date, time, condition of the patient and a written statement of the reason for the transfer. (2) Informed written or telephone acknowledgement of the patient, patient's guardian or authorized representative except in an emergency or as provided in Section 72527(a)(5). On 12/9/15 at 9:40 a.m., an unannounced visit was made to the facility to investigate anonymous complaint CA00468198 regarding the alleged violation of transfer and discharge rights. The facility failed to ensure Resident 28 was afforded the right to be transferred or discharged solely for medical reasons or for the resident's welfare, and to be given reasonable advance written notice to ensure a safe and orderly transfer or discharge. The facility transferred Resident 28 in order to accommodate the alleged plan of a potential new owner to convert the facility to a subacute setting (a specialized type of nursing service provided to Residents who require complex care or rehabilitation). As a result, Resident 28 was displaced from her home and suffered psychological and emotional distress.Review of Resident 28's clinical record titled, "Face Sheet" indicated Resident 28 was admitted to the skilled nursing facility (SNF) 1 on 9/8/14 with diagnoses of anxiety, chronic obstructive pulmonary disease (lung disease), diabetes mellitus (a disease that affects blood sugar), and muscle wasting. Resident 28 was transferred to SNF 2 on 10/16/15. On 12/9/15 at 9:40 a.m., during a tour of SNF 1, no residents were observed in the hallways, resident rooms or dining area in the West Wing of the facility. Four residents were observed sitting in the East Wing main dining room watching television. During a concurrent interview with the facility Interim Administrator (IA) the IA stated the current facility census was seven of 70 available beds licensed for skilled nursing residents. The IA stated the West Wing was closed. The IA stated three of the seven remaining residents were scheduled to transfer out of the facility later that day, 12/9/15, due to a "Change of ownership" of the facility. On 12/9/15 at 12:15 p.m., during a staff interview in the East Wing hallway, Licensed Nurse (LN) 1 stated residents who resided in the facility were transferred out of the facility due to new ownership expected to take place in the near future. LN 1 stated all residents had to transfer out of the facility. LN 1 stated the new owner planned to run a facility that did not include long term care skilled nursing residents. LN 1 stated most residents that transferred were sad and did not want to leave as the facility had been their home for a long time.On 12/9/15 at 1:30 p.m., during an interview with the Social Services Director (SSD) in the social services office, the SSD stated some of the residents who were transferred did not want to transfer to a different facility because they lived at SNF 1 for a long time. The SSD stated those residents were concerned prior to the transfer as to what would happen to them when the new owner took ownership of the facility. On 12/9/15 at 4:18 p.m., during an interview in the Administrator's office, the IA stated the facility had not provided any resident (including Resident 28 or her Responsible Party) that was transferred since 6/1/15 a 30 day advance written notice that included the intent to transfer, the reason for the pending transfer or discharge or the right to appeal the transfer or discharge. The IA stated, "We didn't do those." Review of the facility's administrative policy titled, "California Standard Admission Agreement for Skilled Nursing Facilities and Intermediate Care Facilities" pages eight to nine, dated May 2011 provided to all SNF 1 residents on admission indicated, "VI. Transfers and Discharges...Our written notice of transfer to another facility or discharge against your wishes will be provided 30 days in advance...Our written notice will include the effective day, the location to which you will be transferred or discharged, and the reason the action is necessary. The only reason that we can transfer you to another facility or discharge you against your wishes are: 1) It is required to protect your well-being because your needs cannot be met in our facility; 2) It is appropriate because your health has improved enough that you no longer need the services of our Facility; 3) Your presence in our Facility endangers the health and safety of other individuals; 4) You have not paid for your stay in our Facility or have not arranged to have payment made under Medicare, Medi-Cal, or private insurance; 5) Our Facility ceases to operate; 6) Material or fraudulent misrepresentation of your finances to us... In our written notice, we will advise you that you have the right to appeal the transfer or discharge to the California Department of Health Care Services, and we will also provide the name, address and telephone number of the State Long-Term Care Ombudsman."On 12/16/15 at 3 p.m., during a staff interview, the SSD stated she had worked for SNF 1 for the past seven years. The SSD stated the facility process for discharging residents had begun to change in April 2015. The SSD stated she had been assigned the responsibility to coordinate the discharge of the residents in the facility. The SSD stated that responsibility had previously been a nursing service responsibility. The SSD stated in June 2015 the Clinical Nurse Liaison (CNL) began to assist her with the discharge of residents. She stated the CNL facilitated discharges of residents to other company-owned skilled nursing facilities. The SSD stated when approached by families or residents she had discussed the pending transition, and informed the residents or/and their families the residents could remain at the facility or seek placement before the transition was set to occur, but she could not speak to what would occur after the business was sold. The SSD stated families were given the instruction discharge of the residents was inevitable sooner or later as the type of patients accepted would change to those who required more complex care than was provided in SNF 1. The SSD stated the residents were "fast tracked" to discharge as part of the change in the process. She stated, "The majority of families wanted to seek placement out of fear, not knowing what was going to happen...how could they not be [fearful]? As an employee it was very difficult...they [the facility] were not communicating properly...I felt pressured...that's been very stressful."On 12/17/15 at 7:30 a.m., during an interview, the CNL stated her role at SNF 1 during the transition of ownership was to assist with the discharge of residents from the facility. The CNL stated she learned of an ownership transition in a staff meeting and received direction from the Regional Director of Operations (RDO) to discharge residents. She stated, "I wasn't aware of the regulations...I was stuck in between...it's been a nightmare." The CNL stated, "If they [the residents] asked [what would happen to them], we told them about the change of ownership...don't know when it's going to happen...there was the feeling of uncertainty." Resident 28's Quarterly Social Services Discharge Planning Note dated 6/12/15 indicated under Family Resident Discharge Goals:, "Long Term Care." Under Barriers to Discharge Goals, it indicated, "Resident/Family is incapable of providing care [at] home." Under Discharge Imminent, it indicated, "No." Resident 28's clinical record titled, "MDS (Minimum Data Set) (a tool to assess residents cognitive and physical functional abilities) 3.0 Assessment," dated 9/7/15, indicated under Cognitive (pertaining to comprehension, memory and reasoning ability) Patterns a summary score of 15 out of 15 possible, which indicated she had no cognitive deficits. The assessment indicated Resident 28 required extensive assistance for eating and dressing and was unable to walk.Resident 28's Social Service (SS) Note dated 9/15/15 at 2:14 p.m., indicated, "... [Resident]...alert and oriented, capable of making her needs be known. ..Resident son is her Responsible Party [RP 14]...discharge is anticipated long term care... Resident and son attended goal meeting on 9-12-14. Resident would like to be discharged to another facility [SNF 12] to be closer to her son and where he lives..." Resident 28's Interdisciplinary Team (IDT) (a resident care team including nursing, dietary, social services and activity staff) Care Plan Conference Review dated 9/17/15, indicated under Areas Reviewed, a hash mark next to "Discharge Plan/Potential." IDT notes indicated, "Son/resident had requested [SNF 12] due to closer where he lives, [SNF 12] declined placement."Resident 28's SS Note dated 9/28/15 at 12:12 p.m., indicated, "Resident son with SSD [Social Services Director] ...expressing his concerns of him hearing from community of future changes with facility. SSD reassured him that resident is not being asked to leave. Son/resident is requesting for us to actively start looking for placement." Resident 28's SS Note dated 10/16/15 at 10:15 a.m., indicated, "Late entry. On 10-15-15 SSD met with son [name]. [Name] has heard from his mom/resident of facility transition...would like mom to transfer to [SNF 2] due to resident had been there before. SSD spoke with [SNF 2] and a bed was available. SSD informed resident and [son]. They requested to transfer to [SNF 2]." SS Note dated 10/16/15 at 10:19 a.m., indicated, "Resident [28] discharged to [SNF 2] on 10/16/15...Received order from Physician all paperwork provided." SS Note dated 10/16/15 at 1:31 p.m., indicated, "Resident [28] discharged to [SNF 2]...Resident was eager but a little nervous to go..." SS Note dated 10/20/15 at 10:04 a.m., indicated, "...SSD met with Resident [28] at [SNF 2] on Friday at 4:00 p.m....Resident appeared very happy, smiling. Had no concerns..."On 12/29/15 at 3 p.m., during an interview at SNF 2, Resident 28 stated she was transferred from SNF 1 because it was closing, and "they shipped everybody out." She stated she attended a patient care meeting and it was discussed that everyone was to leave, as SNF 1 was changing to a subacute center. Resident 28 further stated she was scared when told the residents would have to leave, because she didn't know where she would end up, her family lived nearby, and SNF 1 staff was talking about moving her to Sacramento. Resident 28 stated she was upset when she arrived at SNF 2 because she didn't know it well. Resident 28 stated on the first night at SNF 2 she fell while trying to get out of bed three times, and was upset. Resident 28 stated her son was also scared because he thought she may be transferred to Sacramento, as it was the main option at the time. Resident 28 stated, "Everybody was scared...what can you do about it? It [SNF 1] was like a home and we were told we had to leave....the ones without a voice are the ones you really feel sorry for." On 12/29/15 at 3:15 p.m., during an interview at SNF 2, Certified Nurse Assistant (CNA) 5 stated Resident 28 had not adjusted well to SNF 2. CNA 5 stated the resident fell the first night after admission, and fell several more times in the next few days, and now refuses to get out of bed. CNA 5 stated the resident does not participate in activities, and is fearful she won't receive her medication. CNA 5 further stated the day prior, 12/28/15, Resident 28 was crying, feeling depressed, and told CNA 5 to leave her alone. CNA 5 stated Resident 28 could not give a reason why she was crying. CNA 5 stated Resident 28 seemed to be confused more often.On 1/4/16 at 4:15 p.m., during an interview, Resident 28's Responsible Party (RP) 14 stated he was notified one day in advance of Resident 28's transfer. He stated at the time Resident 28 was discharged, SNF 1 staff were being laid off, so he felt Resident 28 needed to leave SNF 1. On 1/8/16 at 8 a.m., during an interview at SNF 1, the SSD stated IDT meetings were held for Resident 28 on 6/16/15 and 9/17/15. The SSD stated the IDT had not met prior to Resident 28's transfer to SNF 2 on 10/16/15 to discuss if it was a safe and appropriate transfer. The SSD stated Resident 28's discharge care plan was not updated for transfer to SNF 2. The SSD further stated SNF 2 did not provide any services that were not available at SNF 1. The SSD stated a 30 day notice of transfer that included the reason for transfer, the date of transfer, the location of the transfer, the right to appeal the transfer and the name and phone number of the state ombudsman was not provided to Resident 28 or RP 14 prior to the transfer. Therefore, the facility failed to honor and protect Resident 28's transfer and discharge rights. Resident 28 was transferred without ensuring the necessity to meet her medical or welfare needs and without reasonable notice. These violations resulted emotional and psychological distress for Resident 28 exhibited by fear, confusion and anxiety.These violations had a direct relationship to Resident 28's health, safety and security and thus constitute a Class B Citation. |
| 100000026 |
Valley Subacute & Rehabilitation Center |
040012105 |
B |
16-Mar-16 |
FZRR11 |
17245 |
42 Code of Federal Regulations Section 483.12(a)(2) Transfer and discharge requirements:The facility must permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless- (i) The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility; (ii) The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility; (iii) The safety of individuals in the facility is endangered; (iv) The health of individuals in the facility would otherwise be endangered; (v) The resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at the facility. For a resident who becomes eligible for Medicaid after admission to a nursing facility, the nursing facility may charge a resident only allowable charges under Medicaid; or (vi) The facility ceases to operate.Title 22 Section 72527 Patients' Rights: (a) Patients have the rights numerated in this section and the facility shall ensure 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 any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (6) To be transferred or discharged only for medical reasons, or the patient's welfare or that of other patient's or for nonpayment for his or her stay and to be given reasonable advance notice to ensure orderly transfer or discharge. Such actions shall be documented in the patient's health record. Title 22 Section 72519 Patient Transfer: (a) The licensee shall maintain written transfer agreements with other nearby health facilities to make the services of those facilities accessible and to facilitate the transfer of patients. Complete and accurate patient information, in sufficient detail to provide for continuity of care shall be transferred with the patient at time of transfer. (b) When a patient is transferred to another facility, the following shall be entered in the patient health record: (1) The date, time, condition of the patient and a written statement of the reason for the transfer. (2) Informed written or telephone acknowledgement of the patient, patient's guardian or authorized representative except in an emergency or as provided in Section 72527(a)(5). On 12/9/15 at 9:40 a.m., an unannounced visit was made to the facility to investigate anonymous complaint CA00468198 regarding the alleged violation of transfer and discharge rights. The facility failed to ensure Resident 29 was afforded the right to be transferred or discharged solely for medical reasons or for the resident's welfare, and to be given reasonable advance written notice to ensure a safe and orderly transfer or discharge. The facility transferred Resident 29 in order to accommodate the alleged plan of a potential new owner to convert the facility to a subacute setting (a specialized type of nursing service provided to Residents who require complex care or rehabilitation). As a result, Resident 29 was displaced from her home, transferred to an unfamiliar environment and suffered psychological and emotional distress and an increase in falls.Review of Resident 29's clinical record titled, "Face Sheet" indicated Resident 29 was admitted to the skilled nursing facility (SNF) 1 on 8/11/12 with diagnoses of dementia (memory loss) with behavioral disturbance, Alzheimer's disease ( a disease causing progressive dementia), and diabetes mellitus ( a disease which affects blood sugar). Resident 29 was transferred to SNF 2 on 7/9/15. On 12/9/15 at 9:40 a.m., during a tour of SNF 1, no residents were observed in the hallways, resident rooms or dining area in the West Wing of the facility. Four residents were observed sitting in the East Wing main dining room watching television. During a concurrent interview with the facility Interim Administrator (IA) the IA stated the current facility census was seven of 70 available beds licensed for skilled nursing residents. The IA stated the West Wing was closed. The IA stated three of the seven remaining residents were scheduled to transfer out of the facility later that day, 12/9/15, due to a "Change of ownership" of the facility. On 12/9/15 at 12:15 p.m., during a staff interview in the East Wing hallway, Licensed Nurse (LN) 1 stated residents who resided in the facility were transferred out of the facility due to new ownership expected to take place in the near future. LN 1 stated all residents had to transfer out of the facility. LN 1 stated the new owner planned to run a facility that did not include long term care skilled nursing residents. LN 1 stated most residents that transferred were sad and did not want to leave as the facility had been their home for a long time.On 12/9/15 at 1:30 p.m., during an interview with the Social Services Director (SSD) in the social services office, the SSD stated some of the residents who were transferred did not want to transfer to a different facility because they lived at SNF 1 for a long time. The SSD stated those residents were concerned prior to the transfer as to what would happen to them when the new owner took ownership of the facility. On 12/9/15 at 4:18 p.m., during an interview in the Administrator's office, the IA stated the facility had not provided any resident (including Resident 29 or her Responsible Party) that was transferred since 6/1/15 a 30 day advance written notice that included the intent to transfer, the reason for the pending transfer or discharge or the right to appeal the transfer or discharge. The IA stated, "We didn't do those." Review of the facility's administrative policy titled, "California Standard Admission Agreement for Skilled Nursing Facilities and Intermediate Care Facilities" pages eight to nine, dated May 2011, provided to all SNF 1 residents on admission indicated, "VI. Transfers and Discharges...Our written notice of transfer to another facility or discharge against your wishes will be provided 30 days in advance...Our written notice will include the effective day, the location to which you will be transferred or discharged, and the reason the action is necessary. The only reason that we can transfer you to another facility or discharge you against your wishes are: 1) It is required to protect your well-being because your needs cannot be met in our facility; 2) It is appropriate because your health has improved enough that you no longer need the services of our Facility; 3) Your presence in our Facility endangers the health and safety of other individuals; 4) You have not paid for your stay in our Facility or have not arranged to have payment made under Medicare, Medi-Cal, or private insurance; 5) Our Facility ceases to operate; 6) Material or fraudulent misrepresentation of your finances to us... In our written notice, we will advise you that you have the right to appeal the transfer or discharge to the California Department of Health Care Services, and we will also provide the name, address and telephone number of the State Long-Term Care Ombudsman."On 12/16/15 at 3 p.m., during a staff interview, the SSD stated she had worked for SNF 1 for the past seven years. The SSD stated the facility process for discharging residents had begun to change in April 2015. The SSD stated she had been assigned the responsibility to coordinate the discharge of the residents in the facility. The SSD stated that responsibility had previously been a nursing service responsibility. The SSD stated in June 2015 the Clinical Nurse Liaison (CNL) began to assist her with the discharge of residents. She stated the CNL facilitated discharges of residents to other company-owned skilled nursing facilities. The SSD stated when approached by families or residents she had discussed the pending transition, and informed the residents or/and their families the residents could remain at the facility or seek placement before the transition was set to occur, but she could not speak to what would occur after the business was sold. The SSD stated families were given the instruction discharge of the residents was inevitable sooner or later as the type of patients accepted would change to those who required more complex care than was provided in SNF 1. The SSD stated the residents were "fast tracked" to discharge as part of the change in the process. She stated, "The majority of families wanted to seek placement out of fear, not knowing what was going to happen...how could they not be [fearful]? As an employee it was very difficult...they [the facility] were not communicating properly...I felt pressured...that's been very stressful."On 12/17/15 at 7:30 a.m., during an interview, the CNL stated her role at SNF 1 during the transition of ownership was to assist with the discharge of residents from the facility. The CNL stated she learned of an ownership transition in a staff meeting and received direction from the Regional Director of Operations (RDO) to discharge residents. She stated, "I wasn't aware of the regulations...I was stuck in between...it's been a nightmare." The CNL stated, "If they [the residents] asked [what would happen to them], we told them about the change of ownership...don't know when it's going to happen...there was the feeling of uncertainty." Resident 29's SNF 1 clinical record titled, "MDS [Minimum Data Set] (a resident assessment tool to evaluate resident cognitive and physical abilities) 3.0 Assessment," dated 3/11/15, indicated under Cognitive (pertaining to comprehension, memory and reasoning ability) Patterns a summary score of 0 out of 15, which indicated she was severely impaired. The assessment indicated Resident 29 had no recall ability and no orientation to day, month, or year. Under Behavior, no resident behaviors were documented. Under Health Conditions, no indication of previous falls was documented. Under Functional Status, eating, personal hygiene, bathing, and dressing were scored 4/2, which indicated total dependence on staff, and required one person to physically assist her in these tasks.Resident 29's SNF 1 clinical record titled, "MDS 3.0 Assessment" dated 6/10/15, indicated the same cognitive summary score and functional scores as the afore mentioned above. The assessment indicated Resident 29 had no recent history of falls. Resident 29's Quarterly Social Services Discharge Planning Note dated 6/10/15, indicated under Family Resident Discharge Goals, "LTC [Long Term Care]. Under Discharge Plans or Discharge Barriers Reviewed with Resident, it indicated, "No." Under Discharge Imminent, it indicated, "No." The note was signed by the Social Services Director (SSD) on 6/18/15.Resident 29's SNF 1 Social Service (SS) Note dated 6/18/15, indicated, "Resident is...alert with confusion, mumbles in her speech...spouse...visits everyday 2 x (times) a day...Residents discharge is anticipated long term care due to spouse is incapable of providing care at home....Resident is incapable of being interviewed r/t [related to] DX [diagnosis] of dementia with behavior....Per staff interview resident has LTM [long term memory] and STM [short term memory loss. Resident is total dependent on all ADL's [Activities of Daily Living]." Resident 29's Interdisciplinary Team (IDT) (a resident care team including nursing, dietary, social services and activity staff) Care Plan Conference Review dated 6/23/15, under Areas Reviewed, indicated a hand marked hash mark which indicated, "Discharge Plan/Potential." IDT note dated 6/24/15 indicated, "IDT conducted a care plan conference with spouse...Resident discharge is anticipated long term care...attends some activities, passive observer..."Resident 29's SS Note dated 7/9/15, indicated, "...Resident anticipated discharge on 7-9-15 to [SNF 2] per [RP (Responsible Party)]. Bed availability has come available so spouse wants to take it...Physician notified with TO [telephone order] done, all appropriate paperwork done and sent to [SNF 2]." Review of Resident 29's SNF 1 clinical record titled, "Transfer/Discharge Summary" dated 7/9/15 contained an area to document, "Reason for Transfer/Discharge" with "Resident/Family Request" selected.Review of Resident 29's SNF 2 clinical record titled, "Incident/Accident Note," dated 7/10/15 at 1:31 a.m., indicated, "CNA [Certified Nurse Assistant]...reported that pt [patient] sustained a skin tear to her left elbow when she and another CNA [name], were transferring the pt. from her w/c [wheelchair] into her bed....first aid done...Reminded CNA's to be gentle when helping pt. due to fragile skin and reminded them to make sure pt's sleeve protectors are on properly to help prevent skin tears." Review of Resident 29's SNF 2 clinical record titled, "Incident/Accident Note," dated 7/15/15 at 7:02 a.m., indicated, "...Resident noted on floor next to her bed at 0430 [a.m.]. Resident lying on left side...Resident with baseline confusion and speech confused. Resident assisted back to bed...no apparent injuries...appeared to have slid off her bed...notified [RP]." Review of Resident 29's SNF 2 clinical record titled, "Incident/Accident Note," dated 7/15/15 at 4:06 p.m., indicated, "...Resident noted crawling out of bed with her hands on the landing pad...Help her back to bed. RP aware." Resident 29's SNF 2 Nurses Note dated 8/21/15 at 10:33 p.m., indicated, "S/P [Status Post] Fall with Head Injury #1...The RN [registered nurse] reported to this nurse that the res[ident] had fallen out of bed at [10:40 p.m.]. Res head was bleeding and a 1 cm [centimeter] laceration was present above eye brow. Res was assisted back to bed. Further inspection showed redness to left shoulder and left knee. DON [Director of Nursing] informed this nurse that she [Resident 29] was to sleep in her Geri chair. This was not communicated in report. CNA reports that she had not been told either....Wound Tx [treatment] and monitoring received. Res is not A&O [alert and oriented] and has contractures..." On 12/29/15 at 5 p.m., during an interview in the SNF 2 dining room, Resident 29's Responsible Party (RP) 15 stated he was notified by both the SNF 1 SSD and the Clinical Nurse Liaison (CNL) approximately the third week of June 2015 that all long term residents at SNF 1 would have to leave, and transfer somewhere else. RP 15 stated he was informed SNF 1 would transfer the resident anywhere within a 50 mile radius. RP 15 stated he became worried and began looking for placement himself as he was afraid Resident 29 would be transferred out of town. RP 15 stated he was unable to find a placement and became very concerned, looked for several weeks longer, and then received a telephone call from the SNF 1 CNL that a bed had been found at SNF 2. RP 15 stated once Resident 29 was admitted to SNF 2 there were adjustment problems, and Resident 29 fell seven or eight times. RP 15 stated during one fall Resident 29 sustained a black eye and a cut to her left eyelid. RP 15 stated he explained to the staff at SNF 2 how to place Resident 29's bed and to put a fall mat on the floor as they had done at SNF 1 to prevent falls. RP 15 stated SNF 2 did not know how the bed had been placed prior to transfer and Resident 29 had fallen the first night she spent in SNF 2.On 1/7/16 at 4:50 p.m., during a staff interview and concurrent clinical record review with the SSD in the SNF 1 social services office, the SSD stated RP 15 had been concerned regarding SNF 1's transition to new ownership. The SSD stated Resident 29's transfer to SNF 2 was sudden, and no formal assessment of Resident 29 had been done prior to transfer. The SSD stated the SNF 1 IDT, had not met prior to Resident 29's transfer to discuss whether it was a safe and appropriate transfer and the discharge care plan was not updated to plan for the transfer to SNF 2. The SSD stated SNF 2 did not provide any care for Resident 29 that SNF 1 could not provide. The SSD stated a 30 day notice of transfer that included the reason for transfer, the date of transfer, the location of the transfer, the right to appeal the transfer and the name and phone number of the state ombudsman was not provided to Resident 29 or RP 15 prior to the transfer. 1/11/16 at 4 p.m., during an interview at SNF 2, Unit Manager (UM) 1, stated Resident 29 had a difficult transition to SNF 2. UM 1stated Resident 29 sustained several falls after admission. UM 1 attributed the falls to the change in environment, which was new and strange to Resident 29. Therefore, the facility failed to honor and protect Resident 29's transfer and discharge rights. Resident 29 was transferred without ensuring the necessity to meet her medical or welfare needs and without reasonable notice. Resident 29 was transferred from her home of three years to an unfamiliar environment and as a result suffered emotional and psychological distress and an increase in falls.These violations had a direct relationship to Resident 29's health, safety and security and thus constitute a Class B Citation. |
| 100000026 |
Valley Subacute & Rehabilitation Center |
040012107 |
B |
16-Mar-16 |
FZRR11 |
14922 |
42 Code of Federal Regulations Section 483.12(a)(2) Transfer and discharge requirements:The facility must permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless- (i) The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility; (ii) The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility; (iii) The safety of individuals in the facility is endangered; (iv) The health of individuals in the facility would otherwise be endangered; (v) The resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at the facility. For a resident who becomes eligible for Medicaid after admission to a nursing facility, the nursing facility may charge a resident only allowable charges under Medicaid; or (vi) The facility ceases to operate.Title 22 Section 72527 Patients' Rights: (a) Patients have the rights numerated in this section and the facility shall ensure 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 any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (6) To be transferred or discharged only for medical reasons, or the patient's welfare or that of other patient's or for nonpayment for his or her stay and to be given reasonable advance notice to ensure orderly transfer or discharge. Such actions shall be documented in the patient's health record. Title 22 Section 72519 Patient Transfer: (a) The licensee shall maintain written transfer agreements with other nearby health facilities to make the services of those facilities accessible and to facilitate the transfer of patients. Complete and accurate patient information, in sufficient detail to provide for continuity of care shall be transferred with the patient at time of transfer. (b) When a patient is transferred to another facility, the following shall be entered in the patient health record: (1) The date, time, condition of the patient and a written statement of the reason for the transfer. (2) Informed written or telephone acknowledgement of the patient, patient's guardian or authorized representative except in an emergency or as provided in Section 72527(a)(5). On 12/9/15 at 9:40 a.m., an unannounced visit was made to the facility to investigate anonymous complaint CA00468198 regarding the alleged violation of transfer and discharge rights. The facility failed to ensure Resident 30 was afforded the right to be transferred or discharged solely for medical reasons or for the resident's welfare, and to be given reasonable advance written notice to ensure a safe and orderly transfer or discharge. The facility transferred Resident 30 in order to accommodate the alleged plan of a potential new owner to convert the facility to a subacute setting (a specialized type of nursing service provided to Residents who require complex care or rehabilitation). As a result, Resident 30 was displaced from her home and suffered psychological and emotional distress.Review of Resident 30's clinical record titled, "Face Sheet" indicated Resident 30 was admitted to the skilled nursing facility (SNF) 1 on 5/19/15 with diagnoses that included diabetes mellitus (disease that affects blood sugar) and chronic pain. Resident 30 was transferred from SNF 1 to SNF 9 on 9/11/15. On 12/9/15 at 9:40 a.m., during a tour of SNF 1, no residents were observed in the hallways, resident rooms or dining area in the West Wing of the facility. Four residents were observed sitting in the East Wing main dining room watching television. During a concurrent interview with the facility Interim Administrator (IA) the IA stated the current facility census was seven of 70 available beds licensed for skilled nursing residents. The IA stated the West Wing was closed. The IA stated three of the seven remaining residents were scheduled to transfer out of the facility later that day, 12/9/15, due to a "Change of ownership" of the facility. On 12/9/15 at 12:15 p.m., during a staff interview in the East Wing hallway, Licensed Nurse (LN) 1 stated residents who resided in the facility were transferred out of the facility due to new ownership expected to take place in the near future. LN 1 stated all residents had to transfer out of the facility. LN 1 stated the new owner planned to run a facility that did not include long term care skilled nursing residents. LN 1 stated most residents that transferred were sad and did not want to leave as the facility had been their home for a long time.On 12/9/15 at 1:30 p.m., during an interview with the Social Services Director (SSD) in the social services office, the SSD stated some of the residents who were transferred did not want to transfer to a different facility because they lived at SNF 1 for a long time. The SSD stated those residents were concerned prior to the transfer as to what would happen to them when the new owner took ownership of the facility. On 12/9/15 at 4:18 p.m., during an interview in the Administrator's office, the IA stated the facility had not provided any resident (including Resident 30) that was transferred since 6/1/15 a 30 day advance written notice that included the intent to transfer, the reason for the pending transfer or discharge or the right to appeal the transfer or discharge. The IA stated, "We didn't do those." Review of the facility's administrative policy titled, "California Standard Admission Agreement for Skilled Nursing Facilities and Intermediate Care Facilities" pages eight to nine, dated May 2011, provided to all SNF 1 residents on admission indicated, "VI. Transfers and Discharges...Our written notice of transfer to another facility or discharge against your wishes will be provided 30 days in advance...Our written notice will include the effective day, the location to which you will be transferred or discharged, and the reason the action is necessary. The only reason that we can transfer you to another facility or discharge you against your wishes are: 1) It is required to protect your well-being because your needs cannot be met in our facility; 2) It is appropriate because your health has improved enough that you no longer need the services of our Facility; 3) Your presence in our Facility endangers the health and safety of other individuals; 4) You have not paid for your stay in our Facility or have not arranged to have payment made under Medicare, Medi-Cal, or private insurance; 5) Our Facility ceases to operate; 6) Material or fraudulent misrepresentation of your finances to us... In our written notice, we will advise you that you have the right to appeal the transfer or discharge to the California Department of Health Care Services, and we will also provide the name, address and telephone number of the State Long-Term Care Ombudsman."On 12/16/15 at 3 p.m., during a staff interview, the SSD stated she had worked for SNF 1 for the past seven years. The SSD stated the facility process for discharging residents had begun to change in April 2015. The SSD stated she had been assigned the responsibility to coordinate the discharge of the residents in the facility. The SSD stated that responsibility had previously been a nursing service responsibility. The SSD stated in June 2015 the Clinical Nurse Liaison (CNL) began to assist her with the discharge of residents. She stated the CNL facilitated discharges of residents to other company-owned skilled nursing facilities. The SSD stated when approached by families or residents she had discussed the pending transition, and informed the residents or/and their families the residents could remain at the facility or seek placement before the transition was set to occur, but she could not speak to what would occur after the business was sold. The SSD stated families were given the instruction discharge of the residents was inevitable sooner or later as the type of patients accepted would change to those who required more complex care than was provided in SNF 1. The SSD stated the residents were "fast tracked" to discharge as part of the change in the process. She stated, "The majority of families wanted to seek placement out of fear, not knowing what was going to happen...how could they not be [fearful]? As an employee it was very difficult...they [the facility] were not communicating properly...I felt pressured...that's been very stressful."On 12/17/15 at 7:30 a.m., during an interview, the CNL stated her role at SNF 1 during the transition of ownership was to assist with the discharge of residents from the facility. The CNL stated she learned of an ownership transition in a staff meeting and received direction from the Regional Director of Operations (RDO) to discharge residents. She stated, "I wasn't aware of the regulations...I was stuck in between...it's been a nightmare." The CNL stated, "If they [the residents] asked [what would happen to them], we told them about the change of ownership...don't know when it's going to happen...there was the feeling of uncertainty." Resident 30's SNF 1 clinical record titled, "MDS [Minimum Data Set] (a resident assessment tool to evaluate resident cognitive and physical abilities) 3.0 Assessment," dated 8/27/15, indicated short and long term memory problems. Under Daily Decision Making Resident 30 was coded 1, which indicated some difficulty in new situations. Under Behavior, no behaviors were documented. Under Functional Status, transfer, walking, feeding, eating, and hygiene were scored 1/1, which indicated supervision was required.Resident 30's Social Service (SS) Note dated 8/27/15 at 4:22 p.m., indicated, "...female with confusion, capable of making her needs be known...Resident's daughter [name] is responsible party [RP]. Resident discharge plan is anticipated long term care..." Resident 30's SNF 1 Nurses Note dated 9/10/15 at 3:25 a.m., indicated, "Resident is on charting for weight loss of 5.8 lbs. [pounds] in one month. Resident is alert and oriented x 4...." Resident 30's Social Services (SS) Note dated 9/10/15 at 2:25 p.m., indicated, "[Hospice] is aware [through] community that the facility has a transition that's going to happen. [Hospice] is proactive on discharging/transitioning resident to another facility and has concerns of waiting. [Hospice] contacted [SNF 9] and was informed that they had availability. [Hospice] spoke with RP [responsible party] and resident moving now to [SNF 9] due to a bed available. Resident daughter visited [SNF 9] on 9-9-15 and liked it. RP/resident agreed..." Physician Communication Fax (facsimile) Request dated 9/10/15, indicated under Request, "Resident [30] will discharge on 9-11-15 to [SNF 9]. The request was signed by MD 1 on 9/10/15. Resident 30's Transfer/Discharge Summary-Post Discharge Plan of Care dated 9/11/15, under Reason for Transfer/Discharge, indicated by hash mark, "Other, Please Explain." Under Summary of Stay it indicated, "Admit on 5/19/15 with [vendor] Hospice for long term care........Res will be going to [SNF 9] acute."Resident 30's SS Note dated 9/11/15 at 10:50 a.m., indicated, "...Resident left facility today at 10:30 am via [by way of ] ambulance. Resident is alert and oriented x 3 [oriented to person, place and time] and is able to communicate wants and needs to staff..." Resident 30's SS Note dated 9/11/15 at 3:48 p.m., indicated, "Resident discharged on 9-11-15 to [SNF 9]. [SNF 1] staff assisted with taking residents belongings to new facility, resident appeared at new facility settling in real good. Resident took her wheel chair and walker..."Resident 30's SNF 9 Health Status Note dated 9/11/15 at 11:12 p.m., indicated, "... [Resident]... has episodes of anxiousness..." Resident 30's SNF 9 Health Status Note dated 9/14/15, indicated, "Resident has an abundance of clothing and items that have been brought with her from previous facility... SSD went through belongings with resident upon arrival, res[ident] is extremely hesitant to donate or allow her daughter to store at home. Resident has been made aware that her belongings will need to be donated or stored at a family member's home/storage."On 12/31/15 at 10:20 a.m., during an interview in SNF 9, Resident 30 stated she could not remember what SNF 1 had told her about her transfer to SNF 9. Resident 30 became tearful, began to cry, and stated, "Where I was staying, they didn't want me anymore...they threw me out like a dog." Resident 30 stated, "I've been moved and moved...I can't take it anymore. I know we're guinea pigs. I could make myself a home, but I'm just tired of being moved...I'm afraid to do the wrong thing." Resident 30 stated she does not go out of her room because she is afraid she will be blamed for something. On 12/31/15 at 10:40 a.m., during an interview at SNF 9, Nursing Supervisor (NS) 1 was asked regarding Resident 30's adjustment to SNF 9. NS 1 stated it was hard to say.On 1/8/16 at 10:05 a.m., during an interview and concurrent record review with the SSD at SNF 1, the SSD stated an Interdisciplinary Team (IDT) (a resident care team including nursing, dietary, social services and activity staff) meeting was held on 9/8/15, but no discussion took place to assess if the transfer to SNF 9 was safe and appropriate for Resident 30. The SSD stated the discharge care plan was not updated for Resident 30's transfer to SNF 9. The SSD stated the record indicated the first documentation of potential transfer of Resident 30 to SNF 9 was on 9/9/15 and the resident was transferred on 9/11/15. The SSD stated a 30 day notice of transfer that included the reason for transfer, the date of transfer, the location of the transfer, the right to appeal the transfer and the name and phone number of the state ombudsman was not provided to Resident 30 or her responsible party prior to the transfer. On 2/4/16 at 10 a.m., during a telephone interview, Hospice Director (HD) stated Resident 30 was transferred to SNF 9 because SNF 1 was changing to a facility that provided subacute care and Resident 30 required long term care. The HD stated the transfer was not prompted or required for purposes of Resident 30's treatment by hospice.Therefore, the facility failed to honor and protect Resident 30's transfer and discharge rights. Resident 30 was transferred without ensuring the necessity to meet her medical or welfare needs and without reasonable notice. These violations resulted in anxiety and emotional and psychological distress for Resident 30.These violations had a direct relationship to Resident 30's health, safety and security and thus constitute a Class B Citation. |
| 100000026 |
Valley Subacute & Rehabilitation Center |
040012108 |
B |
16-Mar-16 |
FZRR11 |
16334 |
42 Code of Federal Regulations Section 483.12(a)(2) Transfer and discharge requirements:The facility must permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless- (i) The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility; (ii) The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility; (iii) The safety of individuals in the facility is endangered; (iv) The health of individuals in the facility would otherwise be endangered; (v) The resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at the facility. For a resident who becomes eligible for Medicaid after admission to a nursing facility, the nursing facility may charge a resident only allowable charges under Medicaid; or (vi) The facility ceases to operate.Title 22 Section 72527 Patients' Rights: (a) Patients have the rights numerated in this section and the facility shall ensure 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 any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (6) To be transferred or discharged only for medical reasons, or the patient's welfare or that of other patient's or for nonpayment for his or her stay and to be given reasonable advance notice to ensure orderly transfer or discharge. Such actions shall be documented in the patient's health record. Title 22 Section 72519 Patient Transfer: (a) The licensee shall maintain written transfer agreements with other nearby health facilities to make the services of those facilities accessible and to facilitate the transfer of patients. Complete and accurate patient information, in sufficient detail to provide for continuity of care shall be transferred with the patient at time of transfer. (b) When a patient is transferred to another facility, the following shall be entered in the patient health record: (1) The date, time, condition of the patient and a written statement of the reason for the transfer. (2) Informed written or telephone acknowledgement of the patient, patient's guardian or authorized representative except in an emergency or as provided in Section 72527(a)(5). On 12/9/15 at 9:40 a.m., an unannounced visit was made to the facility to investigate anonymous complaint CA00468198 regarding the alleged violation of transfer and discharge rights. The facility failed to ensure Resident 31 was afforded the right to be transferred or discharged solely for medical reasons or for the resident's welfare, and to be given reasonable advance written notice to ensure a safe and orderly transfer or discharge. The facility transferred Resident 31 in order to accommodate the alleged plan of a potential new owner to convert the facility to a subacute setting (a specialized type of nursing service provided to Residents who require complex care or rehabilitation). As a result, Resident 31 was displaced from her home and her family. Review of Resident 31's clinical record titled, "Face Sheet" indicated Resident 31 was admitted to the skilled nursing facility (SNF) 1 on 10/5/14 with diagnoses that included major depressive disorder and failure to thrive (weight loss and general decline). Resident 31 was transferred from SNF 1 to SNF 14 on 12/8/15.On 12/9/15 at 9:40 a.m., during a tour of SNF 1, no residents were observed in the hallways, resident rooms or dining area in the West Wing of the facility. Four residents were observed sitting in the East Wing main dining room watching television. During a concurrent interview with the facility Interim Administrator (IA) the IA stated the current facility census was seven of 70 available beds licensed for skilled nursing residents. The IA stated the West Wing was closed. The IA stated three of the seven remaining residents were scheduled to transfer out of the facility later that day, 12/9/15, due to a "Change of ownership" of the facility. On 12/9/15 at 12:15 p.m., during a staff interview in the East Wing hallway, Licensed Nurse (LN) 1 stated residents who resided in the facility were transferred out of the facility due to new ownership expected to take place in the near future. LN 1 stated all residents had to transfer out of the facility. LN 1 stated the new owner planned to run a facility that did not include long term care skilled nursing residents. LN 1 stated most residents that transferred were sad and did not want to leave as the facility had been their home for a long time.On 12/9/15 at 1:30 p.m., during an interview with the Social Services Director (SSD) in the social services office, the SSD stated some of the residents who were transferred did not want to transfer to a different facility because they lived at SNF 1 for a long time. The SSD stated those residents were concerned prior to the transfer as to what would happen to them when the new owner took ownership of the facility. On 12/9/15 at 4:18 p.m., during an interview in the Administrator's office, the IA stated the facility had not provided any resident (including Resident 31 or her Responsible Party) that was transferred since 6/1/15 a 30 day advance written notice that included the intent to transfer, the reason for the pending transfer or discharge or the right to appeal the transfer or discharge. The IA stated, "We didn't do those." Review of the facility's administrative policy titled, "California Standard Admission Agreement for Skilled Nursing Facilities and Intermediate Care Facilities" pages eight to nine, dated May 2011, provided to all SNF 1 residents on admission indicated, "VI. Transfers and Discharges...Our written notice of transfer to another facility or discharge against your wishes will be provided 30 days in advance...Our written notice will include the effective day, the location to which you will be transferred or discharged, and the reason the action is necessary. The only reason that we can transfer you to another facility or discharge you against your wishes are: 1) It is required to protect your well-being because your needs cannot be met in our facility; 2) It is appropriate because your health has improved enough that you no longer need the services of our Facility; 3) Your presence in our Facility endangers the health and safety of other individuals; 4) You have not paid for your stay in our Facility or have not arranged to have payment made under Medicare, Medi-Cal, or private insurance; 5) Our Facility ceases to operate; 6) Material or fraudulent misrepresentation of your finances to us... In our written notice, we will advise you that you have the right to appeal the transfer or discharge to the California Department of Health Care Services, and we will also provide the name, address and telephone number of the State Long-Term Care Ombudsman."On 12/16/15 at 3 p.m., during a staff interview, the SSD stated she had worked for SNF 1 for the past seven years. The SSD stated the facility process for discharging residents had begun to change in April 2015. The SSD stated she had been assigned the responsibility to coordinate the discharge of the residents in the facility. The SSD stated that responsibility had previously been a nursing service responsibility. The SSD stated in June 2015 the Clinical Nurse Liaison (CNL) began to assist her with the discharge of residents. She stated the CNL facilitated discharges of residents to other company-owned skilled nursing facilities. The SSD stated when approached by families or residents she had discussed the pending transition, and informed the residents or/and their families the residents could remain at the facility or seek placement before the transition was set to occur, but she could not speak to what would occur after the business was sold. The SSD stated families were given the instruction discharge of the residents was inevitable sooner or later as the type of patients accepted would change to those who required more complex care than was provided in SNF 1. The SSD stated the residents were "fast tracked" to discharge as part of the change in the process. She stated, "The majority of families wanted to seek placement out of fear, not knowing what was going to happen...how could they not be [fearful]? As an employee it was very difficult...they [the facility] were not communicating properly...I felt pressured...that's been very stressful."On 12/17/15 at 7:30 a.m., during an interview, the CNL stated her role at SNF 1 during the transition of ownership was to assist with the discharge of residents from the facility. The CNL stated she learned of an ownership transition in a staff meeting and received direction from the Regional Director of Operations (RDO) to discharge residents. She stated, "I wasn't aware of the regulations...I was stuck in between...it's been a nightmare." The CNL stated, "If they [the residents] asked [what would happen to them], we told them about the change of ownership...don't know when it's going to happen...there was the feeling of uncertainty." Resident 31's SNF 1 clinical record titled, "MDS [Minimum Data Set] (a resident assessment tool to evaluate resident cognitive and physical abilities) 3.0 Assessment," dated 10/5/15, indicated under Cognitive (pertaining to comprehension, memory and reasoning ability) Functions Resident 31 was unable to complete the assessment, and coded 3, which indicated severely impaired, had no recall and was unable to correctly state the correct day, month, and year. Under Behavior, no behaviors were documented. Under Functional Status, resident transfer, dressing, personal hygiene and bathing were coded to indicate she was totally dependent and required one person physical assist to accomplish the tasks.Resident 31's Interdisciplinary Team (IDT) (a resident care team including nursing, dietary, social services and activity staff) Care Plan Conference Review dated 7/30/15, under Areas Reviewed, indicated a hash mark next to, "Discharge Plan/Potential. IDT notes indicated, "...Resident RP [responsible party] didn't attend meeting...Resident has behaviors resisting care, hitting, yelling, cursing [at] staff during care or positioning her. Resident needs lots of redirection. Resident has an increase in confusion with aggressive behaviors...Resident discharge is anticipated long term care." Resident 31's Quarterly Social Services (SS) Discharge Planning Note dated 10/5/15, under Barriers to Discharge Goals, indicated, "Resident is incapable of living independently." Under Discharge Plans or Discharge Barriers Reviewed with Resident, it indicated, "No," under With Family, "Yes." Under Discharge Imminent, it indicated, "No." Resident 31's SS Note dated 10/8/15 at 2:39 p.m., indicated, "[Resident 31] alert and oriented with confusion...Resident son is her responsible party [RP 17]. RP invited to care conference...Resident son is invited to care plan meeting. Staff interview was conducted due to behaviors of resident and confusion...Resident resists care, refusing showers and taking medications. Resident has persistent anger with self or others, gets verbal[ly] abusive during care. Resident had repetitive verbalization, calling out. Staff redirect when behaviors occur..." Resident 31's IDT Care Plan Conference Review dated 10/13/15, indicated neither resident nor resident's RP attended the meeting. Under Areas Reviewed, a hash mark was indicated next to, "Discharge Plan/Potential. IDT notes indicated, "IDT conducted a care plan conference with no family attending...Resident discharge anticipated LTC [Long Term Care]." Resident 31's Transfer/Discharge Summary-Post Discharge Plan of Care dated 12/8/15, under Reason for Transfer/Discharge, indicated a hash mark next toOther, Please Explain. A handwritten note indicated, "long term care." Under Summary of Care it indicated, "Admitted 10/5/14 for long term care discharged on 12/8/15." Resident 31's Social Services (SS) Note dated 12/8/15 at 2:31 p.m., indicated, "...Resident anticipated discharge on 12/8/15 at 2:30 p.m....Resident RP notified." Resident 31's SS Note dated 12/98/15 at 3:24 p.m., indicated, "...Resident discharged on 12-8-15 at 2:30 p.m....Resident RP notified." Resident 31's SS Note dated 12/10/15 at 7:04 am, indicated, "Late entry: On 11-4-15 resident son was in facility visiting. Resident asked what's happening in facility that he heard from a family member that visits we were closing. SSD explained what I new [I knew] of transition. SSD reassured him that resident can remain here....Son lives in [city] and asked to seek closer to him...Son stated he had already been seeking previously."On 12/29/15 at 8:30 a.m., during an observation, Resident 31 was observed alert, dressed, and sitting in her wheelchair at the bedside. On interview attempt, she was confused, unable to state where she was, and unable to answer simple questions. On 12/29/15 at 8:35 a.m., during an interview at SNF 14, LN 8 was asked regarding Resident 31's adjustment to SNF 14. She stated the resident had good days and bad days, and often yells at the staff, ate in her room and attended, but didn't participate, in SNF 14 activities. On 1/4/16 at 2:50 p.m., during a telephone interview, RP 17 stated he had been informed by SNF 1 staff in November 2015 that SNF 1 was no longer going to be providing care to long term residents and Resident 31 would need to transfer. RP 17 stated he received a phone call from SNF 1's SSD on 12/8/15 at 11 a.m. the resident was being transferred to another city, and she was transferred at 2:15 p.m. that same day. RP 17 stated, "It surprised me, they called me and stated my mother had to go and that they could move her right now...I was very upset." RP 17 requested to visit the facility before her transfer, but was denied. RP 17 further stated, "What really gets to me, and what hurts me, is that they moved her so fast, I didn't have a chance to see her first." RP 17 stated he did not have a choice about where Resident 31 was transferred, and was told if he did not accept the transfer his mother would be discharged home with him. He stated he would never allow SNF 1 to care for his mother again because of the way SNF 1 treated his mother. RP 17 stated, "Her dentures didn't come with her, her TV didn't come with her; this was very upsetting how this happened...they moved mom out of an environment she was used to and moved her to a strange place." RP 17 stated he had not received any advanced written notice regarding the reasons for the transfer or the location of the transfer. On 1/7/16 at 2:10 p.m., during a concurrent interview and record review with the SSD at SNF 1, the SSD stated RP 17 learned of the SNF 1 transition while in SNF 1, and asked her about it. The SSD stated the distance of SNF 14 from SNF 1was not discussed with RP 17 prior to the decision to transfer Resident 31. The SSD stated it was his choice to seek placement. The SSD stated the SNF 1IDT had not met prior to Resident 31's transfer to discuss whether it was a safe and appropriate transfer and the discharge care plan was not updated to plan for the transfer to SNF 14. The SSD stated SNF 14 did not provide any care for Resident 31 that SNF 1 could not provide. The SSD stated a 30 day notice of transfer that included the reason for transfer, the date of transfer, the location of the transfer, the right to appeal the transfer and the name and phone number of the state ombudsman was not provided to Resident 31 or RP 17 prior to the transfer. Review of www.Mapquest.com, an Internet navigation system, indicated SNF 14 was located a distance of 49 miles from SNF 1.Therefore, the facility failed to honor and protect Resident 31's transfer and discharge rights. Resident 31 was transferred from her home and her family without ensuring the necessity to meet her medical or welfare needs and without reasonable notice.These violations had a direct relationship to Resident 31's health, safety and security and thus constitute a Class B Citation. |
| 100000026 |
Valley Subacute & Rehabilitation Center |
040012109 |
B |
16-Mar-16 |
FZRR11 |
13437 |
42 Code of Federal Regulations Section 483.12(a)(2) Transfer and discharge requirements:The facility must permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless- (i) The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility; (ii) The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility; (iii) The safety of individuals in the facility is endangered; (iv) The health of individuals in the facility would otherwise be endangered; (v) The resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at the facility. For a resident who becomes eligible for Medicaid after admission to a nursing facility, the nursing facility may charge a resident only allowable charges under Medicaid; or (vi) The facility ceases to operate.Title 22 Section 72527 Patients' Rights: (a) Patients have the rights numerated in this section and the facility shall ensure 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 any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (6) To be transferred or discharged only for medical reasons, or the patient's welfare or that of other patient's or for nonpayment for his or her stay and to be given reasonable advance notice to ensure orderly transfer or discharge. Such actions shall be documented in the patient's health record. Title 22 Section 72519 Patient Transfer: (a) The licensee shall maintain written transfer agreements with other nearby health facilities to make the services of those facilities accessible and to facilitate the transfer of patients. Complete and accurate patient information, in sufficient detail to provide for continuity of care shall be transferred with the patient at time of transfer. (b) When a patient is transferred to another facility, the following shall be entered in the patient health record: (1) The date, time, condition of the patient and a written statement of the reason for the transfer. (2) Informed written or telephone acknowledgement of the patient, patient's guardian or authorized representative except in an emergency or as provided in Section 72527(a)(5). On 12/9/15 at 9:40 a.m., an unannounced visit was made to the facility to investigate anonymous complaint CA00468198 regarding the alleged violation of transfer and discharge rights. The facility failed to ensure Resident 32 was afforded the right to be transferred or discharged solely for medical reasons or for the resident's welfare, and to be given reasonable advance written notice to ensure a safe and orderly transfer or discharge. The facility transferred Resident 32 in order to accommodate the alleged plan of a potential new owner to convert the facility to a subacute setting (a specialized type of nursing service provided to Residents who require complex care or rehabilitation). As a result, Resident 32 was displaced from her home without her consent and without the necessity for her medical or welfare needs.Review of Resident 32's clinical record titled, "Face Sheet" indicated Resident 32 was admitted to the skilled nursing facility (SNF) 1 on 5/22/14 with diagnoses that included intestinal (bowel) obstruction, pain and muscle weakness. The "Face Sheet" indicated Resident 32 was responsible for her own medical and financial decisions. Resident 32 was transferred from SNF 1 to SNF 5 on 10/19/15. On 12/9/15 at 9:40 a.m., during a tour of SNF 1, no residents were observed in the hallways, resident rooms or dining area in the West Wing of the facility. Four residents were observed sitting in the East Wing main dining room watching television. During a concurrent interview with the facility Interim Administrator (IA) the IA stated the current facility census was seven of 70 available beds licensed for skilled nursing residents. The IA stated the West Wing was closed. The IA stated three of the seven remaining residents were scheduled to transfer out of the facility later that day, 12/9/15, due to a "Change of ownership" of the facility. On 12/9/15 at 12:15 p.m., during a staff interview in the East Wing hallway, Licensed Nurse (LN) 1 stated residents who resided in the facility were transferred out of the facility due to new ownership expected to take place in the near future. LN 1 stated all residents had to transfer out of the facility. LN 1 stated the new owner planned to run a facility that did not include long term care skilled nursing residents. LN 1 stated most residents that transferred were sad and did not want to leave as the facility had been their home for a long time.On 12/9/15 at 1:30 p.m., during an interview with the Social Services Director (SSD) in the social services office, the SSD stated some of the residents who were transferred did not want to transfer to a different facility because they lived at SNF 1 for a long time. The SSD stated those residents were concerned prior to the transfer as to what would happen to them when the new owner took ownership of the facility. On 12/9/15 at 4:18 p.m., during an interview in the Administrator's office, the IA stated the facility had not provided any resident (including Resident 32) that was transferred since 6/1/15 a 30 day advance written notice that included the intent to transfer, the reason for the pending transfer or discharge or the right to appeal the transfer or discharge. The IA stated, "We didn't do those." Review of the facility's administrative policy titled, "California Standard Admission Agreement for Skilled Nursing Facilities and Intermediate Care Facilities" pages eight to nine, dated May 2011, provided to all SNF 1 residents on admission indicated, "VI. Transfers and Discharges...Our written notice of transfer to another facility or discharge against your wishes will be provided 30 days in advance...Our written notice will include the effective day, the location to which you will be transferred or discharged, and the reason the action is necessary. The only reason that we can transfer you to another facility or discharge you against your wishes are: 1) It is required to protect your well-being because your needs cannot be met in our facility; 2) It is appropriate because your health has improved enough that you no longer need the services of our Facility; 3) Your presence in our Facility endangers the health and safety of other individuals; 4) You have not paid for your stay in our Facility or have not arranged to have payment made under Medicare, Medi-Cal, or private insurance; 5) Our Facility ceases to operate; 6) Material or fraudulent misrepresentation of your finances to us... In our written notice, we will advise you that you have the right to appeal the transfer or discharge to the California Department of Health Care Services, and we will also provide the name, address and telephone number of the State Long-Term Care Ombudsman."On 12/16/15 at 3 p.m., during a staff interview, the SSD stated she had worked for SNF 1 for the past seven years. The SSD stated the facility process for discharging residents had begun to change in April 2015. The SSD stated she had been assigned the responsibility to coordinate the discharge of the residents in the facility. The SSD stated that responsibility had previously been a nursing service responsibility. The SSD stated in June 2015 the Clinical Nurse Liaison (CNL) began to assist her with the discharge of residents. She stated the CNL facilitated discharges of residents to other company-owned skilled nursing facilities. The SSD stated when approached by families or residents she had discussed the pending transition, and informed the residents or/and their families the residents could remain at the facility or seek placement before the transition was set to occur, but she could not speak to what would occur after the business was sold. The SSD stated families were given the instruction discharge of the residents was inevitable sooner or later as the type of patients accepted would change to those who required more complex care than was provided in SNF 1. The SSD stated the residents were "fast tracked" to discharge as part of the change in the process. She stated, "The majority of families wanted to seek placement out of fear, not knowing what was going to happen...how could they not be [fearful]? As an employee it was very difficult...they [the facility] were not communicating properly...I felt pressured...that's been very stressful."On 12/17/15 at 7:30 a.m., during an interview, the CNL stated her role at SNF 1 during the transition of ownership was to assist with the discharge of residents from the facility. The CNL stated she learned of an ownership transition in a staff meeting and received direction from the Regional Director of Operations (RDO) to discharge residents. She stated, "I wasn't aware of the regulations...I was stuck in between...it's been a nightmare." The CNL stated, "If they [the residents] asked [what would happen to them], we told them about the change of ownership...don't know when it's going to happen...there was the feeling of uncertainty." Review of Resident 32's clinical record titled, "MDS (Minimum Data Set) (a tool used to assess residents cognitive and physical abilities) 3.0 Assessment," indicated a Brief Interview for Mental Status (BIMS) score was 9 on a scale of 15 with 9 indicating moderate cognitive (pertaining to comprehension, memory and reasoning ability) impairment. The "MDS 3.0 Assessment" indicated Resident 32 required extensive assistance from SNF staff for bed mobility, walking, dressing, toileting and personal hygiene.Review of Resident 32's clinical record titled, "Interdisciplinary Team (IDT) (a resident care team including nursing, dietary, social services and activity staff) Care Plan Review," dated 7/28/15 indicated Resident 32 did not attend the care conference but her Family Member (FM) 11 participated by telephone. The IDT Note indicated, "Son [FM 11] goal is to discharge resident [Resident 32] to San Diego area where he lives." The IDT Note was signed by SSD 1. Review of Resident 32's clinical record titled, "Departmental Notes: Social Service Note," dated 9/15/15 indicated, "...[FM 11] in search with SSD assisting with getting resident [Resident 32] discharged to San Diego area to be closer to family..." Review of Resident 32's clinical record titled, "Departmental Notes: Social Service Note," dated 10/19/15, indicated, "...resident is scheduled today to be transferred to [SNF 5]..." Review of Resident 32's clinical record titled, "Departmental Notes: Social Service Note," dated 10/23/15, indicated "Social Service discharge note: Late Entry: Resident [Resident 32] discharged on 10/19/15 to [SNF 5]..." On 12/14/15 at 2:10 p.m., during an interview in Resident 32's room in SNF 5, Resident 32 stated she wanted to be transferred to San Diego to be closer to her family. Resident 32 stated she did not know she was moving to SNF 5. Resident 32 stated, "One day they just picked me up and moved me here. They never gave any warning. I didn't know I was moving until the day I moved. I didn't know what I could do or not do [about the transfer]. I wasn't in the mood to ask questions. That's what they did to me. They didn't tell me why they moved me here [to SNF 5]." Review of website "www.Mapquest.com" indicated SNF 5 was 375 miles and 6 hours driving time from San Diego. On 1/7/16 at 12:50 p.m., during a staff interview and concurrent clinical record review with the SSD in the SNF 1 Social Services office, the SSD stated Resident 32 had not requested to move to SNF 5 but had agreed to do so. The SSD stated she had been unable to locate a facility in San Diego for Resident 32. The SSD stated FM 11 was aware of the SNF 1 transition to new ownership and was concerned about what would happen to Resident 32 and agreed to the transfer to SNF 5. The SSD confirmed the intent to transfer Resident 32 to SNF 5 was first documented in the clinical record on 10/19/15, the day of the transfer. The SSD stated the SNF 1IDT had not met prior to Resident 32's transfer to discuss whether it was a safe and appropriate transfer and the discharge care plan had not been updated to plan for the transfer to SNF 5. The SSD stated SNF 5 did not provide any services that could not be provided at SNF 1, the level of care was the same and SNF 5 was owned by the same company as SNF 1. The SSD stated a 30 day notice of transfer that included the reason for transfer, the date of transfer, the location of the transfer, the right to appeal the transfer and the name and phone number of the state ombudsman had not been provided to Resident 32 or FM 11 prior to the transfer.Therefore, the facility failed to honor and protect Resident 32's transfer and discharge rights. Resident 32 was transferred without her consent, without ensuring the necessity to meet her medical or welfare needs and without reasonable notice.These violations had a direct relationship to Resident 32's health, safety and security and thus constitute a Class B Citation. |
| 100000026 |
Valley Subacute & Rehabilitation Center |
040012110 |
B |
16-Mar-16 |
FZRR11 |
13082 |
42 Code of Federal Regulations Section 483.12(a)(2) Transfer and discharge requirements:The facility must permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless- (i) The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility; (ii) The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility; (iii) The safety of individuals in the facility is endangered; (iv) The health of individuals in the facility would otherwise be endangered; (v) The resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at the facility. For a resident who becomes eligible for Medicaid after admission to a nursing facility, the nursing facility may charge a resident only allowable charges under Medicaid; or (vi) The facility ceases to operate.Title 22 Section 72527 Patients' Rights: (a) Patients have the rights numerated in this section and the facility shall ensure 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 any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (6) To be transferred or discharged only for medical reasons, or the patient's welfare or that of other patient's or for nonpayment for his or her stay and to be given reasonable advance notice to ensure orderly transfer or discharge. Such actions shall be documented in the patient's health record. Title 22 Section 72519 Patient Transfer: (a) The licensee shall maintain written transfer agreements with other nearby health facilities to make the services of those facilities accessible and to facilitate the transfer of patients. Complete and accurate patient information, in sufficient detail to provide for continuity of care shall be transferred with the patient at time of transfer. (b) When a patient is transferred to another facility, the following shall be entered in the patient health record: (1) The date, time, condition of the patient and a written statement of the reason for the transfer. (2) Informed written or telephone acknowledgement of the patient, patient's guardian or authorized representative except in an emergency or as provided in Section 72527(a)(5). On 12/9/15 at 9:40 a.m., an unannounced visit was made to the facility to investigate anonymous complaint CA00468198 regarding the alleged violation of transfer and discharge rights. The facility failed to ensure Resident 33 was afforded the right to be transferred or discharged solely for medical reasons or for the resident's welfare, and to be given reasonable advance written notice to ensure a safe and orderly transfer or discharge. The facility transferred Resident 33 in order to accommodate the alleged plan of a potential new owner to convert the facility to a subacute setting (a specialized type of nursing service provided to Residents who require complex care or rehabilitation). As a result, Resident 33 was displaced from her home and transferred to SNF 15 without the necessity for the resident's medical or welfare needs.Review of Resident 33's clinical record titled, "Face Sheet" indicated Resident 33 was admitted to the skilled nursing facility (SNF) 1 on 1/26/15 with a diagnosis of dementia (memory loss). Resident 33's "Face Sheet" indicated her daughter was her Responsible Party, (RP) 18, for decision making. Resident 33 was transferred from SNF 1 to SNF 15 on 9/28/15. On 12/9/15 at 9:40 a.m., during a tour of SNF 1, no residents were observed in the hallways, resident rooms or dining area in the West Wing of the facility. Four residents were observed sitting in the East Wing main dining room watching television. During a concurrent interview with the facility Interim Administrator (IA) the IA stated the current facility census was seven of 70 available beds licensed for skilled nursing residents. The IA stated the West Wing was closed. The IA stated three of the seven remaining residents were scheduled to transfer out of the facility later that day, 12/9/15, due to a "Change of ownership" of the facility. On 12/9/15 at 12:15 p.m., during a staff interview in the East Wing hallway, Licensed Nurse (LN) 1 stated residents who resided in the facility were transferred out of the facility due to new ownership expected to take place in the near future. LN 1 stated all residents had to transfer out of the facility. LN 1 stated the new owner planned to run a facility that did not include long term care skilled nursing residents. LN 1 stated most residents that transferred were sad and did not want to leave as the facility had been their home for a long time.On 12/9/15 at 1:30 p.m., during an interview with the Social Services Director (SSD) in the social services office, the SSD stated some of the residents who were transferred did not want to transfer to a different facility because they lived at SNF 1 for a long time. The SSD stated those residents were concerned prior to the transfer as to what would happen to them when the new owner took ownership of the facility. On 12/9/15 at 4:18 p.m., during an interview in the Administrator's office, the IA stated the facility had not provided any resident (including Resident 33 or her RP) that was transferred since 6/1/15 a 30 day advance written notice that included the intent to transfer, the reason for the pending transfer or discharge or the right to appeal the transfer or discharge. The IA stated, "We didn't do those." Review of the facility's administrative policy titled, "California Standard Admission Agreement for Skilled Nursing Facilities and Intermediate Care Facilities" pages eight to nine, dated May 2011, provided to all SNF 1 residents on admission indicated, "VI. Transfers and Discharges...Our written notice of transfer to another facility or discharge against your wishes will be provided 30 days in advance...Our written notice will include the effective day, the location to which you will be transferred or discharged, and the reason the action is necessary. The only reason that we can transfer you to another facility or discharge you against your wishes are: 1) It is required to protect your well-being because your needs cannot be met in our facility; 2) It is appropriate because your health has improved enough that you no longer need the services of our Facility; 3) Your presence in our Facility endangers the health and safety of other individuals; 4) You have not paid for your stay in our Facility or have not arranged to have payment made under Medicare, Medi-Cal, or private insurance; 5) Our Facility ceases to operate; 6) Material or fraudulent misrepresentation of your finances to us... In our written notice, we will advise you that you have the right to appeal the transfer or discharge to the California Department of Health Care Services, and we will also provide the name, address and telephone number of the State Long-Term Care Ombudsman."On 12/16/15 at 3 p.m., during a staff interview, the SSD stated she had worked for SNF 1 for the past seven years. The SSD stated the facility process for discharging residents had begun to change in April 2015. The SSD stated she had been assigned the responsibility to coordinate the discharge of the residents in the facility. The SSD stated that responsibility had previously been a nursing service responsibility. The SSD stated in June 2015 the Clinical Nurse Liaison (CNL) began to assist her with the discharge of residents. She stated the CNL facilitated discharges of residents to other company-owned skilled nursing facilities. The SSD stated when approached by families or residents she had discussed the pending transition, and informed the residents or/and their families the residents could remain at the facility or seek placement before the transition was set to occur, but she could not speak to what would occur after the business was sold. The SSD stated families were given the instruction discharge of the residents was inevitable sooner or later as the type of patients accepted would change to those who required more complex care than was provided in SNF 1. The SSD stated the residents were "fast tracked" to discharge as part of the change in the process. She stated, "The majority of families wanted to seek placement out of fear, not knowing what was going to happen...how could they not be [fearful]? As an employee it was very difficult...they [the facility] were not communicating properly...I felt pressured...that's been very stressful."On 12/17/15 at 7:30 a.m., during an interview, the CNL stated her role at SNF 1 during the transition of ownership was to assist with the discharge of residents from the facility. The CNL stated she learned of an ownership transition in a staff meeting and received direction from the Regional Director of Operations (RDO) to discharge residents. She stated, "I wasn't aware of the regulations...I was stuck in between...it's been a nightmare." The CNL stated, "If they [the residents] asked [what would happen to them], we told them about the change of ownership...don't know when it's going to happen...there was the feeling of uncertainty." Review of Resident 33's clinical record titled, "MDS (Minimum Data Set) (A tool used to assess resident cognitive and physical abilities) 3.0 Assessment," indicated Resident 33's cognitive (pertaining to comprehension, memory and reasoning ability) skills for daily decision making were, "1. Modified independence - some difficulty in new situations only." Resident 33's "MDS 3.0 Assessment" indicated she required staff supervision for walking, dressing, eating and hygiene.Review of Resident 33's clinical record titled, "Departmental Notes: Social Service Note," dated 9/28/15, indicated, "Resident discharged at 3 p.m. transportation provided by [RP 18]..." On 12/29/15 at 11:30 a.m., during an observation and concurrent interview in Resident 33's room in SNF 15, Resident 33 was sitting on the side of the bed with a walker placed in front of her. Resident 33 stated she did not remember attending any meetings to discuss the transfer to SNF 15 and did not know if anyone from SNF 15 visited her to provide information about the facility prior to the move.On 1/5/16 at 5:30 p.m., during a telephone interview, RP 18 stated she had not initiated the transfer of Resident 33 to SNF 15. RP 18 stated she first heard SNF 1 was changing owners from Resident 33 but she wasn't sure that was true because Resident 33 had some confusion at times. RP 18 stated she inquired of SNF 1 staff what was going on and the SSD confirmed the facility was changing owners and Resident 33 needed to "find another home." RP 18 stated, "I was told [by the SSD] that [Resident 33] had to leave because [SNF 1] would not be caring for long term residents anymore." RP 18 stated she had been given very short notice, about a week and a half, to locate a new facility. RP 18 stated she had done all the research to find a place for the resident until she found a place at SNF 15. RP 18 stated she was scared because she didn't know what would happen to Resident 33 if she did not find a place for her to stay.On 1/8/16 at 3 p.m., during a staff interview and concurrent clinical record review with the SSD in the Social Services office in SNF 1, the SSD stated the first documentation of the intent to transfer Resident 33 to SNF 15 was on 9/28/15, which was the day of the transfer. The SSD stated the "Interdisciplinary Team Care Plan Review (IDT) (a resident care team including nursing, dietary, social services and activity staff) Note" dated 8/6/15 indicated there were no plans to transfer or discharge Resident 33 at that time. The SSD stated she was unable to find any documentation of advance planning for the transfer in Resident 33's clinical record. The SSD stated the SNF 1 IDT had not met prior to Resident 33's transfer to discuss whether it was a safe and appropriate transfer. The SSD stated the discharge care plan had not been updated to plan for the transfer to SNF 15. The SSD stated SNF 15 did not provide any services that could not be provided at SNF 1. The SSD stated a 30 day notice of transfer that included the reason for the transfer, the date of transfer, the location of the transfer, the right to appeal the transfer and the name and phone number of the state ombudsman had not been provided to Resident 33 or RP 18 prior to the transfer.Therefore, the facility failed to honor and protect Resident 33's transfer and discharge rights. Resident 33 was transferred without ensuring the necessity to meet her medical or welfare needs and without providing a reasonable notice.These violations had a direct relationship to Resident 33's health, safety and security and thus constitute a Class B Citation. |
| 100000026 |
Valley Subacute & Rehabilitation Center |
040012111 |
B |
16-Mar-16 |
FZRR11 |
12864 |
42 Code of Federal Regulations Section 483.12(a)(2) Transfer and discharge requirements:The facility must permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless- (i) The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility; (ii) The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility; (iii) The safety of individuals in the facility is endangered; (iv) The health of individuals in the facility would otherwise be endangered; (v) The resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at the facility. For a resident who becomes eligible for Medicaid after admission to a nursing facility, the nursing facility may charge a resident only allowable charges under Medicaid; or (vi) The facility ceases to operate.Title 22 Section 72527 Patients' Rights: (a) Patients have the rights numerated in this section and the facility shall ensure 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 any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (6) To be transferred or discharged only for medical reasons, or the patient's welfare or that of other patient's or for nonpayment for his or her stay and to be given reasonable advance notice to ensure orderly transfer or discharge. Such actions shall be documented in the patient's health record. Title 22 Section 72519 Patient Transfer: (a) The licensee shall maintain written transfer agreements with other nearby health facilities to make the services of those facilities accessible and to facilitate the transfer of patients. Complete and accurate patient information, in sufficient detail to provide for continuity of care shall be transferred with the patient at time of transfer. (b) When a patient is transferred to another facility, the following shall be entered in the patient health record: (1) The date, time, condition of the patient and a written statement of the reason for the transfer. (2) Informed written or telephone acknowledgement of the patient, patient's guardian or authorized representative except in an emergency or as provided in Section 72527(a)(5). On 12/9/15 at 9:40 a.m., an unannounced visit was made to the facility to investigate anonymous complaint CA00468198 regarding the alleged violation of transfer and discharge rights. The facility failed to ensure Resident 34 was afforded the right to be transferred or discharged solely for medical reasons or for the resident's welfare, and to be given reasonable advance written notice to ensure a safe and orderly transfer or discharge. The facility transferred Resident 34 in order to accommodate the alleged plan of a potential new owner to convert the facility to a subacute setting (a specialized type of nursing service provided to Residents who require complex care or rehabilitation). As a result, Resident 34 was displaced from his home and transferred to SNF 16 without the necessity to meet his medical or welfare needs and not honoring the 7-day bed hold at SNF 1.Review of Resident 34's clinical record titled, "Face Sheet" indicated Resident 34 was admitted to the skilled nursing facility (SNF) 1 on 12/13/13 with diagnoses that included schizophrenia (severe mental disorder), major depression, anxiety and impulse disorder. The "Face Sheet," indicated Resident 34 was transferred to the acute care hospital (Hosp) 4 on 11/5/15. Resident 34 was transferred from Hosp 4 to SNF 16 on 11/10/15. The "Face Sheet" indicated Public Guardian (PG) 3 was responsible for decisions regarding Resident 34's care.On 12/9/15 at 9:40 a.m., during a tour of SNF 1, no residents were observed in the hallways, resident rooms or dining area in the West Wing of the facility. Four residents were observed sitting in the East Wing main dining room watching television. During a concurrent interview with the facility Interim Administrator (IA) the IA stated the current facility census was seven of 70 available beds licensed for skilled nursing residents. The IA stated the West Wing was closed. The IA stated three of the seven remaining residents were scheduled to transfer out of the facility later that day, 12/9/15, due to a "Change of ownership" of the facility. On 12/9/15 at 12:15 p.m., during a staff interview in the East Wing hallway, Licensed Nurse (LN) 1 stated residents who resided in the facility were transferred out of the facility due to new ownership expected to take place in the near future. LN 1 stated all residents had to transfer out of the facility. LN 1 stated the new owner planned to run a facility that did not include long term care skilled nursing residents. LN 1 stated most residents that transferred were sad and did not want to leave as the facility had been their home for a long time.On 12/9/15 at 1:30 p.m., during an interview with the Social Services Director (SSD) in the social services office, the SSD stated some of the residents who were transferred did not want to transfer to a different facility because they lived at SNF 1 for a long time. The SSD stated those residents were concerned prior to the transfer as to what would happen to them when the new owner took ownership of the facility. On 12/9/15 at 4:18 p.m., during an interview in the Administrator's office, the IA stated the facility had not provided any resident (including Resident 34 and PG 3) that was transferred since 6/1/15 a 30 day advance written notice that included the intent to transfer, the reason for the pending transfer or discharge or the right to appeal the transfer or discharge. The IA stated, "We didn't do those." Review of the facility's administrative policy titled, "California Standard Admission Agreement for Skilled Nursing Facilities and Intermediate Care Facilities" pages eight to nine, dated May 2011, provided to all SNF 1 residents on admission indicated, "VI. Transfers and Discharges...Our written notice of transfer to another facility or discharge against your wishes will be provided 30 days in advance...Our written notice will include the effective day, the location to which you will be transferred or discharged, and the reason the action is necessary. The only reason that we can transfer you to another facility or discharge you against your wishes are: 1) It is required to protect your well-being because your needs cannot be met in our facility; 2) It is appropriate because your health has improved enough that you no longer need the services of our Facility; 3) Your presence in our Facility endangers the health and safety of other individuals; 4) You have not paid for your stay in our Facility or have not arranged to have payment made under Medicare, Medi-Cal, or private insurance; 5) Our Facility ceases to operate; 6) Material or fraudulent misrepresentation of your finances to us... In our written notice, we will advise you that you have the right to appeal the transfer or discharge to the California Department of Health Care Services, and we will also provide the name, address and telephone number of the State Long-Term Care Ombudsman."On 12/16/15 at 3 p.m., during a staff interview, the SSD stated she had worked for SNF 1 for the past seven years. The SSD stated the facility process for discharging residents had begun to change in April 2015. The SSD stated she had been assigned the responsibility to coordinate the discharge of the residents in the facility. The SSD stated that responsibility had previously been a nursing service responsibility. The SSD stated in June 2015 the Clinical Nurse Liaison (CNL) began to assist her with the discharge of residents. She stated the CNL facilitated discharges of residents to other company-owned skilled nursing facilities. The SSD stated when approached by families or residents she had discussed the pending transition, and informed the residents or/and their families the residents could remain at the facility or seek placement before the transition was set to occur, but she could not speak to what would occur after the business was sold. The SSD stated families were given the instruction discharge of the residents was inevitable sooner or later as the type of patients accepted would change to those who required more complex care than was provided in SNF 1. The SSD stated the residents were "fast tracked" to discharge as part of the change in the process. She stated, "The majority of families wanted to seek placement out of fear, not knowing what was going to happen...how could they not be [fearful]? As an employee it was very difficult...they [the facility] were not communicating properly...I felt pressured...that's been very stressful."On 12/17/15 at 7:30 a.m., during an interview, the CNL stated her role at SNF 1 during the transition of ownership was to assist with the discharge of residents from the facility. The CNL stated she learned of an ownership transition in a staff meeting and received direction from the Regional Director of Operations (RDO) to discharge residents. She stated, "I wasn't aware of the regulations...I was stuck in between...it's been a nightmare." The CNL stated, "If they [the residents] asked [what would happen to them], we told them about the change of ownership...don't know when it's going to happen...there was the feeling of uncertainty." Review of Resident 34's clinical record titled, "MDS (Minimum Data Set) (a tool used to assess residents cognitive and physical abilities) 3.0 Assessment," dated 8/27/15, indicated a Brief Interview for Mental Status (BIMS) was incomplete and the Resident's cognition (pertaining to comprehension, memory and reasoning ability) had not been assessed. The "MDS 3.0 Assessment" indicated Resident 34 was "Totally dependent" on staff for transferring, toileting, hygiene and bathing.Review of Resident 34's clinical record titled, "Departmental Notes: Nurses Note," dated 11/5/15 at 3:08 p.m., indicated, "...received order to send resident to hospital [Hosp 4]. [Ambulance] arrived at 2:30 p.m. and left with resident to [Hosp 4] at 2:46 p.m...." Review of Resident 34's clinical record titled, "California Bedhold Notification Form," dated 11/5/15 indicated PG 3 requested SNF 1 hold Resident 34's bed for seven days while he was at Hosp 4.Review of Resident 34's Hosp 4 clinical record titled, "Case Management Note" dated 11/9/15, indicated, "Current Discharge Plan: Back to [SNF 1]...Anticipated Discharge Date:11/9/15...Per case management note [SNF 1] is willing to take the patient back for long term care while they continue to work with the conservator to find a new long term care facility. Initial Case Management Assessment: Current Discharge Plan: Discharge to [SNF 16]. [SNF 1 CNL] would like to be notified when patient is discharged smoothly." Review of Resident 34's SNF 16 clinical record titled, "Case Management Note" dated 11/10/15 indicated, "Transferred to [SNF 16]..." On 1/5/16 at 10 a.m., during a telephone interview, PG 3 stated Resident 34 had been transferred from SNF 1 to Hosp 4 on 11/5/15 for treatment of an acute illness. PG 3 stated Resident 34 went to SNF 16 on 11/10/15 when the resident was ready for discharge from Hosp 4. PG 3 stated Resident 34 went to SNF 16 because "[SNF 1] didn't want him back because they were changing owners and would no longer care for long term patients." PG 3 stated Hosp 4 had located placement for Resident 34 at SNF 16.On 1/8/16 at 2:50 p.m., during a staff interview and concurrent clinical record review with the SSD in the SNF 1 Social Services office, the SSD stated Resident 34 was transferred to Hosp 4 on 11/5/15 due to sudden illness. The SSD stated Resident 34 had a signed Bedhold Notice in his clinical record which indicated he should have returned to SNF 1 if discharged from Hosp 4 by 11/12/15. The SSD stated she did not know why Resident 34 transferred to SNF 16 instead of returning to SNF 1. The SSD stated she was unable to locate any documentation in Resident 34's clinical record indicating a request to transfer to the area near SNF 16 and no advance planning had been done for such a transfer.Therefore, the facility failed to honor and protect Resident 34's transfer and discharge rights. Resident 34 was transferred without ensuring the necessity to meet his medical or welfare needs, without reasonable notice and without honoring his bed hold request. These violations had a direct relationship to Resident 34's health, safety and security and thus constitute a Class B Citation. |
| 100000026 |
Valley Subacute & Rehabilitation Center |
040012112 |
B |
16-Mar-16 |
FZRR11 |
12574 |
42 Code of Federal Regulations Section 483.12(a)(2) Transfer and discharge requirements:The facility must permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless- (i) The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility; (ii) The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility; (iii) The safety of individuals in the facility is endangered; (iv) The health of individuals in the facility would otherwise be endangered; (v) The resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at the facility. For a resident who becomes eligible for Medicaid after admission to a nursing facility, the nursing facility may charge a resident only allowable charges under Medicaid; or (vi) The facility ceases to operate.Title 22 Section 72527 Patients' Rights: (a) Patients have the rights numerated in this section and the facility shall ensure 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 any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (6) To be transferred or discharged only for medical reasons, or the patient's welfare or that of other patient's or for nonpayment for his or her stay and to be given reasonable advance notice to ensure orderly transfer or discharge. Such actions shall be documented in the patient's health record. Title 22 Section 72519 Patient Transfer: (a) The licensee shall maintain written transfer agreements with other nearby health facilities to make the services of those facilities accessible and to facilitate the transfer of patients. Complete and accurate patient information, in sufficient detail to provide for continuity of care shall be transferred with the patient at time of transfer. (b) When a patient is transferred to another facility, the following shall be entered in the patient health record: (1) The date, time, condition of the patient and a written statement of the reason for the transfer. (2) Informed written or telephone acknowledgement of the patient, patient's guardian or authorized representative except in an emergency or as provided in Section 72527(a)(5). On 12/9/15 at 9:40 a.m., an unannounced visit was made to the facility to investigate anonymous complaint CA00468198 regarding the alleged violation of transfer and discharge rights. The facility failed to ensure Resident 1 was afforded the right to be transferred or discharged solely for medical reasons or for the resident's welfare, and to be given reasonable advance written notice to ensure a safe and orderly transfer or discharge. The facility discharged Resident 1 in order to accommodate the alleged plan of a potential new owner to convert the facility to a subacute setting (a specialized type of nursing service provided to Residents who require complex care or rehabilitation). As a result, Resident 1 was displaced from his home without adequate assessment or planning to ensure a safe and orderly discharge.Review of Resident 1's clinical record titled, "Face Sheet" indicated Resident 1 was admitted to the skilled nursing facility (SNF) 1 on 2/9/15 with diagnoses that included major depressive disorder and end stage renal disease (kidney failure). Resident 1 was discharged from SNF 1 to Guest Home (GH) 1 on 12/9/15.On 12/9/15 at 9:40 a.m., during a tour of SNF 1, no residents were observed in the hallways, resident rooms or dining area in the West Wing of the facility. Four residents were observed sitting in the East Wing main dining room watching television. During a concurrent interview with the facility Interim Administrator (IA) the IA stated the current facility census was seven of 70 available beds licensed for skilled nursing residents. The IA stated the West Wing was closed. The IA stated three of the seven remaining residents, including Resident 1, were scheduled to transfer out of the facility later that day, 12/9/15, due to a "Change of ownership" of the facility. On 12/9/15 at 12:15 p.m., during a staff interview in the East Wing hallway, Licensed Nurse (LN) 1 stated residents who resided in the facility were transferred out of the facility due to new ownership expected to take place in the near future. LN 1 stated all residents had to transfer out of the facility. LN 1 stated the new owner planned to run a facility that did not include long term care skilled nursing residents. LN 1 stated most residents that transferred were sad and did not want to leave as the facility had been their home for a long time.On 12/9/15 at 1:30 p.m., during an interview with the Social Services Director (SSD) in the social services office, the SSD stated some of the residents who were transferred did not want to transfer to a different facility because they lived at SNF 1 for a long time. The SSD stated those residents were concerned prior to the transfer as to what would happen to them when the new owner took ownership of the facility. On 12/9/15 at 4:18 p.m., during an interview in the Administrator's office, the IA stated the facility had not provided any resident (including Resident 1) that was transferred or discharged since 6/1/15 a 30 day advance written notice that included the intent to transfer or discharge, the reason for the pending transfer or discharge or the right to appeal the transfer or discharge. The IA stated, "We didn't do those." Review of the facility's administrative policy titled, "California Standard Admission Agreement for Skilled Nursing Facilities and Intermediate Care Facilities" pages eight to nine, dated May 2015 provided to all SNF 1 residents on admission indicated, "VI. Transfers and Discharges...Our written notice of transfer to another facility or discharge against your wishes will be provided 30 days in advance...Our written notice will include the effective day, the location to which you will be transferred or discharged, and the reason the action is necessary. The only reason that we can transfer you to another facility or discharge you against your wishes are: 1) It is required to protect your well-being because your needs cannot be met in our facility; 2) It is appropriate because your health has improved enough that you no longer need the services of our Facility; 3) Your presence in our Facility endangers the health and safety of other individuals; 4) You have not paid for your stay in our Facility or have not arranged to have payment made under Medicare, Medi-Cal, or private insurance; 5) Our Facility ceases to operate; 6) Material or fraudulent misrepresentation of your finances to us... In our written notice, we will advise you that you have the right to appeal the transfer or discharge to the California Department of Health Care Services, and we will also provide the name, address and telephone number of the State Long-Term Care Ombudsman."On 12/16/15 at 3 p.m., during a staff interview, the SSD stated she had worked for SNF 1 for the past seven years. The SSD stated the facility process for discharging residents had begun to change in April 2015. The SSD stated she had been assigned the responsibility to coordinate the discharge of the residents in the facility. The SSD stated that responsibility had previously been a nursing service responsibility. The SSD stated in June 2015 the Clinical Nurse Liaison (CNL) began to assist her with the discharge of residents. She stated the CNL facilitated discharges of residents to other company-owned skilled nursing facilities. The SSD stated when approached by families or residents she had discussed the pending transition, and informed the residents or/and their families the residents could remain at the facility or seek placement before the transition was set to occur, but she could not speak to what would occur after the business was sold. The SSD stated families were given the instruction discharge of the residents was inevitable sooner or later as the type of patients accepted would change to those who required more complex care than was provided in SNF 1. The SSD stated the residents were "fast tracked" to discharge as part of the change in the process. She stated, "The majority of families wanted to seek placement out of fear, not knowing what was going to happen...how could they not be [fearful]? As an employee it was very difficult...they [the facility] were not communicating properly...I felt pressured...that's been very stressful."On 12/17/15 at 7:30 a.m., during an interview, the CNL stated her role at SNF 1 during the transition of ownership was to assist with the discharge of residents from the facility. The CNL stated she learned of an ownership transition in a staff meeting and received direction from the Regional Director of Operations (RDO) to discharge residents. She stated, "I wasn't aware of the regulations...I was stuck in between...it's been a nightmare." The CNL stated, "If they [the residents] asked [what would happen to them], we told them about the change of ownership...don't know when it's going to happen...there was the feeling of uncertainty." Review of Resident 1's clinical record titled, "MDS (Minimum Data Set) (a resident assessment tool for cognitive and physical abilities) 3.0 Assessment," dated 11/23/15, indicated Res 1's cognitive skills for daily decision making were "Independent - decisions consistent/reasonable." Resident 1's "MDS 3.0 Assessment" indicated he required staff supervision for bed mobility, walking and transferring and limited staff assistance for dressing, toileting and personal hygiene. On 12/9/15 at 11:45 a.m., during an observation and concurrent interview in the east wing of SNF 1, Resident 1 was sitting in a wheelchair in his room. Resident 1 stated he was going to be leaving the facility at 3:30 p.m. that day because he had been scheduled to discharge to another facility. Resident 1 stated he had been scheduled for discharge because, "Some new people bought this place. They aren't taking [keeping] people like me." Review of Resident 1's clinical record titled, "Transfer/Discharge Summary" dated 12/9/15 contained an area to document, "Reason for Transfer/Discharge" which was blank. There was no documented rationale for the transfer/discharge to GH 1 indicated on the form. Review of Resident 1's clinical record titled, "Departmental Notes" dated 12/9/15 at 3:37 p.m., indicated, "Social Service discharge note:...Resident said bye to staff..." On 12/14/15 at 4:15 p.m., during an observation and interview at GH 1, Resident 1 was sitting in a wheelchair by his bed. Resident 1 stated he liked SNF 1 better than GH 1 because he had friends at SNF 1. Resident 1 stated he lived at SNF 1 for about seven months and was only given a couple of days' notice that he would move to GH 1. Resident 1 stated he was unsure how much assistance he would receive from GH 1 staff. On 1/8/15 at 4:55 p.m., during a staff interview and concurrent clinical record review with the SSD in the SNF 1 Social Services office, the SSD stated Resident 1 had discharged to GH 1 on 12/9/15 which was a lower level of care than SNF 1. The SSD stated a safety assessment was not done prior to the discharge to GH 1. The SSD stated the SNF 1 Interdisciplinary Team (IDT) (a resident care team including nursing, dietary, social services and activity staff) had not met prior to the resident's transfer to discuss whether it was a safe and appropriate discharge and the discharge care plan had not been updated to plan for the discharge to GH 1. The SSD stated a 30 day notice of discharge that included the reason for discharge, the date of discharge, the location of the discharge, the right to appeal the discharge and the name and phone number of the state ombudsman had not been provided to Resident 1 prior to the discharge to GH 1.Therefore, the facility failed to honor and protect Resident 1's transfer and discharge rights. Resident 1 was discharged without adequate assessment to ensure a safe and orderly discharge, without ensuring the necessity to meet his medical or welfare needs and without reasonable notice.These violations had a direct relationship to Resident 1's health, safety and security and thus constitute a Class B Citation. |
| 100000026 |
Valley Subacute & Rehabilitation Center |
040012113 |
B |
16-Mar-16 |
FZRR11 |
12018 |
42 Code of Federal Regulations Section 483.12(a)(2) Transfer and discharge requirements:The facility must permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless- (i) The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility; (ii) The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility; (iii) The safety of individuals in the facility is endangered; (iv) The health of individuals in the facility would otherwise be endangered; (v) The resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at the facility. For a resident who becomes eligible for Medicaid after admission to a nursing facility, the nursing facility may charge a resident only allowable charges under Medicaid; or (vi) The facility ceases to operate.Title 22 Section 72527 Patients' Rights: (a) Patients have the rights numerated in this section and the facility shall ensure 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 any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (6) To be transferred or discharged only for medical reasons, or the patient's welfare or that of other patient's or for nonpayment for his or her stay and to be given reasonable advance notice to ensure orderly transfer or discharge. Such actions shall be documented in the patient's health record. Title 22 Section 72519 Patient Transfer: (a) The licensee shall maintain written transfer agreements with other nearby health facilities to make the services of those facilities accessible and to facilitate the transfer of patients. Complete and accurate patient information, in sufficient detail to provide for continuity of care shall be transferred with the patient at time of transfer. (b) When a patient is transferred to another facility, the following shall be entered in the patient health record: (1) The date, time, condition of the patient and a written statement of the reason for the transfer. (2) Informed written or telephone acknowledgement of the patient, patient's guardian or authorized representative except in an emergency or as provided in Section 72527(a)(5). On 12/9/15 at 9:40 a.m., an unannounced visit was made to the facility to investigate anonymous complaint CA00468198 regarding the alleged violation of transfer and discharge rights. The facility failed to ensure Resident 2 was afforded the right to be transferred or discharged solely for medical reasons or for the resident's welfare, and to be given reasonable advance written notice to ensure a safe and orderly transfer or discharge. The facility transferred Resident 2 in order to accommodate the alleged plan of a potential new owner to convert the facility to a subacute setting (a specialized type of nursing service provided to Residents who require complex care or rehabilitation). As a result, Resident 2 was displaced from her home and transferred to an unfamiliar location.Review of Resident 2's clinical record titled, "Face Sheet" indicated Resident 2 was admitted to the skilled nursing facility (SNF) 1 on 6/20/13 with diagnoses that included dementia (memory loss), anxiety and depression. Resident 2 was transferred from SNF 1 to SNF 6 on 12/9/15.On 12/9/15 at 9:40 a.m., during a tour of SNF 1, no residents were observed in the hallways, resident rooms or dining area in the West Wing of the facility. Four residents were observed sitting in the East Wing main dining room watching television. During a concurrent interview with the facility Interim Administrator (IA) the IA stated the current facility census was seven of 70 available beds licensed for skilled nursing residents. The IA stated the West Wing was closed. The IA stated three of the seven remaining residents, including Resident 2, were scheduled to transfer out of the facility later that day, 12/9/15, due to a "Change of ownership" of the facility. On 12/9/15 at 12:15 p.m., during a staff interview in the East Wing hallway, Licensed Nurse (LN) 1 stated residents who resided in the facility were transferred out of the facility due to new ownership expected to take place in the near future. LN 1 stated all residents had to transfer out of the facility. LN 1 stated the new owner planned to run a facility that did not include long term care skilled nursing residents. LN 1 stated most residents that transferred were sad and did not want to leave as the facility had been their home for a long time.On 12/9/15 at 1:30 p.m., during an interview with the Social Services Director (SSD) in the social services office, the SSD stated some of the residents who were transferred did not want to transfer to a different facility because they lived at SNF 1 for a long time. The SSD stated those residents were concerned prior to the transfer as to what would happen to them when the new owner took ownership of the facility. On 12/9/15 at 4:18 p.m., during an interview in the Administrator's office, the IA stated the facility had not provided any resident (including Resident 2 or her Responsible Party) that was transferred since 6/1/15 a 30 day advance written notice that included the intent to transfer, the reason for the pending transfer or discharge or the right to appeal the transfer or discharge. The IA stated, "We didn't do those." Review of the facility's administrative policy titled, "California Standard Admission Agreement for Skilled Nursing Facilities and Intermediate Care Facilities" pages eight to nine, dated May 2011, provided to all SNF 1 residents on admission indicated, "VI. Transfers and Discharges...Our written notice of transfer to another facility or discharge against your wishes will be provided 30 days in advance...Our written notice will include the effective day, the location to which you will be transferred or discharged, and the reason the action is necessary. The only reason that we can transfer you to another facility or discharge you against your wishes are: 1) It is required to protect your well-being because your needs cannot be met in our facility; 2) It is appropriate because your health has improved enough that you no longer need the services of our Facility; 3) Your presence in our Facility endangers the health and safety of other individuals; 4) You have not paid for your stay in our Facility or have not arranged to have payment made under Medicare, Medi-Cal, or private insurance; 5) Our Facility ceases to operate; 6) Material or fraudulent misrepresentation of your finances to us... In our written notice, we will advise you that you have the right to appeal the transfer or discharge to the California Department of Health Care Services, and we will also provide the name, address and telephone number of the State Long-Term Care Ombudsman."On 12/16/15 at 3 p.m., during a staff interview, the SSD stated she had worked for SNF 1 for the past seven years. The SSD stated the facility process for discharging residents had begun to change in April 2015. The SSD stated she had been assigned the responsibility to coordinate the discharge of the residents in the facility. The SSD stated that responsibility had previously been a nursing service responsibility. The SSD stated in June 2015 the Clinical Nurse Liaison (CNL) began to assist her with the discharge of residents. She stated the CNL facilitated discharges of residents to other company-owned skilled nursing facilities. The SSD stated when approached by families or residents she had discussed the pending transition, and informed the residents or/and their families the residents could remain at the facility or seek placement before the transition was set to occur, but she could not speak to what would occur after the business was sold. The SSD stated families were given the instruction discharge of the residents was inevitable sooner or later as the type of patients accepted would change to those who required more complex care than was provided in SNF 1. The SSD stated the residents were "fast tracked" to discharge as part of the change in the process. She stated, "The majority of families wanted to seek placement out of fear, not knowing what was going to happen...how could they not be [fearful]? As an employee it was very difficult...they [the facility] were not communicating properly...I felt pressured...that's been very stressful."Resident 2's SNF 1 clinical record titled, "MDS (Minimum Date Set) (a tool used to assess resident cognitive and physical functional abilities) 3.0 Assessment," dated 11/4/15, indicated under Cognitive (pertaining to comprehension, memory and reasoning ability) Function Resident 2 was severely impaired, with short term and long term memory problems. Under Behavior, no behaviors were documented. The assessment indicated Resident 2 was unable to walk and required total assistance from staff for dressing, hygiene and bathing. Review of Resident 2's Transfer/Discharge Summary-Post Discharge Plan of Care dated 12/9/15, under Reason for Transfer/Discharge, indicated a hash mark next to Other, Please Explain., which indicated, "Long Term Care." Under Summary of Care it indicated, "Admitted 6/20/13 for long term care." No other written documentation was indicated for the reason for transfer. On 12/9/15 at 12:49 p.m., during a telephone interview, Resident 2's Responsible Party (RP) 1 stated she lived out of state and handled Resident 2's affairs. RP 1 stated she had been contacted by telephone in late October or early November [2015] by facility staff and was told SNF 1 was changing hands and would not be doing skilled nursing any longer. RP 1 stated she had not requested Resident 2 transfer to another facility. RP 1 stated, "I was told by the facility that it [the transfer] needed to be done. I was given a list of places [to call for possible transfer]." RP 1 stated she did not receive any written notice of the reason necessitating the transfer of Resident 2. RP 1 stated she had not been provided information regarding orientation to the new facility.Resident 2's SNF 1 Social Services Notes dated 12/9/15 at 3:52 p.m., indicated, "...Resident [2] discharge on 12/9/15...P/U [pick up] at 1:30..." On 12/29/15 at 3:30 p.m., during an observation at SNF 2, Resident 2 was found in her room lying in bed under her covers. Resident 2 was not able to respond to questions. On 1/7/16 at 3:50 p.m., during a staff interview and concurrent clinical record review with the SSD at SNF 1, the SSD stated RP 1 was notified of Resident 2's pending transfer on 12/8/15 and Resident 2 was transferred to SNF 2 the next day, 12/9/15. The SSD stated SNF 1's Interdisciplinary Team (IDT) (a resident care team including nursing, dietary, social services and activity staff) had not met prior to Resident 2's transfer to discuss whether it was a safe and appropriate transfer and the discharge care plan was not updated to plan for the transfer to SNF 2. The SSD stated SNF 2 did not provide any care for Resident 2 that SNF 1 could not provide. The SSD stated a 30 day notice of transfer that included the reason for transfer, the date of transfer, the location of the transfer, the right to appeal the transfer and the name and phone number of the state ombudsman was not provided to Resident 2 or RP 1 prior to the transfer. Therefore, the facility failed to honor and protect Resident 2's transfer and discharge rights. Resident 2 was displaced from her home without ensuring the necessity to meet her medical or welfare needs and without reasonable notice.These violations had a direct relationship to Resident 2's health, safety and security and thus constitute a Class B Citation. |
| 100000026 |
Valley Subacute & Rehabilitation Center |
040012114 |
A |
16-Mar-16 |
FZRR11 |
25207 |
42 Code of Federal Regulations Section 483.12(a)(2) Transfer and discharge requirements:The facility must permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless- (i) The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility; (ii) The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility; (iii) The safety of individuals in the facility is endangered; (iv) The health of individuals in the facility would otherwise be endangered; (v) The resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at the facility. For a resident who becomes eligible for Medicaid after admission to a nursing facility, the nursing facility may charge a resident only allowable charges under Medicaid; or (vi) The facility ceases to operate.Title 22 Section 72527 Patients' Rights: (a) Patients have the rights numerated in this section and the facility shall ensure 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 any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (6) To be transferred or discharged only for medical reasons, or the patient's welfare or that of other patient's or for nonpayment for his or her stay and to be given reasonable advance notice to ensure orderly transfer or discharge. Such actions shall be documented in the patient's health record. Title 22 Section 72519 Patient Transfer: (a) The licensee shall maintain written transfer agreements with other nearby health facilities to make the services of those facilities accessible and to facilitate the transfer of patients. Complete and accurate patient information, in sufficient detail to provide for continuity of care shall be transferred with the patient at time of transfer. (b) When a patient is transferred to another facility, the following shall be entered in the patient health record: (1) The date, time, condition of the patient and a written statement of the reason for the transfer. (2) Informed written or telephone acknowledgement of the patient, patient's guardian or authorized representative except in an emergency or as provided in Section 72527(a)(5). On 12/9/15 at 9:40 a.m., an unannounced visit was made to the facility to investigate anonymous complaint CA00468198 regarding the alleged violation of transfer and discharge rights. The facility failed to ensure Resident 8 was afforded the right to be transferred or discharged solely for medical reasons or for the resident's welfare, and to be given reasonable advance written notice to ensure a safe and orderly transfer or discharge. The facility transferred Resident 8 in order to accommodate the alleged plan of a potential new owner to convert the facility to a subacute setting (a specialized type of nursing service provided to Residents who require complex care or rehabilitation). Resident 8 was admitted to the skilled nursing facility, (SNF) 1on 9/24/14 with diagnoses that included dementia (memory loss), impulse disorder, anxiety, heart failure, Parkinson's (a neurological disorder causing tremors and rigidity) and high blood pressure. Resident 8 was transferred from SNF 1 to SNF 4, a distance of 900 miles, on 12/2/15. This displaced Resident 8 from his home and family and as a result Resident 8 suffered serious emotional and psychological harm. On 12/9/15 at 9:40 a.m., during a tour of SNF 1, no residents were observed in the hallways, resident rooms or dining area in the West Wing of the facility. Four residents were observed sitting in the East Wing main dining room watching television. During a concurrent interview with the facility Interim Administrator (IA) the IA stated the current facility census was seven of 70 available beds licensed for skilled nursing residents. The IA stated the West Wing was closed. The IA stated three of the seven remaining residents were scheduled to transfer out of the facility later that day, 12/9/15, due to a "Change of ownership" of the facility. On 12/9/15 at 12:15 p.m., during a staff interview in the East Wing hallway, Licensed Nurse (LN) 1 stated residents who resided in the facility were transferred out of the facility due to new ownership expected to take place in the near future. LN 1 stated all residents had to transfer out of the facility. LN 1 stated the new owner planned to run a facility that did not include long term care skilled nursing residents. LN 1 stated most residents that transferred were sad and did not want to leave as the facility was their home for a long time. LN 1 stated one resident [Resident 8] was transferred to another state and that resident was not happy about the transfer. LN 1 stated that resident [Resident 8] did not request to move to another state and did not have a change of condition that required a different level of care other than what was already provided in the facility. LN 1 stated Resident 8 was transferred because the new owners were not going to run a long term care facility. On 12/9/15 at 1:30 p.m., during an interview with the Social Services Director (SSD) in the social services office, the SSD stated some of the residents who were transferred did not want to transfer to a different facility because they lived at SNF 1 for a long time. The SSD stated those residents were concerned prior to the transfer as to what would happen to them when the new owner moved in.On 12/9/15 at 2:30 p.m., during a telephone interview, the facility Medical Director (MD) 1 stated he understood the facility building was sold to a new owner and residents were transferred out for that reason. MD 1 stated he was not directly involved with the transfers of residents. MD 1 stated, "I don't have the skills or the time to be directly involved in the transfers - that's social services responsibility." On 12/9/15 at 4:18 p.m., during an interview in the Administrator's office, the IA stated the facility had not provided any resident (including Resident 8) that was transferred since 6/1/15 a 30 day advance written notice that included the intent to transfer, the reason for the pending transfer or discharge or the right to appeal the transfer or discharge. The IA stated, "We didn't do those."On 12/10/15 at 8:40 a.m., during a staff interview, the Interim Director of Nursing (IDON) 1stated when resident asked her about what would happen when the facility changed ownership, she responded she didn't know and couldn't say. The IDON 1 stated SNF 1 was not admitting any new residents because the new owner wanted the building empty of residents when they took over the business.Review of the facility's administrative policy titled, "California Standard Admission Agreement for Skilled Nursing Facilities and Intermediate Care Facilities" pages eight to nine, dated May 2011 provided to all SNF 1 residents on admission indicated, "VI. Transfers and Discharges...Our written notice of transfer to another facility or discharge against your wishes will be provided 30 days in advance...Our written notice will include the effective day, the location to which you will be transferred or discharged, and the reason the action is necessary. The only reason that we can transfer you to another facility or discharge you against your wishes are: 1) It is required to protect your well-being because your needs cannot be met in our facility; 2) It is appropriate because your health has improved enough that you no longer need the services of our Facility; 3) Your presence in our Facility endangers the health and safety of other individuals; 4) You have not paid for your stay in our Facility or have not arranged to have payment made under Medicare, Medi-Cal, or private insurance; 5) Our Facility ceases to operate; 6) Material or fraudulent misrepresentation of your finances to us... In our written notice, we will advise you that you have the right to appeal the transfer or discharge to the California Department of Health Care Services, and we will also provide the name, address and telephone number of the State Long-Term Care Ombudsman."On 12/16/15 at 3 p.m., during a staff interview, the SSD stated she had worked for SNF 1 for the past seven years. The SSD stated the facility process for discharging residents had begun to change in April 2015. The SSD stated she was assigned responsibilities for discharging residents that was previously a nursing services responsibility. She stated in June 2015 the Clinical Nurse Liaison (CNL) began assisting her in the discharging of residents. She stated the CNL facilitated discharges of residents to other company-owned skilled nursing facilities. The SSD stated when approached by families or residents she had discussed the pending transition, and informed them they could remain at the facility or seek placement before the transition was set to occur, but she could not speak to what would occur after the business was sold. She stated families were given the instruction discharge was inevitable sooner or later as the type of patients accepted would change. The SSD stated the residents were "fast tracked" to discharge as part of the change in the process. She stated, "The majority of families wanted to seek placement out of fear, not knowing what was going to happen...how could they not be [fearful]? As an employee it was very difficult...they [the facility] were not communicating properly...I felt pressured...that's been very stressful." She further stated the facility had stopped admitting new residents in June 2015.On 12/17/15 at 7:30 a.m., during an interview, the CNL stated her role in the transition was to discharge residents from the facility. The CNL stated she learned of an ownership transition in a staff meeting and received direction from the Regional Director of Operations (RDO) to discharge residents. She stated, "I wasn't aware of the regulations...I was stuck in between...it's been a nightmare." The CNL stated, "If they [the residents] asked [what would happen to them], we told them about the change of ownership...don't know when it's going to happen...there was the feeling of uncertainty." On 12/17/15 at 1:30 p.m., during an interview, the IA stated she had started to work at the facility on 9/4/15 and the West Wing hallway of the facility was empty of residents. The IA stated she contacted the facility RDO who informed her there was a pending sale of the skilled nursing license. The IA stated her role in the transition was to talk to concerned families, seek availability of beds at other facilities for the transfer of residents, and assist the staff in discharging residents. She stated her directive from the RDO was to discharge residents when an appropriate facility had an available bed. She stated her job was to make sure discharges happened. The IA stated, "Shame on us in hindsight, we let [the pending owner] run it. We would do it differently if we could do it again...We [the IA and the RDO] were caught in the middle." Review of Resident 8's clinical record titled, "MDS [Minimum Data Set] 3.0 Assessment," (an assessment tool used in a SNF to evaluate residents cognitive and functional abilities) dated 9/22/15, indicated Resident 8's cognitive (pertaining to comprehension, memory and reasoning ability) skills for daily decision making were "Moderately impaired-decisions poor," and he required "Extensive assistance" to transfer between surfaces such as chair to wheelchair.Review of Resident 8's clinical record titled, "Departmental Notes" dated 9/24/15 at 11:08 a.m., indicated, "Resident wanders from room to lobby...Resident removes alarm, disrobes himself and tries to get out of bed without assistance. Resident receives Quetiapine [a medication to treat psychosis] 50 mg [milligrams, a dosage measurement] po [by mouth] QPM [every evening] for auditory hallucinations, delirium...Xanax [a medication to treat anxiety] 0.25 mg po BID [twice a day] for agitation... " Review of Resident 8's clinical record titled, "Transfer/Discharge Summary" dated 12/2/15 contained an area to document "Reason for Transfer/Discharge." A box on the document indicated, "Other, Please Explain" was the single box checked and "Long term" was written on the line next to the box. There was no documented rationale for the transfer to SNF 4 indicated on the form or in the clinical record.Review of Resident 8's clinical record titled, "Physician Orders" dated December 2015, indicated medications ordered were: Xanax (medication to treat anxiety) to be given twice a day; Citalopram (medication to treat depression) to be given every morning; Seroquel (antipsychotic medication used to treat Resident 8's psychosis and auditory hallucinations) to be given every evening; Hydralazine (medication to treat high blood pressure) to be given four times a day; Metoprolol Tartrate (medication to treat high blood pressure) to be given every 12 hours; Ferrous Sulfate (an iron supplement to treat anemia) to be given three times per day; Carbidopa-Levodopa (a medication to treat Parkinson's Disease, a neurological disorder) to be given three times per day; Casodex (medication to treat cancer) to be given every morning; Ranitidine (medication to treat acid reflux) to be given at bedtime; Donepezil (medication to treat Alzheimer's dementia) to be given at bedtime; Fludrocortisone (a hormone) to be given every morning; Aspirin (to treat heart disease) to be given every morning; Folic Acid (vitamin to treat anemia ) to be given every morning; Vitamin C to be given every morning; Multivitamin to be given every morning; Docusate Sodium (to treat constipation) to be given twice a day.On 1/6/16 at 2:10 p.m., during a telephone interview, Resident 8's Responsible Party (RP) 2 stated SNF's SSD had contacted her by phone near the end of October 2015. RP 2 stated the SSD told her SNF 1 had been sold and Resident 8 needed to move out by November 30, 2015. She stated the SSD told her they did not know what would happen if Resident 8 stayed at the facility. RP 2 stated the SSD had explained it was unclear what the new owner would do after the ownership change transpired, and it was a possibility the new owner could move Resident 8 anywhere. RP 2 stated she had been very worried about what would happen to Resident 8 when the facility had a new owner. RP 2 stated she spent countless hours trying to find another skilled nursing facility in the area to transfer Resident 8 to, without success, and finally, a family member helped her find a place, but it was in another state and away from most of Resident 8's extended family. RP 2 stated there were 10 extended family members near SNF 1 who would visit four to five times per week, bring Resident 8 snacks and visit. RP 2 stated she did Resident 8's laundry and visited him frequently. RP 2 stated there was only one family member near the out of state facility to visit the resident. RP 2 stated she purchased a one-way airline ticket for Resident 8 to fly to the new facility and a one-way ticket for Family Member (FM) 2 to accompany him on the flight. She stated the money for the tickets, parking and travel expenses were paid out of Resident 8's checking account and that amounted to about $600. RP 2 stated another family member paid for FM 2's return ticket home and additional travel expenses which was about $400. RP 2 stated, "We don't have much money. [FM 2] had to stay with the relative out of state until we could get the money together for the return ticket." RP 2 stated Resident 8 did not have identification required to fly so she applied for a copy of his birth certificate, which cost $46. RP 2 stated because of the short time frame of the request she was not sure if the birth certificate would arrive in time for the scheduled flight to another state. RP 2 stated the airline tickets were not refundable and she had worried what would happen if the birth certificate didn't arrive on time. RP 2 stated the birth certificate arrived the day before the scheduled flight. RP 2 stated SNF 1 did not assist her with planning Resident 8's transfer. RP 2 stated, "The only concern they had was what time we would pick him up to take him to the airport. I felt like they didn't want anything to do with him." RP 2 stated she purchased new clothing for Resident 8 for the trip because the weather was colder in the new location and he only was able to take the belongings that would fit in his check-in baggage. She stated, "It was so stressful I felt physically sick. I was so worried what would happen to him. It was horrible. If I ever have to do this again, just kill me now!"On 1/8/16 at 2:15 p.m., during a staff interview and concurrent clinical record review in the SNF 1 social services office, the SSD stated Resident 8's family was aware of the pending transition of facility ownership and the family was worried about what would happen. The SSD stated Resident 8 transferred to SNF 4 on 12/2/15. The SSD stated Resident 8 did not require any special care that could not have been provided at SNF 1. The SSD stated SNF 1's Interdisciplinary Team (IDT), (a resident care team including nursing, dietary, social services and activity staff) did not meet prior to Resident 8's transfer to discuss whether it was a safe and appropriate transfer. The SSD stated the discharge care plan was not updated to plan for the transfer to SNF 4. The SSD stated a 30 day notice of transfer that included the reason for transfer, the date of the transfer, the location of the transfer, the right to appeal the transfer and the name and phone number of the state ombudsman, was not provided to Resident 8 or his Responsible Party. On 1/11/16 at 9:45 a.m., during a telephone interview, LN 2 stated she was on duty on 12/2/15 when Resident 8 was discharged for transfer to SNF 4. LN 2 stated the family arrived at the facility before 6 a.m. on 12/2/15 to transport Resident 8 to the airport. LN 2 stated she did not administer Resident 8's medications that morning because they were scheduled to be given at 8 a.m. and he left by 6 a.m. LN 2 stated nurses would sometimes contact the physician to get an order to give medications earlier than scheduled if there was an unusual circumstance which required a resident to be gone during the scheduled time; but she had not contacted Resident 8's physician. LN 2 stated she placed Resident 8's transfer paperwork into a large manila envelope and placed his medications into a zip lock bag and then placed the zip lock bag into the manila envelope. She stated the manila envelope was then closed with metal tabs. LN 2 stated she did not provide Resident 8's family members written or verbal instructions to administer the medications. LN 2 stated she did not provide teaching on what the medications were ordered to treat or how or when to administer the medications. LN 2 stated Resident 8 had problems with incontinence and behavior issues and would often refuse care. LN 2 stated she did not provide Resident 8's family information on how to handle Resident 8's issues with incontinence. LN 2 stated she did not provide teaching on how to handle Resident 8's identified behaviors issues during the transport to SNF 4. LN 2 stated no other nurses provided information or teaching to Resident 8's family regarding medications, incontinence care or handling identified behavior issues. On 1/11/16 at 10:25 a.m., during a telephone interview, LN 3 stated she was the admitting nurse when Resident 8 arrived at SNF 4. LN 3 stated, when admitted to SNF 4, Resident 8 had excoriated (reddened and broken) skin on his buttocks and perineal areas, most likely due to sitting in a soiled brief for a prolonged period. LN 3 stated she could not administer medications that had were not supplied and labeled by the pharmacy that serviced SNF 4, and she had to destroy the medications sent without administering them to Resident 8. LN 3 stated Resident 8 was very quiet and withdrawn, had difficulty sleeping and did not eat well for the first week he was at SNF 4.On 1/11/16 at 4:15 p.m., during a telephone interview, Resident 8's FM 2 stated she accompanied Resident 8 on the trip to SNF 4. FM 2 stated Resident 8 was transferred from SNF 1 to SNF 4 because the facility was sold and the family was told he had to leave. She stated she accompanied RP 2 on 12/2/15 to pick up Resident 8 for the trip. FM 2 stated the family made arrangements to pick him up early, just before 6 a.m., so that he could make the flight on time. FM 2 stated, "They [the facility staff] had not packed his bags, he had not been given breakfast or a snack. He hadn't been given his morning medications. I requested some briefs in case he needed to be changed during the trip, but I wasn't given any." FM 2 stated the nurse sent an envelope with paperwork for the new facility and a zip lock bag containing medications with Resident 8. FM 2 stated she was not given verbal or written instructions to administer any medications. FM 2 stated, "There were no instructions to give them [the medications]. I was afraid to give anything because I didn't know what I was supposed to do or what they were for." FM 2 stated she had not been given verbal or written instructions from SNF 1 on how to handle Resident 8's behavior issues or incontinence during the trip. FM 2 stated they were detained by security at the airport because Resident 8 was very anxious and restless and started pulling his clothing off. FM 2 stated, "He was flipping a wig [behavior was out of control] because he hadn't had his medication." FM 2 stated Resident 8 became angry with her for taking him away from the facility. She stated Resident 8 pulled a blanket over his head and started crying when he got settled on the plane. He refused to eat or drink anything during the trip. FM 2 stated when they arrived at SNF 4, about 12 hours after leaving SNF 1, Resident 8 was still wearing the same brief, which was wet and soiled. FM 2 stated, "It was embarrassing. If he was more aware he would have been humiliated." FM 2 stated SNF 4's admitting nurse told her Resident 8 had some skin redness from sitting in a wet brief for so long. FM 2 stated the admitting nurse informed her they could not administer medications that their pharmacy had not provided or labeled and the medications in the manila envelope were destroyed. FM 2 stated Resident 8 did not receive any of his medications the day of transfer. FM 2 stated SNF 1 wanted Resident 8 to move by November 30 but the airline ticket prices were extremely high due to the Thanksgiving holiday and they waited until prices went down on 12/2/15 to get tickets; but then they received a bill for December from SNF 1. FM 2 stated it was "crazy expensive" to make the trip. The trip incurred expenses for the resident and the family which included one way airline tickets, parking and travel expenses in the amount of $600 for Resident 8 and herself. FM 2 stated her return trip was paid by another family member but she had to stay with family in another state until the money could be raised for the return trip. FM 2 stated she visited Resident 8 every day at SNF 4 before she flew home. FM 2 stated Resident 8 had a difficult time adjusting to the move at SNF 4 and refused to eat "hardly anything." FM 2 stated Resident 8 had been upset, and stated, "He cried and his chin was quivering. He said he wanted to go home." FM 2 stated, "I adore [Resident 8] but when I told him I was leaving to go home he said he hated me for making him leave home. It hurt me. I don't have the money to fly there any time again soon. It's probably the last thing I'll ever hear him say to me." Review of the commercial airline receipt dated 12/2/15 issued for Resident 8 and the airline receipt dated 12/2/15 for FM 2 indicated a ticket cost of $222.60 for each ticket with additional charges of $25.00 per first checked bag and $35 per second checked bag. The ticket receipts indicated the tickets were non-refundable. Review of the commercial airline receipt dated 12/5/15 issued for FM 2 indicated a ticket cost of $241.60 with additional charges of $25 per first checked bag and $35 per second checked bag. The receipt indicated the ticket was non-refundable. Review of website "www.Mapquest.com" indicated SNF 4 was located 904 miles from SNF 1. Resident 8 was transferred 900 miles away from his family without the necessity to meet his medical or welfare needs and without reasonable notice. These violations resulted in serious emotional and psychological harm and significant anxiety, anger and humiliation. Therefore, the facility failed to honor and protect Resident 8's transfer and discharge rights. These violations presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result and thus constitute a Class A Citation. |
| 100000026 |
Valley Subacute & Rehabilitation Center |
040012117 |
A |
16-Mar-16 |
FZRR11 |
16951 |
42 Code of Federal Regulations Section 483.12(a)(2) Transfer and discharge requirements:The facility must permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless- (i) The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility; (ii) The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility; (iii) The safety of individuals in the facility is endangered; (iv) The health of individuals in the facility would otherwise be endangered; (v) The resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at the facility. For a resident who becomes eligible for Medicaid after admission to a nursing facility, the nursing facility may charge a resident only allowable charges under Medicaid; or (vi) The facility ceases to operate.Title 22 Section 72527 Patients' Rights: (a) Patients have the rights numerated in this section and the facility shall ensure 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 any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (6) To be transferred or discharged only for medical reasons, or the patient's welfare or that of other patient's or for nonpayment for his or her stay and to be given reasonable advance notice to ensure orderly transfer or discharge. Such actions shall be documented in the patient's health record. Title 22 Section 72519 Patient Transfer: (a) The licensee shall maintain written transfer agreements with other nearby health facilities to make the services of those facilities accessible and to facilitate the transfer of patients. Complete and accurate patient information, in sufficient detail to provide for continuity of care shall be transferred with the patient at time of transfer. (b) When a patient is transferred to another facility, the following shall be entered in the patient health record: (1) The date, time, condition of the patient and a written statement of the reason for the transfer. (2) Informed written or telephone acknowledgement of the patient, patient's guardian or authorized representative except in an emergency or as provided in Section 72527(a)(5). On 12/9/15 at 9:40 a.m., an unannounced visit was made to the facility to investigate anonymous complaint CA00468198 regarding alleged violation of transfer and discharge rights. The facility failed to ensure Resident 9 was afforded the right to be transferred or discharged solely for medical reasons or for the resident's welfare, and to be given reasonable advance written notice to ensure a safe and orderly transfer or discharge. The facility transferred Resident 9 in order to accommodate the alleged plan of a potential new owner to convert the facility to a subacute setting (a specialized type of nursing service provided to Residents who require complex care or rehabilitation). As a result, Resident 9 suffered significant psychological and emotional harm and avoidable weight loss.Review of Resident 9's clinical record titled, "Face Sheet" indicated Resident 9 was 49 years old. Resident 9 was admitted to the skilled nursing facility (SNF) 1 on 6/26/02 with diagnoses that included hemiplegia (paralysis on one side of the body), cerebrovascular disease (stroke), anxiety disorder, and aphasia (difficulty speaking). Resident 9 was transferred from SNF 1 to SNF 5 on 10/5/15.On 12/9/15 at 9:40 a.m., during a tour of SNF 1, no residents were observed in the hallways, resident rooms or dining area in the West Wing of the facility. Four residents were observed sitting in the East Wing main dining room watching television. During a concurrent interview with the facility Interim Administrator (IA) the IA stated the current facility census was seven of 70 available beds licensed for skilled nursing residents. The IA stated the West Wing was closed. The IA stated three of the seven remaining residents were scheduled to transfer out of the facility later that day, 12/9/15, due to a "Change of ownership" of the facility. On 12/9/15 at 12:15 p.m., during a staff interview in the East Wing hallway, Licensed Nurse (LN) 1 stated residents who resided in the facility were transferred out of the facility due to new ownership expected to take place in the near future. LN 1 stated all residents had to transfer out of the facility. LN 1 stated the new owner planned to run a facility that did not include long term care skilled nursing residents. LN 1 stated most residents that transferred were sad and did not want to leave as the facility had been their home for a long time.On 12/9/15 at 1:30 p.m., during an interview with the Social Services Director (SSD) in the social services office, the SSD stated some of the residents, including Resident 9, who were transferred did not want to transfer to a different facility because they lived at SNF 1 for a long time. The SSD stated those residents were concerned prior to the transfer as to what would happen to them when the new owner took ownership of the facility. On 12/9/15 at 4:18 p.m., during an interview in the Administrator's office, the IA stated the facility did not provide any resident (including Resident 9) that was transferred since 6/1/15 a 30 day advance written notice that included the intent to transfer, the reason for the pending transfer or discharge, or the right to appeal the transfer or discharge. The IA stated, "We didn't do those." Review of the facility's administrative policy titled, "California Standard Admission Agreement for Skilled Nursing Facilities and Intermediate Care Facilities," pages eight to nine, dated May 2011 provided to all SNF 1 residents on admission indicated, "VI. Transfers and Discharges...Our written notice of transfer to another facility or discharge against your wishes will be provided 30 days in advance...Our written notice will include the effective day, the location to which you will be transferred or discharged, and the reason the action is necessary. The only reason that we can transfer you to another facility or discharge you against your wishes are: 1) It is required to protect your well-being because your needs cannot be met in our facility; 2) It is appropriate because your health has improved enough that you no longer need the services of our Facility; 3) Your presence in our Facility endangers the health and safety of other individuals; 4) You have not paid for your stay in our Facility or have not arranged to have payment made under Medicare, Medi-Cal, or private insurance; 5) Our Facility ceases to operate; 6) Material or fraudulent misrepresentation of your finances to us... In our written notice, we will advise you that you have the right to appeal the transfer or discharge to the California Department of Health Care Services, and we will also provide the name, address and telephone number of the State Long-Term Care Ombudsman."On 12/16/15 at 3 p.m., during a staff interview, the SSD stated she had worked for SNF 1 for the past seven years. The SSD stated the facility process for discharging residents had begun to change in April 2015. The SSD stated she had been assigned the responsibility to coordinate the discharge of the residents in the facility. The SSD stated that responsibility had previously been a nursing service responsibility. The SSD stated in June 2015 the Clinical Nurse Liaison (CNL) began to assist her with the discharge of residents. She stated the CNL facilitated discharges of residents to other company-owned skilled nursing facilities. The SSD stated when approached by families or residents she had discussed the pending transition, and informed the residents or/and their families the residents could remain at the facility or seek placement before the transition was set to occur, but she could not speak to what would occur after the business was sold. The SSD stated families were given the instruction discharge of the residents was inevitable sooner or later as the type of patients accepted would change to those who required more complex care than was provided in SNF 1. The SSD stated the residents were "fast tracked" to discharge as part of the change in the process. She stated, "The majority of families wanted to seek placement out of fear, not knowing what was going to happen...how could they not be [fearful]? As an employee it was very difficult...they [the facility] were not communicating properly...I felt pressured...that's been very stressful."On 12/17/15 at 7:30 a.m., during an interview, the CNL stated her role at SNF 1 during the transition of ownership was to assist with the discharge of residents from the facility. The CNL stated she learned of an ownership transition in a staff meeting and received direction from the Regional Director of Operations (RDO) to discharge residents. She stated, "I wasn't aware of the regulations...I was stuck in between...it's been a nightmare." The CNL stated, "If they [the residents] asked [what would happen to them], we told them about the change of ownership...don't know when it's going to happen...there was the feeling of uncertainty." Review of Resident 9's clinical record titled, "Transfer/Discharge Summary" dated 10/5/15 contained an area to document, "Reason for Transfer/Discharge." A box indicating "Other, Please Explain" was the single box checked and "Facility Transfer" was written on the line next to the box. There was no documented rationale for the transfer to SNF 5 indicated on the form.Review of Resident 9's clinical record titled, "MDS [Minimum Data Set] 3.0 Assessment," (a tool used in a SNF to assess resident cognitive and functional abilities) dated 10/12/15, indicated Resident 9's Brief Interview for Mental Status (BIMS) score was 15 on a scale of 0 to 15 with 15 indicating the resident was cognitively (pertaining to comprehension, memory and reasoning ability) intact. The section of Resident 9's MDS assessment under functional ability indicated Resident 9 was "totally dependent" on staff for bed mobility, dressing, bathing and hygiene. Review of Resident 9's clinical record titled, "Physician Orders" dated December 2015, indicated she was "Capable" of participating in her own plan of care and "Capable" of understanding and exercising her rights. On 12/29/15 at 8 a.m., during an interview at SNF 5, the Interim Director of Nursing (IDON) 2 stated Resident 9 was transferred to SNF 5 on 10/5/15 from SNF 1, but was transferred back to SNF 1 again on 12/22/15. The IDON 2 stated Resident 9 never liked being at SNF 5. The IDON 2 stated, "She [Resident 9] expressed many times she was not happy here. She didn't know why she ended up here and she called her mother about it several times. She was angry and went on a starvation protest for a while." On 12/29/15 at 8:25 a.m., during a staff interview in SNF 5's hallway, LN 4 stated she had cared for Resident 9 during the two months she resided at SNF 5. LN 4 stated, "She [Resident 9] didn't want to be here. She wasn't happy. She didn't leave her room, didn't go to activities or the dining room."On 12/29/15 at 9:05 a.m., during an interview, SNF 5's Admission Coordinator (AC) 1 stated Resident 9 had "A very particular way of doing everything. The change in her routines was very upsetting [for Resident 9]." On 12/30/15 at 9:30 a.m., during a staff interview and concurrent clinical record review with the SSD in the social services office at SNF 1, the SSD stated Resident 9 was transferred to SNF 5 on 10/5/15. The SSD stated Resident 9 had not requested to be moved and had not initiated a conversation regarding a move. The SSD stated the SNF 1 Interdisciplinary Team (IDT), (a resident care team including nursing dietary, social services and activity staff) had not met prior to Resident 9's transfer to SNF 5 to discuss whether it was a safe and appropriate transfer, and the discharge care plan was not updated to plan for the transfer to SNF 5. The SSD stated SNF 5 was first contacted to request a transfer for Resident 9 four days prior to her transfer. The SSD stated a 30 day notice of transfer that included the reason for transfer, the date of the transfer, the location of the transfer, the right to appeal the transfer and the name and phone number of the state ombudsman was not provided to Resident 9 or her Responsible Party. The SSD stated SNF 5 did not provide any services that were not available at SNF 1. On 12/30/15 at 9:50 a.m., during an interview in Resident 9's room at SNF 1, Resident 9 was awake and alert, lying on her side in bed holding a white letter board for spelling. Resident 9 was able to speak with difficulty and spell out words when needed. Resident 9 stated she lived at SNF 1 for 12 years and did not want to leave. She stated the SSD visited her in her room four days before the transfer and told her she would be going to SNF 5 because SNF 1 was closing. Resident 9 stated, "I didn't ask to go. I didn't want to go. When they told me I had to move I was scared. I was worried. I didn't know what to think. I didn't have a choice." Resident 9 stated she "hated" being at SNF 5 and stated, "I stopped eating for a while. I lost weight." Resident 9 stated when given the opportunity to leave SNF 5 and return to SNF 1 she immediately requested to return. Resident 9 stated she had not been provided any advance written notice of the transfer before transferring to SNF 5 or of her right to appeal the transfer. On 1/7/16 at 7:30 a.m., during a telephone interview, Resident 9's Responsible Party (RP) 3 stated she lived out of state and was responsible for Resident 9's financial affairs. RP 3 stated she received a phone call from the SNF 1 Interim Administrator (IA) around the first of October 2015 informing her SNF 1 was closing. RP 3 stated the IA told her they would try to move Resident 9 near her. RP 3 stated she had just started looking for facilities near her but by that weekend Resident 9 had already been moved to SNF 5. RP 3 stated Resident 9 was "emotionally fragile" and did not adjust to the move. She stated, "She did nothing but cry after the move to [SNF 5]. She had the nurse assistant call me on the phone three or four times per day...she cried and I would try to comfort her..." RP 3 stated Resident 9 "never really adjusted to the move. She just got quiet after a while. I think she was depressed." RP 3 stated she did not receive any advanced written notice of the pending transfer or of the right to appeal the transfer.Review of Resident 9's clinical record from SNF 5 titled, "Departmental Notes" dated 10/5/15, indicated, "At admission resident noted to be agitated, home sick and tearful." Review of Resident 9's clinical record from SNF 5 titled, "Departmental Notes" dated 10/7/15, indicated, "She [Resident 9] wanted to call 911 because she said that she was here against her will and wants to go to the hospital." "Review of Resident 9's SNF 1 clinical record titled, "Weight Change Comparison," dated 10/5/15, indicated Resident 9 left SNF 1 on 10/5/15 weighing 137.7 pounds.Review of Resident 9's SNF 5 clinical record titled, "Vital Sign Data" dated 11/5/15, indicated Resident 9's weight was 125.8 pounds; a weight loss of 11.9 pounds or 8.6 percent of her body weight in the one month period after leaving SNF 1.Review of professional reference, "Prevention of Unintentional Weight Loss in Nursing Home Residents: A Controlled Trial of Feeding Assistance": Sandra F Simmons, Ph.D., Journal of American Geriatric Society, August 2008, indicated, " Unintentional weight loss is a common problem among nursing home residents and one that is associated with adverse, costly clinical outcomes including increases in hospitalizations, morbidity and mortality. A clinically significant weight loss episode is defined for nursing home residents by the Minimum Data Set (MDS) as a loss equal to or greater than 5% within a 30 day period or 10% within a 180 day period. This study also showed that a weight loss episode equal to or greater than 5% within 30 days was associated with an increased risk of death."Therefore, the facility failed to honor and protect Resident 9's transfer and discharge rights. Resident 9 was transferred without ensuring the necessity to meet her medical or welfare needs, without reasonable notice, and against her wishes.These violations caused serious emotional and psychological harm and avoidable weight loss. These violations presented imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result and thus constitute a Class A Citation. |
| 100000026 |
Valley Subacute & Rehabilitation Center |
040012118 |
A |
16-Mar-16 |
FZRR11 |
28502 |
42 Code of Federal Regulations Section 483.12(a)(2) Transfer and discharge requirements:The facility must permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless- (i) The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility; (ii) The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility; (iii) The safety of individuals in the facility is endangered; (iv) The health of individuals in the facility would otherwise be endangered; (v) The resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at the facility. For a resident who becomes eligible for Medicaid after admission to a nursing facility, the nursing facility may charge a resident only allowable charges under Medicaid; or (vi) The facility ceases to operate.Title 22 Section 72527 Patients' Rights: (a) Patients have the rights numerated in this section and the facility shall ensure 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 any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (6) To be transferred or discharged only for medical reasons, or the patient's welfare or that of other patient's or for nonpayment for his or her stay and to be given reasonable advance notice to ensure orderly transfer or discharge. Such actions shall be documented in the patient's health record. Title 22 Section 72519 Patient Transfer: (a) The licensee shall maintain written transfer agreements with other nearby health facilities to make the services of those facilities accessible and to facilitate the transfer of patients. Complete and accurate patient information, in sufficient detail to provide for continuity of care shall be transferred with the patient at time of transfer. (b) When a patient is transferred to another facility, the following shall be entered in the patient health record: (1) The date, time, condition of the patient and a written statement of the reason for the transfer. (2) Informed written or telephone acknowledgement of the patient, patient's guardian or authorized representative except in an emergency or as provided in Section 72527(a)(5). On 12/9/15 at 9:40 a.m., an unannounced visit was made to the facility to investigate anonymous complaint CA00468198 regarding alleged violation oftransfer and discharge rights. The facility failed to ensure Resident 10 was afforded the right to be transferred or discharged solely for medical reasons, the resident's welfare, or because his health had improved sufficiently that he no longer needed the services provided by the facility, and to be given reasonable advance written notice to ensure a safe and orderly discharge. The facility discharged Resident 10 in order to accommodate the alleged plan of a potential new owner to convert the facility to a subacute setting (a specialized type of nursing service provided to Residents who require complex care or rehabilitation). As a result, Resident 10 was discharged home without adequate planning or preparation and suffered physical decline, worsening pressure ulcers and family stress. Review of Resident 10's clinical record titled, "Face Sheet" indicated Resident 10 was admitted to the skilled nursing facility (SNF) 1 on 3/31/15 with multiple diagnoses which included colostomy (a surgical opening onto the surface of the abdomen to bypass a damaged or diseased bowel), pressure ulcers (skin breakdown due to pressure, also called bedsores), and the inability to walk or to move his lower body without assistance. Resident 10 was discharged home on 10/20/15.On 12/9/15 at 9:40 a.m., during a facility tour, no residents were observed in the hallways, resident rooms or dining area in the West Wing of the facility. Four residents were observed sitting in the East Wing main dining room watching television. During a concurrent interview with the facility Interim Administrator (IA) the IA stated the current facility census was seven of 70 available beds licensed for skilled nursing residents. The IA stated the West Wing was closed. The IA stated three of the seven remaining residents were scheduled to transfer out of the facility later that day, 12/9/15, due to a "Change of ownership" of the facility. On 12/9/15 at 12:15 p.m., during a staff interview in the East Wing hallway, Licensed Nurse (LN) 1 stated residents who resided in the facility were transferred out of the facility due to new ownership expected to take place in the near future. LN 1 stated all residents had to transfer out of the facility. LN 1 stated the new owner planned to run a facility that did not include long term care skilled nursing residents. LN 1 stated most residents that transferred were sad and did not want to leave as the facility had been their home for a long time. On 12/9/15 at 1:30 p.m., during an interview with the Social Services Director (SSD) in the social services office, the SSD stated some of the residents who were transferred did not want to transfer to a different facility because they lived at SNF 1 for a long time. The SSD stated those residents were concerned prior to the transfer as to what would happen to them when the new owner took ownership of the facility. On 12/9/15 at 4:18 p.m., during an interview in the Administrator's office, the IA stated the facility had not provided any resident (including Resident 10) that was transferred or discharged since 6/1/15 a 30 day advance written notice that included the intent to transfer or discharge, the reason for the pending transfer or discharge or the right to appeal the transfer or discharge. The IA stated, "We didn't do those." Review of the facility's administrative policy titled "California Standard Admission Agreement for Skilled Nursing Facilities and Intermediate Care Facilities" pages eight to nine, dated May 2011, provided to all facility residents on admission indicated, "VI. Transfers and Discharges...Our written notice of transfer to another facility or discharge against your wishes will be provided 30 days in advance...Our written notice will include the effective day, the location to which you will be transferred or discharged, and the reason the action is necessary. The only reason that we can transfer you to another facility or discharge you against your wishes are: 1) It is required to protect your well-being because your needs cannot be met in our facility; 2) It is appropriate because your health has improved enough that you no longer need the services of our Facility; 3) Your presence in our Facility endangers the health and safety of other individuals; 4) You have not paid for your stay in our Facility or have not arranged to have payment made under Medicare, Medi-Cal, or private insurance; 5) Our Facility ceases to operate; 6) Material or fraudulent misrepresentation of your finances to us... In our written notice, we will advise you that you have the right to appeal the transfer or discharge to the California Department of Health Care Services, and we will also provide the name, address and telephone number of the State Long-Term Care Ombudsman."On 12/16/15 at 3 p.m., during a staff interview, the SSD stated she had worked for the facility for the past seven years. The SSD stated the facility process for discharging residents had begun to change in April 2015. The SSD stated she had been assigned the responsibility to coordinate the discharge of the residents in the facility. The SSD stated that responsibility had previously been a nursing services responsibility. The SSD stated in June 2015 the Clinical Nurse Liaison (CNL) began to assist her with the discharge of residents. She stated the CNL facilitated discharges of residents to other company-owned skilled nursing facilities. The SSD stated when approached by families or residents she had discussed the pending transition, and informed the residents or/and their families the residents could remain at the facility or seek placement before the transition was set to occur, but she could not speak to what would occur after the business was sold. The SSD stated families were given the instruction discharge of the residents was inevitable sooner or later as the type of patients accepted would change to those who required more complex care than was currently provided in SNF 1. The SSD stated the residents were "fast tracked" to discharge as part of the change in the process. She stated, "The majority of families wanted to seek placement out of fear, not knowing what was going to happen...how could they not be [fearful]? As an employee it was very difficult...they [the facility] were not communicating properly...I felt pressured...that's been very stressful."On 12/17/15 at 7:30 a.m., during an interview, the CNL stated her role at SNF 1 in the transition of ownership was to assist with the discharge of residents from the facility. The CNL stated she learned of an ownership transition in a staff meeting and received direction from the Regional Director of Operations (RDO) to discharge residents. She stated, "I wasn't aware of the regulations...I was stuck in between...it's been a nightmare." The CNL stated, "If they [the residents] asked [what would happen to them], we told them about the change of ownership...don't know when it's going to happen...there was the feeling of uncertainty." A review of Resident 10's clinical record titled, "MDS [Minimum Data Set] (a tool used to assess a resident's cognitive and physical function abilities) 3.0 Assessment," dated 9/21/15, indicated under Functional Status, a bed mobility score of 3/3, which indicated he required extensive assistance by at least two persons. Under Transfer, he scored 4/3, which indicated he was totally dependent, and required two persons to assist him. Under Walk, he scored of 8/8, which indicated he did not walk. Under Toilet Use, he scored 4/2, which indicated total dependence, and required one person to assist him. Under Skin Conditions, it indicated he was at risk of developing pressure ulcers. Under Skin and Ulcer Treatments, a check was indicated next to pressure reducing device for his chair and for his bed. A check was indicated next to both Turning/repositioning program, and Pressure Ulcer care, which indicated he received those services.Resident 10's untitled Care Plan (CP) dated 3/31/15, indicated under Problem/Need, "Potential for Pressure Ulcers r/t [related to]: Bed Mobility, generalized weakness, thoracic brace." Under Goal and Target Date it indicated, "...Resident will have no skin breakdown d/t [due to] impaired bed mobility." Under Approaches it indicated, "Pressure redistributing device to bed and wheelchair. Encourage and assist resident to turn and reposition every 1 to 2 hours..." An untitled CP dated 8/05/15, indicated under Problem/Need, "Resident has redness to bottom." Under Goal and Target Date it indicated, "Will have no complications related to impaired skin integrity through next review." Under Approaches it indicated, "...Encourage staff to reposition resident q [every] 2 hrs. [hours] prn [as needed]." A Physician Communication Fax (Facsimile) Request dated 8/15/15, indicated under Nursing concern, "Closed blister Stage II [involving the upper layers of skin, the epidermis and dermis] to ABD [abdomen] midline."Resident 10's Social Service Notes dated 10/5/15, indicated, "Social Service pre-discharge note: IDT [Interdisciplinary Team] and Therapy director [Physical Therapy aide] conducted a care plan meeting on 10/5/15 with resident and FM [Family Member] ...Recommendations family training on lift [mechanical lifting device used to transfer people who cannot do so on their own]...Recommended a Hospital bed, wheelchair, [mechanical] lift.." Resident 10's Nurses Notes dated 10/6/15 at 12:42 a.m., indicated, "...Resident is on monitoring for stage two pressure ulcer to buttock. On treatment per md order." An untitled CP dated 10/07/15, indicated under Problem/Need, "Res[ident] has stage II [pressure ulcer] noted to left buttocks." Under Goal & Target Date it indicated, "Will prevent further deterioration of skin integrity through next review..." Under Approaches it indicated, "Res to be turned Q [every] 2 hour while in bed...Monitor area for increase in size, pain bleeding and s/sx [signs/symptoms] of infection...Monitor status of surrounding skin every day...Notify wound DR [doctor]..." The facility document titled, "Pressure Sore Staging Protocol" revised January 2010, indicated under Pressure Sore Staging Protocol, "A pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear or friction." Under Stage II it indicated, "Partial thickness loss of dermis [outer layer of skin] presenting as a shallow open ulcer with a red pink wound bed. May also present as an intact or open/ruptured serum filled blister. Presents as a shiny or dry shallow ulcer without slo[u]gh or bruising." Under 3. it indicated, "This staging system should be used only to describe pressure ulcers. Wounds from other causes.....should not be staged using this system." Resident 10's Physician Communication Fax Request dated 10/12/15, indicated under Request: "Resident discharge home on 10/20/15 [a previous date of 10/17/15 lined through and revised]. Home Health with Physical Therapy and Occupational therapy. Needed a Hospital bed, standard Wheelchair, [mechanical] lift." Under MD Response it indicated, "OK." The form was signed by a Licensed Nurse and Medical Director (MD) 1. The Physical Therapy (PT) Treatment Encounter Note dated 10/14/15, indicated under Daily Skilled Treatment, "Daughter present for entire therapy session...Discussed use of [mechanical] lift at home for transfers. Bed mobility in home and need for turning and pressure relief to prevent pressure sores." Nurses Notes dated 10/17/15 at 9:33 p.m., indicated, "Resident on charting for Stage II [skin ulcer] to left buttocks treatment done per md [physician] order. No s/s[signs or symptoms] infection. Resident resting in bed in low position." Nurses Notes dated 10/19/15 at 11:57 p.m., indicated, "...resident has reddened areas to back, thighs, and torso, see treatment book.....Resident cannot move lower extremities, denies numbness and tingling." The PT Treatment Encounter Notes dated 10/19/15, indicated under Additional Objective, "...Daughter/caregiver training completed for ROM [range of motion], positioning, wt. [weight] shifting...pressure relief in bed and up in wc [wheelchair]." Under Subjective it indicated, "WC [wheelchair], hospital bed and [mechanical] lift in place." The note was electronically signed by the Physical Therapy Aide (PTA). Resident 10's PT Discharge Summary dated 10/19/15, indicated under Discharge, "...residents family educated in the use of the [mechanical lift]." Under Comments: it indicated, "Training for safety and use of the [mechanical lift]." Under D/C [Discharge] Reason: it indicated, "All Goals Met." Under D/C Recs [recommendations] it indicated, "Discharge Recommendations: family performed well...family trained on returning home." The document was signed electronically by Physical Therapist (PT) 1. Skilled Daily Charting notes dated 10/20/15 at 11:19 a.m., indicated, "...resident has reddened areas to back, thighs and torso..." The note was electronically signed by Licensed Nurse (LN) 10. Resident 10's Social Services Note dated 10/20/15 at 4:49 p.m., indicated, "Social Service discharge note: Resident discharged to home...with daughter and son-in-law. [Vendor] transport pick up at 4 p.m....Family training provided. All medical equipment delivered to home... [Vendor] Home Health in place." The note was electronically signed by the Social Services Director (SSD). The Skilled Daily Charting Note dated 10/20/15 at 5:13 p.m., indicated, "Resident has colostomy to abdomen drainage moderate....CN [charge nurse] with another licensed nurse as a witness provided health teachings concerning....colostomy care..." The note was electronically signed by LN 10. Resident10's Transfer/Discharge Summary-Post Discharge Plan of Care dated 10/20/15 indicated under Skin Assessment, "pressure sore [at] left buttock...skin redness on both elbows, 1.5 cm [centimeter] wound blister medial aspect of R [Right] foot." Under Pressure Ulcers: it indicated, "Yes", under Stage it indicated, "II." Under Equipment Needed, it indicated, "Hospital Bed, [mechanical] lift." Under Resident Teaching For Home the document indicated, "Provided medication administration teaching, provided colostomy care teaching, provided treatment care, resident and family had been instructed to contact a primary physician for continuation of medication and treatment as necessary." On 12/23/15 at 3:25 p.m., during a phone interview, Family Member (FM) 9 stated Resident 10 was Spanish speaking and currently living at her home. She spoke in a distressed tone, stated she was pregnant, near term, and the family was concerned regarding their ability to continue care for the resident. On 12/30/15 at 1:10 p.m., during an observation and interview at Resident 10's home, he was found covered with a blanket, lying on a bath towel, spread horizontally over a fitted sheet, which was stretched over a plastic mattress. He was found in a small room at the rear of the mobile home. No pressure reducing/relieving bed devices for prevention of pressure ulcers were observed.A mechanical lift was observed in the corner of the room. FM 10 stated she was called by the SSD at SNF 1 in October 2015 who had informed her the facility was being renovated and the resident was ready for discharge. When asked about participation in discharge planning, FM 10 stated she went to the facility to observe his physical therapy session. FM 10 stated she was shown the mechanical lift but denied having used the lift before discharge. FM 10 stated she had received verbal instruction on maintaining the resident's colostomy, and how to change the colostomy bag, but the nurse had not demonstrated how to change the bag or the colostomy dressing, nor provide the opportunity to perform a return demonstration of the procedure under facility staff guidance. FM 10 stated she was given two cases of colostomy bags but one case was the wrong size, so she was unable to use it. FM 10 stated the facility had not conducted a pre discharge home evaluation. FM 10 stated on the date of discharge he was transported to the family home, but the van driver refused to assist the family in moving the resident up the ramp and into the house. FM 10 stated, "It was a struggle to get him up [the ramp]." FM 10 then attempted to reposition Resident 10 in bed. He grimaced and moved slowly to his right side, grabbing the side rail, stating turning was painful. Resident 10's left heel was observed with a large black circular closed wound measuring approximately 1 1/4 in. (inch) by 1 1/4 in. A second smaller dark discolored area was noted on the lateral aspect of his left foot. A large open circular wound which measured approximately 3 cm. (centimeters) by 2 cm. was observed on his right hip. Resident 10's coccyx (bottom) area skin was observed bright red, skin peeling, with multiple small open areas of broken skin. FM 10 looked at the resident's coccyx area and stated, "It's the moisture...his skin sweats." She then became tearful and stated, "I don't feel that he was ready [for discharge]...it's been really hard on me and my sister." The resident's elbows were found bright red, with patches of peeling skin. FM 10 stated the family had not been able to transport her father to a physician since discharge. When asked, Resident 10 stated he felt he had physically declined since discharge, his skin was broken down, and he was not feeling well. On 12/31/15 at 9:15 a.m., during an interview and concurrent record review with the SSD, the SSD stated she had participated in Resident 10's discharge planning. When asked whether a pressure relieving device was ordered for his bed, she stated, "I would order it if he needed it....no, he didn't need a [pressure relieving] mattress." When asked who attended the pre discharge meeting for Resident 10, she stated she participated with staff from physical therapy, dietary, and activities. During the concurrent clinical record review, no written evidence of nursing participation was found. When asked if a home evaluation was conducted to evaluate safety of the home, the SSD, stated, "If it's not in the notes, it didn't happen."On 12/31/15 at 10:15 a.m., during an interview, LN 10 stated he conducted the resident's discharge teaching with Resident 10's family the afternoon of his discharge. LN 10 stated he had not demonstrated a colostomy dressing change for the family, or observed a return demonstration, because the dressing did not require a change. When asked if the resident received a pressure reducing device for his bed, he stated, "As far as I know, no." On inquiry, he stated, "I believe I should have reviewed that...it got missed." When asked about physician follow up for the resident, he stated, "I was told when they were discharged, the resident had to set up the appointments...that's what I told them [FM] to do."On 1/5/16 at 8:30 a.m., during a phone interview with FM 10, she stated Resident 10 was febrile (had an elevated temperature) and transported to the acute care hospital. She stated, "We can't do this anymore," and stated she felt overwhelmed with the resident's care. On 1/8/15 during a staff interview and concurrent clinical record review with the SSD in the social services office, the SSD stated the facility IDT met on 10/5/15 and set a tentative discharge date of 10/17/15 for Resident 10. The SSD stated no formal assessment of Resident 10's home needs was done, the discharge care plan was not updated and no home visit to determine appropriateness of transfer was done prior to discharge. The SSD stated a 30 day notice of intent to discharge and the right to appeal the discharge was not provided to Resident 10 or his family (FM 9, FM 10). On 1/12/16 at 12:50 p.m., during an interview, FM 10 stated the resident was fully independent prior to his illness and hospitalization. She stated no staff came to Resident 10's home prior to discharge and no pressure relieving devices were ordered or received for his bed. She further stated, "I didn't know the care he needed."On 1/12/16 at 3 p.m., during an interview, FM 9 stated she attended training with facility staff on the mechanical lift. She stated staff spoke to her about the equipment, but she did not use the equipment during the training session. She further stated, "I never knew the care he really needed, until he came home." On 1/14/16 at 9 a.m., during an interview, the Physical Therapy Assistant (PTA) stated she participated in Resident 10's discharge planning. She stated she attempted to train him on slide board transfers but the resident did not have sufficient strength, so a mechanical lift was ordered. When asked regarding the content of the lift training done, she stated she showed the FM how to use the sling (cloth that is positioned under resident that supports the body when raised off the bed). When asked if the family operated the lift or conducted a return demonstration, she stated, "I don't know," and added that a Certified Nurse Assistant (CNA) provided the training. When asked whether a pre-discharge home evaluation was conducted to assess resident safety and adaptive equipment needs prior to discharge, she stated, "We did not...we just figured we'd transfer to home health." When asked about the contingency plan for problems arising between discharge and the home health agency admission, she stated, "I don't know." When asked if a pressure relieving device for Resident 10's bed was discussed at any of the meetings, ordered for him, or received by the family, she stated, "I don't know, that's usually nursing." On 1/14/16 at 10 a.m., during an interview, the Physical Therapist (PT) 1 stated he had provided care to Resident 10 while in the facility. When asked about Resident 10's discharge goals he stated, "To make sure the patient is safe at home." On inquiry as to why a home evaluation was not conducted prior to the resident's discharge, he stated, "We taught them [FMs] how to use all the equipment." When asked regarding his expectations for staff in providing caregiver mechanical lift training, he stated he expected staff to educate the family on the lift, how it operated, demonstrate its use for the caregiver and require the family conduct a return demonstration. When asked if this occurred for Resident 10's caregiver, he stated, "I believe it did."Review of facility policy titled, "Post Discharge Plan" revised March 2010, indicated "Guidelines: When a resident is discharged, a post-discharge plan shall be provided to the resident, and/or his/her representative (sponsor). Considerations: 1.When the facility anticipates a resident's discharge to a private residence or other nursing care facility...a post-discharge plan will be developed which will assist the resident to adjust to his or her new living environment...4. At a minimum, the post-discharge plan will include...c. A description of how the care should be coordinated if continuing treatment involves multiple caregivers; d. The identity of specific resident needs after discharge (i.e., personal care...sterile dressings, physical therapy, etc.). e. A description of how the resident and family need to prepare for the discharge..." Review of a professional reference titled, "Competent Care for Persons with Spinal Cord Injury and Dysfunction in Acute Inpatient Rehabilitation" Top Spinal Cord Injury Rehabilitation, 2012 Spring; 18(2): 149-166, Lyn Emerich, PT, MS., Kenneth C. Parsons, MD., and Adam Stein, MD., the document indicated under Interdisciplinary Team Approach, "It is important to appreciate the psychosocial impact of SCI/D [Spinal Cord Injury or Dysfunction]. The team must be able to implement complex discharge plans and arrange for lifelong follow-up and health promotion....The patient and family/support system are the central members of the interdisciplinary team..."Under Education, it indicated, "Educational interventions must prepare the person served and their caregivers to manage healthy routines, maintain safety, and solve issues that commonly occur after SCI/D. Knowing when and how to access additional assistance and resources in the community and health care system is a critical component of SCI/D education....Topics that should be addressed in the education of persons with SCI/D include, but are not limited to: Bowel management......Home and community safety, Follow-up medical care, including the need for and how to access care; Independent living;...Pain management...Skin care and prevention and treatment of pressure ulcers..." Under Special Populations it indicated, "...it is not surprising that the care of older individuals who acquire SCI is more complex. These patients are less likely to regain functional independence...They also have a significantly greater rate of mortality than younger patients within the first year following onset of SCI, 47% compared to 5%..." Therefore the facility failed to honor and protect Resident 10's transfer and discharge rights to ensure his health had improved sufficiently for a safe and appropriate discharge to home. The facility did not ensure Resident 10 had appropriate equipment at home to prevent worsening pressure ulcers. Resident 10's caregivers were not provided adequate training and were not assessed for their competency to care for Resident 10 at home.The facility failed to provide adequate preparation and planning prior to discharge home and as a result Resident 10 suffered physical decline, worsening pressure ulcers and family stress.These violations presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result and thus constitute a Class A Citation. |
| 100000026 |
Valley Subacute & Rehabilitation Center |
040012663 |
B |
20-Oct-16 |
DJXQ11 |
6510 |
F465 483.70 (h) The facility must provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. 22 CCR Section 72601 Section 72601. Alterations to Existing Buildings or New Construction. (a) Alterations to existing buildings licensed as skilled nursing facilities or new construction shall be in conformance with Chapter 1, Division 17, Part 6, Title 24, California Administrative Code, and requirements of the State Fire Marshal. (c) All facilities shall maintain in operating condition all buildings, fixtures, and spaces in the numbers and types as specified in the construction requirements under which the facility or unit was first licensed. Note: Authority cited Sections 208(a) and 1275, Health and Safety Code. Reference: Section 1276, Health, and Safety Code. The facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public, when 10 of 10 sampled residents (Resident 1, 2, 3, 4, 5, 6,7, 8, 9, and 10) were exposed to a facility environment of unprotected wiring, unfinished construction, a malfunctioning nurse call system, and unsafe conditions due to interior building construction changes that were unauthorized and performed without appropriate permits from local or state planning and development authorities. These failures resulted in placing residents at the facility in an unsafe, dangerous, and hazardous environment. On 9/1/16 an unannounced visit was made to the facility to investigate complaint CA 00500840. On 9/1/16 at 10:00 a.m., during an observation of the building with the Office of Statewide Health Planning and Development (OSHPD) inspectors, the east wing was under construction and remodeling. The walls, from ceiling to the floor, at the entrance to the east wing were covered with plastic protector sheets. Electrical wiring from the walls was exposed including what appeared to be an electrical circuit, a nurse call system, and cabling for television. Additional work in progress included removal of dry wall and copper pipe exposure. During a tour of the central wing four rooms were occupied by residents. Residents observed were the following: Resident 1 in Room 16, Resident 2 and Resident 3 in Room 18, Resident 6 and Resident 7 in Room 19 and Resident 8 in Room 20. On the west wing, work extended from the north exterior door, which included a non-functional call light system. Across from the nurse's station located between the east and the west wing, wires were exposed without a covering panel in place. By the nurse's station on the west wing, Room 33 was occupied by 2 residents (Resident 9 and Resident 10) with no call light in place. Electrical wires hung from the wall above the top part of the door with no fixtures attached. On 9/1/16 at 10:05 a.m., during an interview at the nurses station located between the central and the west wing, the Medical Record Assistant (MRA), stated she was aware of the interior construction occurring, but could not provide any specific date as to when the construction started. When asked about the call light system, the MRA stated, while pointing to the exposed wiring near Room 33, she could not say how long the call light system had not been working. On 9/1/16 at 10:30 a.m., during an observation with OSHPD, in the central wing hall area, the shower room call system when activated did not light on the call system panel. In Room 17 and Room 18, call systems did not light on the system panel. When activated in Room 16 the call light illuminated for Room 17. Room 33 had no call system in place. On 9/1/16 at 10:34 a.m., during an interview, the Chief Executive Officer (CEO) stated she had not notified the California Department of Public Health, Licensing and Certification office, and was not aware if a local building permit was obtained. The CEO stated all she knew was that a design professional was hired and all contractors were licensed. On 9/1/16 at 11:50 a.m., during an interview, Resident 1 stated the call light in his room was not answered right away, and sometimes it took up to one hour before the call light was answered. On 9/1/16 at 11:57 a.m., Resident 5 had a little bell on her bedside table to use as a call light. Resident 5 was unable to answer questions. On 9/1/16 at 12:11 p.m., during an interview, Resident 4 stated staff answered the call light sometimes, but not all the time. On 9/1/16 at 12:37 p.m., Resident 9 stated she had no call light in her room. On 9/2/16 at 9:30 a.m., during an interview, the Facility Operations Manager (FOM) stated he was out on an extended leave when the current change of ownership had occurred. The FOM stated when he returned on 7/1/16 the construction was in progress, floors were done and painting was in progress. The FOM stated he had 18 years' experience on the job and was assigned to all three facilities owned by the new owner. The FOM stated some flooding had occurred at the facility when he was away and he did not know when the construction had started. The FOM stated there had been no permit for construction obtained. The OSHPD report dated 9/1/16 indicated, "...because the scope of the work of construction was unknown, unpermitted, and uninspected by an Independent Certified Hospital inspector, OSHPD FDD [Facilities Development Division] could not make a recommendation of re-occupancy of the apparent completed construction or the current work of construction witnessed in progress...When entering the west wing from the north exterior door at 10:00 [a.m.] it was observed the Nurse Call system was being worked on in the west wing and was not functional. A test of the nurse call system in the intermediate wing of the facility housing patients was tested because the facility had requested to continue housing patients in this area. The nurse call system as tested was misreporting locations and not reporting some locations. Additionally, there was no nurse call provided in the west wing which had a patient..." The facility failed to obtain appropriate building permits from local and state authorities and OSHPD. Residents were exposed to an unsafe physical environment in various stages of remodeling and without a functional nurse call system to alert staff to their needs. These violations, either separately or jointly, had a direct or immediate relationship to 10 of 10 sampled residents, (Resident 1, 2, 3, 4, 5, 6, 7, 8, 9, and 10) health, safety, or security, or therefore constitute a Class "B" Citation. |
| 040000069 |
VALLEY HEALTHCARE CENTER |
040012932 |
A |
2-Feb-17 |
ZKDB11 |
8674 |
"A" Citation: Neglect
F224: The facility must develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property.
Guidelines: 483.13(c), F224
"Neglect" means failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. (42 CFR 488.301)
The facility failed to ensure a system was in place to prohibit neglect for one of five residents (Resident 1) when:
Registered Nurse (RN) 1 failed to perform an ongoing physical assessment (a systematic evaluation of the resident's physical, emotional and mental health status for the purpose of providing resident focused nursing services) for Resident 1 which included a shift assessment by the nurse. Resident 1 was diagnosed with end stage kidney failure that required hemodialysis (a process to filter the blood of waste products that accumulate when the kidneys fail using an external mechanical device) three times per week. Resident 1 missed two consecutive scheduled dialysis procedures. RN 2 failed to inform Resident 1's physician of the missed dialysis procedures and RN 1 failed to perform ongoing physical assessments after the missed dialysis procedures and as a result provided no interventions to stabilize and provide treatment for Resident 1. The missed dialysis treatments led to a decline of Resident 1's condition.
These failures resulted in Resident 1's untimely death which occurred when RN 2 failed to notify Resident 1's physician of the missed dialysis procedures and RN 1 failed to perform ongoing physical assessments. RN 1 failed to recognize and monitor Resident 1's change of condition and provide an accurate account of Resident 1's care, which could have led to the provision of possible life-saving interventions.
The admission face sheet (record containing personal information) of Resident 1's clinical record and the nurses notes indicated Resident 1 was admitted to the facility on XXXXXXX16 at 7 p.m. for rehabilitation following a below knee amputation (BKA) at a local acute care hospital. Resident 1's diagnoses included End Stage Renal Disease (kidney failure), Dependence on Renal (kidney) Hemodialysis, and Insulin (medication to control high blood sugar) Dependent Diabetes Mellitus (a metabolic disease characterized by high blood sugar and usually caused by deficiency of the hormone insulin). Resident 1's Physician's Orders dated 8/24/16 (Resident 1's admission date to the skilled nursing facility) indicated, "Dialysis T [Tuesday] TH [Thursday] S [Saturday] at [local dialysis facility] at 5 p.m."
The Certificate of Death indicated Resident 1 died in the facility on XXXXXXX16 at 4:30 a.m., less than four days after admission. The Death Certificate indicated the immediate cause of death was Respiratory Failure (too little oxygen passes from the lungs to the blood); Pulmonary Edema (buildup of fluid in the air sacs of the lungs) and Cardiomyopathy (chronic disease of the heart muscle). End Stage Renal Disease was indicated as "other significant conditions contributing to death."
On 9/7/16, at 4:30 p.m., during a telephone interview, Resident 1's family member (Family Member [FM] 1) stated Resident 1 was an established dialysis patient. FM 1 stated Resident 1's dialysis service was to be transferred to a more conveniently located sister dialysis facility while being treated at the skilled nursing facility (SNF). FM 1 stated Resident 1 was sent from the SNF to the dialysis center on XXXXXXX16 but returned to the SNF without having received the hemodialysis treatment on that day. FM 1 stated the reason given for sending Resident 1 back to the SNF without first having received dialysis was because the dialysis center needed Resident 1 to have a chest x-ray done prior to receiving dialysis. FM 1 stated Resident 1 missed his second consecutive dialysis on 8/27/16, because the transportation van had not picked him up at the SNF for his 5 p.m. dialysis appointment. FM 1 stated Resident 1's death four days after admission was completely unexpected.
On 9/14/16 at 8:45 a.m., during an interview, RN 1 stated he was assigned to care for Resident 1 the night of 8/27/16, and stated Resident 1 died on his shift, on XXXXXXX 16 at 4:30 a.m. RN 1 stated he went out of his way to not disturb Resident 1 the night he died. RN 1 stated he had checked Resident 1's vital signs around 1 a.m. RN 1 stated he had not performed a physical assessment on Resident 1 as he had not wanted to disturb him. RN 1 stated the information he entered on Resident 1 into the electronic health record (HER) on 8/28/16 at 12:33 a.m., did not reflect the care he provided to Resident 1. RN 1 stated he cut and pasted (copied and transferred) the documentation from a previous entry in the EHR made by another nurse rather than information based on a physical assessment he performed himself. RN 1 stated on 8/28/16 at 12:33 a.m., he had not spoken to the resident, had not listened to his lung sounds, or asked Resident 1 how he was doing. RN 1 stated RN 2 gave him report at the beginning of his shift. RN 1 stated he was informed Resident 1 had missed the dialysis procedure but new arrangements had been made for another day.
On 9/14/16 at 11 a.m., during an interview, RN 2 stated she admitted Resident 1 to the facility on XXXXXXX16 at approximately 7 p.m. RN 2 stated she cared for Resident 1 when he returned to the SNF without having received the dialysis procedure on 8/25/16, and again when he missed the second procedure on 8/27/16. RN 2 stated the transportation van did not pick Resident 1 up on 8/27/16 for his dialysis treatment. RN 2 stated she called the transportation company and was told all the drivers had gone home for the day. RN 2 stated she knew Resident 1 missed two consecutively scheduled dialysis treatments. RN 2 stated she had not notified Resident 1's physician of the two missed dialysis treatments and stated she should have.
Review of professional reference titled, "What Is Dialysis? What is Kidney Dialysis?" http://www.medicalnewstoday.com/articles/152902.php, updated 6/29/15, indicated, "Dialysis is the artificial process of eliminating waste (diffusion) and unwanted water (ultrafiltration) from the blood. Our kidneys do this naturally. Some people, however, may have failed or damaged kidneys which cannot carry out the function properly - they may need dialysis. People whose kidneys either do not work properly or not at all experience a buildup of waste in their blood. Without dialysis the amount of waste products in the blood would increase and eventually reach levels that would cause coma and death."
Review of professional reference titled, "Relationship of Missed and Shortened Hemodialysis Treatments to Hospitalization and Mortality: Observations from a US Dialysis Network," Clinical Kidney Journal, dated 8/1/12, indicated, "...Patients who miss dialysis are more likely to have poor control of their anemia [low red blood count], bone mineral milieu [related to bone strength and density] and blood pressure, more severe electrolyte [salts in the body including sodium, potassium and chlorine] imbalance with resultant life-threatening arrhythmias [irregular heart rhythms] and recurrent volume overload [fluid build-up in the body]...the morbidity [pertaining to causing disease] and mortality [pertaining to causing death] effects of missed/shortened dialysis cannot be overlooked."
The facility's policy and procedure (P&P) titled, "2.0 Abuse Prohibition," revision dated 8/1/16, indicated, "[The facility's Corporate name] Residential Care Facilities shall prohibit...neglect...for all residents... Neglect is defined as...deprivation of essential needs... PURPOSE to ensure that the Facility is doing all that is within its control to prevent occurrences of ...neglect..."
The facility's P&P titled, "NSG205 Assessment: Nursing," revision dated 3/15/16, indicated, "POLICY A nursing assessment will be performed by a licensed nurse for all patients upon admission. Routine and focused assessments will be performed on an ongoing basis as needed..."
Therefore, the facility failed to protect Resident 1's right to be free from neglect. As a result, the physician was not notified Resident 1 had missed two consecutive dialysis treatment sessions, and RN 1 had not recognized Resident 1's condition was declining because RN 1 failed to perform a physical assessment the night Resident 1 died.
The above violation had an immediate direct relationship to Resident 1's health, safety, and security and therefore constitutes a Class "A" Citation. |
| 050000068 |
VISTA COVE CARE CENTER AT SANTA PAULA |
050007262 |
A |
19-Jul-12 |
9B5G11 |
6059 |
F 323 483.25(h) (h) Accidents - The facility must ensure that each resident receives adequate supervision and assistance devices to prevent accidents. The facility did not comply with the above regulation when it failed to provide a resident with adequate supervision to prevent a fall. Resident A was admitted to the facility from the hospital, after he fell at home, struck his head, and sustained bilateral subdural hematomas (form of traumatic brain injury resulting in a collection of blood on the surface of the brain). Resident A was assessed upon admission, determined to be at high risk for falls, and was observed attempting to climb out of bed without assistance. The facility failed to provide the resident with adequate supervision, however, and the morning following admission, Resident A had an unwitnessed fall and was found sitting on the bathroom floor. Resident A was 86 years old and was admitted to the facility from the hospital on 4/21/09, for observation and rehabilitation therapy with diagnoses including bilateral subdural hematomas, fractures of the fourth and fifth digits of the right hand, Alzheimer's dementia, chronic obstructive pulmonary disease, hypertension, vertigo, and a history of stroke. Resident A was hospitalized prior to admission, after he fell at home, struck his head, and sustained acute bilateral subdural hematomas. Hospital discharge instructions noted that Resident A was to get out of bed with assistance only, and needed to be supervised at all times.A nursing assessment was completed upon admission and indicated that Resident A was alert, oriented to person, and required assistance with activities of daily living including, transfers, ambulation, personal hygiene, bathing and dressing. A fall risk assessment was also completed on 4/21/09 and identified that Resident A was at high risk for falls. A care plan titled "Potential for injury/fall risk" as evidenced by a history of falls, an inability to transfer and ambulate without assistance, and poor safety awareness was initiated on 4/21/09. Interventions to prevent falls and injury indicated that staff would ensure Resident A's call light was in reach, remind the resident to ask and to wait for assistance, and assess the need for fall interventions such as a low bed and chair or bed alarms. Care plan interventions, however, did not address supervision of the resident.The initial nursing note documented on 4/21/09 at 11:15 pm noted that Resident A was alert, oriented times one, and that call light use was explained to the resident. The note also indicated that Resident A was observed trying to climb out of bed. There was no evidence the need for fall interventions, such as a bed alarm were assessed or that a plan to monitor and supervise the resident was implemented, however, despite the observation and the resident's high risk for falls.The following morning at 7:25 am, nursing documented that Resident A had an unwitnessed fall and was found sitting on the bathroom floor. The resident was assessed, no injuries were noted and Resident A was placed in his wheelchair near the nursing station for increased supervision.The physician was notified and came to the facility at 8:30 am and examined the resident. Following the fall, neurological checks and 72 hour charting were initiated by nursing to monitor Resident A for a change of condition, and orders were requested and received for use of a seat belt when Resident A was up in his wheelchair and for a roll belt when he was in bed.From 4/22/09 to 4/26/09, no change in Resident A's condition was identified by nursing.On 4/27/09, however, the physician came to facility for a family meeting, examined the resident and noted that Resident A's speech had decreased and he was only using single words. The physician's progress note included a plan to decrease the frequency of physical therapy, to reassess the resident in one week, and "no repeat head CT at this time."On the morning of 4/28/09 Resident A had a significant change in condition. Nursing documented that Resident A was disoriented, lethargic, had difficulty swallowing, was short of breath, had a cough and was wheezing. At 11:10 am, the nurse noted that orders for oxygen administration and suctioning were received, that family reported the resident was exhibiting signs of a stroke, and that Resident A's vital signs were taken and included a temperature of 100.6, a heart rate of 108, a respiratory rate of 32, and blood pressure of 220/112. The physician was notified and Resident A was transferred to the emergency room by ambulance and evaluated for an altered level of consciousness and fever.A chest x-ray showed that the resident had a right upper lobe infiltrate, and a CT scan of the resident's head showed that the left subdural hematoma he sustained prior to admission, had increased in size.The physician indicated that Resident A's family was aware of his grave prognosis, wanted Resident A to be treated for pneumonia and provided with comfort care, but did not want any further intervention. Resident A was admitted to the hospital with diagnoses including right upper lobe pneumonia and worsening subdural hematoma with altered level of consciousness.The facility violated the above regulation by failing to ensure that Resident A received adequate supervision to prevent a fall. Resident A was admitted to the facility with a serious head injury sustained from a fall and discharge instructions from the hospital which indicated he needed to be supervised at all times. Following admission, Resident A was assessed and determined to be at high risk for falls, and was observed attempting to climb out of bed without assistance. The facility failed to provide the resident with adequate supervision, however, and the morning following admission, Resident A had an unwitnessed fall and was found sitting on the bathroom floor. The violation presented an imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result. |
| 050000069 |
VALLE VERDE HEALTH FACILITY |
050010827 |
A |
01-Jul-14 |
KFBN11 |
4074 |
CFR 483.25(h)(2) F323 Accidents. (2) The facility must ensure that each resident receives adequatesupervision and assistance devices to prevent accidents The Department determined the facility failed to provide adequate supervision and assistance devices to prevent an injury related to an accident to Resident A. The facility failed to implement identified supervision and revise fall prevention interventions to Resident A's plan of care after Resident A experienced multiple falls. These failures resulted in Resident A falling while attempting to get out of bed and sustained a fractured arm.Resident A was a 96 year old female admitted to the facility with diagnoses including dementia (with documented forgetfulness) and osteoarthritis (degeneration of joint cartilage causing pain and stiffness). A comprehensive assessment dated August 22, 2013 revealed Resident A was at high risk for falls, able to make her needs known, able to understand others, ambulated with assistance, and required extensive assistance of one staff member for transferring. Review of subsequent comprehensive assessments showed a decline in the physical functioning of Resident A since admission.On October 27, 2013 at 10:44 a.m., Resident A fell while ambulating with a walker and landed on her buttocks. The fall risk assessment indicated new interventions were identified and the care plan updated. Review of the care plan revealed no new fall prevention interventions were implemented following Resident A's fall. Later, Resident A chose to utilize a wheelchair to get around in the facility versus her walker. Review of the certified nursing assistant (CNA) flow sheet dated December 2013, listed the following intervention, "I need to have supervision when I am up in my wheelchair..."Resident A fell again on December 13, 2013 and again on December 26, 2013 while attempting an unassisted transfer, from the wheelchair to the bed. Neither fall was supervised by staff despite the identified need for supervision when Resident A was up in her wheelchair. On December 13th, it appeared Resident A tried to transfer herself to the bed and slipped. Resident A indicated she hit her head on that fall and there was no injury. On December 26th, Resident A was trying to transfer from the wheelchair back to bed and fell complaining of "tail bone" pain and there was no injury related to that fall.Review of the fall risk assessment following the December 13th and the December 26th falls indicated new interventions were identified and the care plan updated, however there were no new interventions listed on Resident A's plan of care related to transfers in and out of bed with the use of a wheelchair such as safety mats on the floor, increasing the frequency of toileting assistance, or considering moving Resident A to a room that was in the line of sight of the nursing station for increased supervision.On February 17, 2014 Resident A, was observed on the floor next to her bed lying on her right side. It appeared Resident A had attempted to get out of bed and slipped. Resident A complained of right shoulder pain. The results of Resident A's right shoulder x-ray on February 18, 2014 revealed Resident A sustained a fractured right upper arm as a result of the fall.During an interview and record review on June 9, 2014, the Director of Nursing confirmed the facility did not evaluate the effectiveness of existing interventions and explore possible alternative interventions to prevent an injury related to Resident A's history of multiple falls.The facility's failure to provide the necessary supervision, as previously assessed when transferring between the wheelchair to the bed and back, along with the failure to consistently evaluate the effectiveness of current interventions while exploring alternatives to prevent injury related to falls and revise the plan of care resulted in Resident A's fractured arm.These failures presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result. |
| 050000075 |
Vista Del Monte |
050010903 |
A |
16-Oct-14 |
UMCX11 |
3044 |
CFR 483.25(h) ACCIDENTS- The facility must ensure that: (2) Each resident receives adequate supervision and assistance devices to prevent accidents. The Department determined the facility failed to provide adequate supervision and assistive devices to prevent Resident A from falling. As a result, Resident A fell in a bathroom sustaining a displaced left hip fracture with a moderate sized hematoma.Resident A was admitted to the facility with diagnoses including Prostatic hypertrophy (enlarged prostate), urinary retention with urinary indwelling catheter, general muscle weakness, Dementia, Diabetes, Atrial Fibrillation, and cirrhosis of the liver.The facility assessed Resident A to be at risk for falls due to urinary retention with a urinary indwelling catheter, history of falls, unsteady gait, poor balance, and impaired vision. Resident A's diagnoses of Diabetes, low blood pressure, Dementia, impaired cognition, and episodes of urinary incontinence also placed the resident at risk for falls according to the facility's assessment. The facility's care plan interventions to address the fall risk included: bed in lowest position, offer rest periods, remind resident not to try to get up without assistance.On 1/27/14 Resident A fell in a bathroom. On 3/26/14 Resident A fell again in the bathroom. The facility's plan of care to prevent Resident A from falls after the fall on 1/27/14 and 3/26/14 included: re-instruct resident to use brakes on walker, monitor proper use of walker, calling for assistance, nursing to monitor behavior, and a restorative exercise program.On 5/24/14 the facility assessed Resident A as forgetful, needed extensive assistance, and one person physical assist with toileting, transferring, dressing, and guided maneuvering with walking in the room and personal hygiene. On 5/27/14 the urinary indwelling catheter was removed. The facility failed to revise the plan of care to include offering a urinal, implementing a toileting program, and/or a bedside commode.On 6/30/14 Resident A was alone and unsupervised in the bathroom when he fell. The facility found Resident A on the bathroom floor, lying on his back with arms and legs extended and complaining of pain. Resident A was transferred via Emergency Medical Services to an acute care hospital, where he was diagnosed with left hip fracture and hematoma.During an interview on 7/7/14 at 10:30 a.m., the Director of Nursing (DON) agreed the urinal and / or bedside commode was not considered for Resident A.The facility identified Resident A to be at risk for falls due to history of falls, episodes of urinary incontinence, unsteady gait, impaired vision, and diagnosis of Diabetes, low blood pressure, and Dementia. Resident A continued to fall while using the bathroom but the facility failed to provide adequate supervision and assistive devices to prevent a fall and/or injury.These failures presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result. |
| 050000074 |
VILLA MARIA HEALTHCARE CENTER |
050011179 |
A |
12-Apr-16 |
1XP011 |
4932 |
CFR 483.25 Quality of Care Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care.The Department determined the facility failed to prevent avoidable skin breakdown from occurring. The facility failed to place a sock on Resident A's left foot prior to applying a cast boot (boot covering toes to middle calf with straps) and did not monitor the skin condition every shift as ordered by the physician. The facility did not assess the left foot for 15 days while wearing the cast boot. These failures resulted in Resident A developing six wounds to the left foot. Resident A was readmitted to the facility on 9/16/14 with diagnoses including a fractured pelvis, fractured ankle and diabetes. The comprehensive assessment dated 9/23/14 revealed Resident A usually can make herself understood and clearly understood others. Resident A required extensive assistance of two staff for transfers and going to the bathroom. The admission assessment dated 9/16/14 indicated Resident A had no pressure sores upon admission but was at risk for developing pressure sores.On 9/22/14, Resident A developed redness on both heels and the physician ordered to apply skin prep (a film to protect against friction) twice a day. The facility failed to provide documentation to indicate a plan of care was developed to address the redness on both heels. On 9/25/14, Resident A's x-ray revealed a fractured left ankle. On 9/30/14, the physician ordered not to bear weight on the left leg for four weeks, wear a cast boot on the left leg and take off the boot for hygiene, put sock under the boot for protection from skin breakdown, and monitor the left leg's skin condition every shift. The medication administration record (MAR) for September 2014 revealed, the order to have the cast boot on for protection and taken off for hygiene was noted as: "FYI" (for information only). The MAR did not indicate a sock was to be worn under the boot or the condition of the left leg was to be monitored every shift. The MAR between 10/1 and 10/15/14, did not contain documentation or assessment of the skin condition of Resident A's left foot, did not indicate a sock was to be worn under the boot, and did not indicate the condition of Resident A's left leg was to be monitored every shift.On 10/16/14, the wound assessment reports of Resident A's left foot identified four separate wounds had developed, and were described as "dry scabs." The wounds were located on the left ankle, on top of the left foot, on the left third toe, and on the left fourth toe. On 10/19/14, the wound assessment for Resident A's left heel, identified an unstageable suspected deep tissue injury (discolored intact skin due to damage of underlying soft tissue from pressure). No new interventions were implemented. There was no documentation indicating the skin condition of Resident A's left heel was assessed or monitored between 9/22 and 10/16/14. Review of a note by a podiatrist (foot doctor) dated 11/10/14 identified eschar (dead tissue) on three areas of the left foot, one area of the third toe, one area of the fourth toe and one on the left heel.During a concurrent interview and record review, on 12/8/14 at 2 p.m., a licensed nurse (LN 1) confirmed, the physician's order to monitor Resident A's left leg skin condition every shift had not been transcribed to the 10/14 MAR. There was no documentation of the left foot's skin assessment for 16 days after the cast boot was applied, from 9/30/14 until 10/16/14. LN 1 stated, "The cause of the scabs was most likely from friction of the boot." LN 1 confirmed, Resident A had been wearing the boot 24 hours a day, every day between 9/30/14 and 10/16/14. During a concurrent interview and record review on 12/9/14 at 10:10 a.m., LN 2 confirmed, there was no documentation of an assessment of the skin condition of Resident A's left foot between 10/1/14 and 10/16/14, on either the resident's MAR or treatment record.During a concurrent interview and record review on 12/9/14 at 11 a.m., LN 3 confirmed, the treatment record lacked documentation of the skin prep being applied to Resident A's heels on 10/5/, 10/6/14, during four evening shifts on 10/7, 10/8, 10/9 and 10//10/14, and two morning shifts on 10/12 and 10/13/14.The facility's failure to ensure Resident A received the necessary care and services to maintain skin integrity while the resident was wearing a cast boot resulted in Resident A developing six wounds to the left foot. These wound were unresolved at the time of discharge from the facility and required ongoing treatment by a home health nurse.These failures presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result. |
| 050000068 |
VISTA COVE CARE CENTER AT SANTA PAULA |
050011614 |
A |
01-Feb-16 |
L80411 |
2108 |
CFR 483.25 (h) ACCIDENTS. The facility must ensure that - (1) The resident environment remains as free from accident hazards as is possible; and (2) Each resident receives adequate supervision and assistance devices to prevent accidents.The Department determined the facility failed to provide adequate supervision and assistive devices to prevent an injury related to Resident A falling during an unassisted transfer. The facility failed to implement physical therapy (PT) recommendations for the use of a pressure alarm and low bed to minimize injury risk. As a result, Resident A fell and sustained a fractured hip. Resident A was an 81 year old female, admitted to the facility with diagnoses including dementia and generalized muscle weakness. Review of the comprehensive assessment dated 4/30/15 revealed, Resident A have impaired cognition (mental process of understanding), required extensive assistance with transfers and bed mobility, and had balance problems during transitions and walking. Resident A was assessed to be a fall risk related to intermittent confusion, use of drugs for high blood pressure control, and use of mood-altering medications.Review of the PT evaluations before Resident A's fall of 6/15/15 revealed several recommendations for the use of pressure alarm and to keep the bed in low position due to Resident A's poor balance and difficulty coordinating body movements. On 6/15/15 at 1 p.m., Resident A attempted an unassisted transfer to the bathroom and fell sustaining a hip fracture. On 6/18/15 at 2:30 p.m., an interview with licensed nurse (LN 1) confirmed, she was unaware of the PT's recommendations to use pressure alarm and to keep the bed lowered. These were not reflected in Resident A's plan of care and were not communicated during the daily interdisciplinary team meeting. On 7/2/15 at 1:30 p.m., an interview with LN 1 confirmed, there was no pressure alarm in use for Resident A prior to the fall on 6/15/15. This presented imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result. |
| 050000069 |
VALLE VERDE HEALTH FACILITY |
050012298 |
B |
30-Sep-16 |
L8TL11 |
2264 |
Title 22 of the California Code of Regulations Division 5, Article 5, 72541: Unusual Occurrences. Occurrences such as epidemic outbreaks, poisonings, fires, major accidents, death from unnatural causes or other catastrophes and unusual occurrences which threaten the welfare, safety or health of patients, personnel or visitors shall be reported by the facility within 24 hours either by telephone (and confirmed in writing) or by telegraph to the local health officer and the Department. An incident report shall be retained on file by the facility for one year. The facility shall furnish such other pertinent information related to such occurrences as the local health officer or the Department may require. Every fire or explosion which occurs in or on the premises shall be reported within 24 hours to the local fire authority or in areas not having an organized fire service, to the State Fire Marshal. The Department determined the facility was in violation of the above statute by its failure to report to the Department immediately or within 24 hours when Patient 1 fell which resulted in a fracture to the right hip. Patient 1 was a 93 year old female, initially admitted to the facility on 6/20/13 and was re-admitted 3/31/16 with diagnoses including dementia (decline in mental ability). Record review Progress Notes indicated on 3/14/16 Patient 1 was observed falling onto her right side. X-rays results March 15, 2016 noted a right hip fracture. On 3/15/16 Patient 1 was transferred to an acute hospital where the hip fracture was surgically repaired. Interview with a licensed nurse (LN 1) on 5/24/16 at 3:05 p.m., LN 1confirmed Patient 1 fell on 3/14/16. Review of ACTS Complaint/Incident Investigation Report dated 5/11/16, the Department was notified of this incident on 5/11/16, 58 days after the event. Interview with the director of nurses (DON) on 5/24/16 at 4 p.m., the DON acknowledged, the facility did not report the incident in the Department within the required 24 hour time frame, as required by regulation. The facility should know or should have known, they have to report to the Department immediately, or within 24 hours, the unusual occurrence which affected the health of Patient 1, specially a fall which resulted in a fracture. |
| 050000069 |
VALLE VERDE HEALTH FACILITY |
050012504 |
B |
26-Aug-16 |
TB5Y11 |
2306 |
California Health and Safety Code 1418.21(a) A skilled nursing facility that has been certified for purposes of Medicare or Medicaid shall post the overall facility rating information determined by the federal Centers for Medicare and Medicaid Services (CMS) in accordance with the following requirements: (1) The information shall be posted in at least the following locations, in the facility: (A) An area accessible and visible to members of the public. (B) An area used for employee breaks. (C) An area used by residents for communal functions, such as dining, resident council meetings, or activities. (2)(C) The most recent overall star rating given by CMS to that facility, except that a facility shall have seven business days from the date when it receives a different rating from the CMS to include the updated rating in the posting. The star rating shall be aligned in the center of the page. The star rating shall be expressed as the number reflects the number of stars given to the facility by the CMS. The number shall be in a clear and easily readable font of at least 2 inches print. The Department determined the facility was in violation of the above statute by failure to post its overall facility rating (Five-Star Quality Rating) in areas accessible and visible to the public, residents, and employees. During observations on 8/1/16 beginning at 2:45 p.m. and at 3 p.m., the facility star rating was not posted in any area accessible to the public, in any area used by residents for communal functions (dining rooms, living rooms, activities, and hallways), and in any area used for employee breaks. During an interview on 8/1/16 at 3 p.m., interim administrator (IA) acknowledged the facility's star rating was not currently posted. IA confirmed, previously posted star posting was located solely next to the postings board and nowhere else. The Five-Star Quality rating System was created by CMS to help consumers, their families, and caregivers compare nursing homes more easily. The ratings are based on health inspection rating, staffing, and quality measures. The facility's failure in posting its star rating deprived consumers, their families, and caregivers valuable information in determining sound decisions for nursing home placement and continued stay in the nursing home. |
| 050000068 |
Vista Cove Care Center at Santa Paula |
050012550 |
B |
14-Oct-16 |
G3J511 |
3541 |
Title 22 of the California Code of Regulations Division 5, Article 5, 72541: Unusual Occurrences. Occurrences such as epidemic outbreaks, poisonings, fires, major accidents, death from unnatural causes or other catastrophes and unusual occurrences which threaten the welfare, safety or health of patients, personnel or visitors shall be reported by the facility within 24 hours either by telephone (and confirmed in writing) or by telegraph to the local health officer and the Department. An incident report shall be retained on file by the facility for one year. The facility shall furnish such other pertinent information related to such occurrences as the local health officer or the Department may require. Every fire or explosion which occurs in or on the premises shall be reported within 24 hours to the local fire authority or in areas not having an organized fire service, to the State Fire Marshal. The Department determined the facility was in violation of the above regulation when it failed to report to the Department within 24 hours, an elopement (leaving the facility without facility acknowledgment) of Patient 1 which resulted in a fall causing skin tears to left hand. Review of medical recorded indicated Patient 1 was an 83 year old male admitted to the facility 11/10/15 with diagnoses including dementia (a gradual decline of mental abilities). A comprehensive assessment dated 5/19/16 revealed Patient 1's cognition (processes of thinking) was severely impaired and required one person assistance with activities of daily living such as dressing, toileting, eating, bathing. During an interview on 8/24/16 at 3:30 p.m., a licensed nurse (LN 2) confirmed Patient 1 was able to self-propel (scoot) about the facility in a wheelchair Record review of Nurses Progress Notes dated 8/10/16 at 6:18 p.m. indicated Patient 1 went, unescorted, outside the facility and fell from his wheelchair. A person(s) unknown to the facility called emergency services/paramedics and also ran into the building to inform a licensed nurse (LN 2) Patient 1 was outside the facility. Further record review of Nurses Progress Notes dated 8/10/16 at 6:34 p.m. indicated LN 1 found Patient 1 outside the facility. Patient 1 was transferred to a hospital emergency room. During an interview on 10/5/16 at 11:45 a.m., the director of nurses (DON) acknowledged, an elopement is an unusual occurrence and confirmed Patient 1's elopement on 8/10/16 was not reported to the Department. Interview with the administrator (ADM) and DON on 10/3/16 at 3:30 p.m., and observation of the distance scooted by Patient 1 in his wheelchair, the ADM and DON confirmed the distance travelled by Patient 1 was a distance of 144 feet from the facility front door. Interview with LN 1 and LN 2 on 10/4/16 at 3:17 p.m. and 10/5/16 at 2:38 p.m., both LN 1 and LN 2 confirmed Patient 1 left the facility without facility knowledge by scooting himself in his wheelchair on 8/10/16. LN 1 and LN 2 confirmed when Patient 1 was found, he was laying on his left side, in the street, where cars park and pass by, wearing seatbelt attached to his wheelchair. Record review of the hospital emergency department record dated 8/10/16, indicated, Patient 1 was treated in emergency department for skin tears to the left hand. The facility should know or should have known, they have to report to the Department within 24 hours, incident of elopement to the street involving Patient, subsequent fall with injury that threatened the life and safety of Patient 1 but failed to do so. |
| 050000068 |
Vista Cove Care Center at Santa Paula |
050012759 |
B |
28-Dec-16 |
QU6N11 |
6191 |
Code of Federal Regulations F226 483.13(c) Develop/Implement Abuse, Neglect Policies: The facility must develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. The Department determined the facility was in violation of the above statute by its failure to report to the Department allegations of abuse immediately or within 24 hours. The facility policy and procedure titled "Abuse Prohibition Program" undated, indicated, "Response and Reporting: Reporting to required agencies." The policy and procedure did not specify specific agencies nor time frames. 1. During an interview and concurrent record review on 11/15/16 at 3:50 p.m., the administrator (ADM) acknowledged the night supervisor (LN 5) wrote the following in certified nursing assistant's (CNA 1) Counseling Report date July 15, 2016, "Resident 2 very angry with CNA 1. Resident being accusatory with CNA 1 with escalating agitation, the CNA 1 asked to leave room. CNA 1 began arguing with resident. I (LN 5) had to repeat myself twice asking her (CNA 1) to leave room, because her yelling at the resident wasn't resolving anything only making it worse...Other residents have gotten upset with this CNA 1 leading to increased agitation which results in this CNA 1 getting punched in the stomach, scratched, bitten..." LN 5, director of nursing (DON) and ADM signed the Counseling report. The ADM (also abuse coordinator) confirmed yelling is not tolerated in the facility and stated, "Yelling is abuse." The ADM was unsure if any other residents were interviewed regarding the involved CNA 1's behavior. The ADM was unable to explain why this incident was not reported per facility's abuse policy and procedure. Review of Resident 2's record indicated, the Minimum Data Set (a comprehensive assessment) dated 9/4/16, indicated Resident 2's cognitive status was severely impaired. Resident 2 had diagnoses of cognitive communication deficit, anxiety disorder and dementia. 2. During an interview and concurrent record review on 11/9/16 at 8:45 a.m., the social worker (SW) reported she wrote a note in Resident's 19 chart on 8/19/16 indicating Resident 19 and his sister came to her office on 8/16/16 to complain that during the night shift someone is coming in his room asking to see his private parts (front and back). SW reported she immediately reported this to the administrator (ADM). An inter disciplinary team (IDT) meeting was held and concluded the certified nursing assistant (CNA 2) was only checking to see if Resident 19 needed changing, and CNA 2 was instructed to only change Resident 19 if requested. The Minimum Data Set (a comprehensive assessment) dated 9/18/16, indicated Resident 19's cognitive status was moderately impaired. Resident 19 had diagnoses including paranoid schizophrenia (chronic mental disorder in which a person loses touch with reality) and dementia (decrease in the ability to think and remember that is great enough to affect a person's daily functioning). During an interview and concurrent record review on 11/9/16 at 9:30 a.m., the ADM and director of nursing (DON) acknowledged Resident 19's allegation was not reported to the required agencies indicated in the facility's policy because they did not think this was abuse. 3. During an interview with Resident 8 on 11/10/16, at 4:30 p.m., with the presence of director of staff development (DSD), Resident 8 stated "(name of CNA) every time she changes me, (name of CNA) is rude and brutal." Resident 8 added, "I told ADM about (name of CNA) being rude." The Minimum Data Set (comprehensive assessment) indicated Resident 8's cognition to be moderately impaired. Resident 8's diagnoses included bipolar disorder (mental disorder with periods of depression and periods of elevated mood) and dementia (decrease in the ability to think and remember that is great enough to affect a person's daily functioning). During an interview with the DSD on 11/10/16, at 4:36 p.m., DSD acknowledge the statement made by Resident 8 regarding (name of CNA) being rude and brutal when changing the resident and Resident 8 told the ADM. 4. During an interview with Resident 13, on 11/8/16, at 12:07 p.m., Resident 13 reported there is a certified nursing assistant (CNA 1) in the facility who insists on checking Resident 13's briefs, even after the resident tells CNA 1 there is no need. Resident 13 reported it was happening "almost every day" while she was living on another wing of the facility for a few months after the admission to the facility. Resident 13 stated "CNA 1 would say "Why didn't you ask for a bed pan? You're getting lazy." Resident 13 explained she was admitted to the facility after a stroke (sudden death of brain cells due to lack of oxygen, caused by blockage of blood flow or rupture of an artery to the brain) and could not control her bladder at the time. Resident began to cry. Resident 13 stated "After a while I couldn't take it anymore. I think someone spoke to CNA 1 about it because she approached me and asked why I don't want to work with her anymore. I told another CNA (CNA 5) about it, back then. I really felt like maybe I was wrong, maybe I was the one at fault. It made me cry. I cry especially when my feelings are hurt." During an interview on 11/8/16 at 4:45 p.m., the director of staff development (DSD), director of nurses (DON), and administrator (ADM) were unaware of incident regarding Resident 13 and CNA 1. DSD reported CNA 1 assignment was changed but was unaware of the reported incident. The DSD reported there is no follow up when a resident asks for a different CNA. During an interview on 11/14/16 at 9:26 a.m., CNA 5 reported remembering an incident occurring months ago with Resident 13. CNA 5 described she was called to the room by CNA 6 because Resident 13 was crying. CNA 5 reported Resident 13 was crying talking about how she did not like CNA 1 and something about changing her briefs. I went and got the director of DSD and she came." The facility was in violation of the statute by its failure to report to the Department four allegations of abuse immediately or within 24 hours. |
| 050000069 |
VALLE VERDE HEALTH FACILITY |
050013117 |
A |
8-May-17 |
UVP011 |
16367 |
Code of Federal Regulations 483.24, 483.25
Quality of life: Quality of life is a fundamental principle that applies to all care and services provided to facility residents. Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident's comprehensive assessment and plan of care.
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 Department determined during the investigation of an entity reported incident, the facility failed to provide the necessary care and services to prevent Resident 1 injuries from fall. Resident 1 suffered from two falls, one resulted to injury to the forehead, second fall resulted to fracture of the left hip, and had two dislocations of the left hip. The failure resulted in Resident 1 becoming disabled and no longer being able to walk.
a. Resident 1 fell on 8/10/16 sustaining injury to the forehead.
b. Resident 1 was left alone in her room, which led to Resident 1 sustaining another fall on 10/10/16 resulting in a fracture (broken bone) of the left hip.
c. Certified nursing assistants (CNAs) did not follow hip precautions (important guidelines for those who have recently had a hip surgery to replace a hip joint; hip precautions are ways of moving around that help prevent hip dislocation or separation of the new joint until the joint has time to heal). Additionally, the facility did not ensure a physician's order and care plan for hip precautions were in place for Resident 1 which resulted in Resident 1's left hip being dislocated sometime between 10/7/16 and 10/13/16.
d. CNAs did not follow hip precautions for Resident 1 after Resident 1's first dislocation and another surgical procedure of the left hip, which resulted in Resident 1's left hip being re-dislocated sometime between 10/17/16 and 11/23/16.
Resident 1 was originally admitted to the facility on XXXXXXX16 with diagnoses including subdural hemorrhage (collection of blood between the lining of the brain and the brain), dementia (persistent disorder of the mental processes marked by memory disorders, personality changes, and impaired reasoning), unspecified lack of coordination, difficulty in walking, and Parkinson's disease (disease of the nervous system marked by tremor, muscular rigidity, and slow, and imprecise movement).
Review of Nursing Assessment including a Fall Risk Assessment dated 2/16/16, indicated Resident 1 to be at high risk for falls with a score of 23. The Fall Risk Assessment indicated "Total Score of 10 or above represents HIGH RISK." Resident 1 indicators for the score of 23 included "Intermittent level of consciousness/mental status, 3 or more falls in past 3 months, chair bound, balance problem while standing, balance problem while walking, decreased muscular coordination, change in gait pattern when walking through doorway, jerking or unstable when making turns, requires use of assistive devices-can, wheelchair, walker, furniture, fall with injuries on 2/13/16."
Review of Assistance with Activities of Daily Living care plan initiated 2/15/16, revised 10/7/16 indicated the facility staff to provide assistance to Resident 1 with toileting at least before meals, after meals, at bedtime, and as needed.
a. Review of Physical Therapy Discharge Summary dated 4/28/16, indicated Resident 1 was receiving physical therapy from 3/23/16 to 4/26/16. Upon physical therapy discharge on 4/26/16, Resident 1 was able to walk 200 feet using a front wheel walker (device to help with balance) and with contact guard assist (staff need to have one or two hands on the body of a resident, but provide no other assistance to perform a functional task; the contact is made to help steady the body or help with balance) of one person.
Review of a Minimum Data Set (MDS), a comprehensive assessment, dated 5/21/16, completed before the 8/10/16 fall incident, indicated Resident 1 had severely impaired cognition and required one person physical assist with toileting.
Review of Committee Review Progress Note dated 8/10/16, indicated Resident 1 was found on the floor in the bathroom and sustained a "raised area on the top part of her forehead."
During an interview with Resident 1's responsible party (RP), on 12/9/16, at 10:35 a.m., RP indicated on a couple of occasions witnessing the facility staff leaving Resident 1 on the toilet unsupervised.
During an interview with a certified nursing assistant (CNA 2), on 12/9/16, at 2:18 p.m., CNA 2 stated, "Sometimes I make her (Resident 1) bed while she is there (on the toilet)...To me, as long as I stay in the room with her means I'm not leaving her (Resident 1) alone..."
During an interview with a clinical supervisor nurse (LN 1), on 12/9/16, at 2:30 p.m., LN 1 confirmed Resident 1 required supervision at all times while toileting, stated "...she cannot be left alone in the bathroom..."
During an interview with LN 2, on 12/9/16, at 2:45 p.m., LN 2 stated "...those people (residents) that need assistance with toileting need continuous assistance at all times and cannot be left alone."
b. During a record review of the clinical record for Resident 1 on 12/9/16, the High Risk for Falls care plan initiated 5/20/16, indicated Resident 1 needed activities that minimize the potential for falls while providing diversion and distraction such as "putting charge stickers on, folding linens, offer use of year book, bring to activities of choice."
Progress Notes dated 10/4/16 and 10/5/16, indicated Resident 1 sustained a fall in her room on 10/4/16. "Resident was found lying on the floor on her left side with the wheelchair in front of her. Resident stated that she wants to go to the bathroom...Resident c/o (complained of) left hip pain...Resident was transferred to (name of the hospital) ER (emergency room) for evaluation and management."
During an interview with CNA 1, 12/14/16, at 10:20 a.m., CNA 1 described the fall incident Resident 1 sustained on 10/4/16 and stated "...she (Resident 1) was in the room (where Resident 1 resides), but she (Resident 1) wasn't supposed to be in the room...She (Resident 1) said she was trying to go to the bathroom. We try to keep her (Resident 1) in front of the nursing station..."
During a record review of the clinical record for Resident 1 from a general acute care hospital on 12/15/16, the physician's Consultation Report dated 10/5/16, indicated Resident 1 sustained a left hip fracture (broken bone). The Discharge Summary Details of Hospital Stay report dated 10/7/16 indicated Resident 1 underwent left hip arthroplasty (surgical reconstruction or replacement of a joint) on 10/5/16 without surgical or post-surgical complications.
c. The Admission Progress Note dated 10/7/16 indicated Resident 1 was readmitted to the facility.
During a record review of the clinical record for Resident 1 on 12/14/16, the Interfacility Transfer After Visit Summary dated 10/7/16, under Interfacility Transfer Note, indicated Resident 1 had hip precautions (important guidelines for those who have recently had a hip surgery to replace a hip joint; hip precautions are ways of moving around that help prevent hip dislocation or separation of the new joint until the joint has time to heal) after left hip surgery performed on 10/5/16.
During a record review and a concurrent interview with LN 2, on 12/14/16, at 2:15 p.m., LN 2 confirmed the facility did not initiate a hip precautions care plan after Resident 1 was readmitted to the facility and did not have one in place between XXXXXXX16 and XXXXXXX16.
During an interview with the physician (MD 2) and LN 2, on 12/14/16, at 1:58 p.m., MD 2 explained when a resident is discharged from a general acute care hospital with new orders, MD 2 would either write them as new orders on a prescription (an instruction written by a medical practitioner that authorizes a patient to be provided a medicine or treatment) or sign new hospital orders electronically. LN 2 reviewed Resident 1's clinical record and confirmed there was no prescription or electronically signed orders signed by MD 2 for Resident 1's hip precautions between 10/7/16 and 10/13/16.
Review of the Health Status Progress Note dated 10/13/16, indicated Resident 1 was not able to bear weight upon standing and was noted to have the left hip to be shortened, internally rotated and moved toward the midline of the body. Emergency 911 was called and Resident 1 was sent to the emergency room for an evaluation.
During a record review of the clinical record from the general acute care hospital for Resident 1 on 12/15/16, the Emergency Department Provider Physician's Note dated 10/13/16, indicated Resident 1 was admitted to the general acute care hospital on XXXXXXX16 and was found to have a left hip dislocation. The Discharge Summary dated 10/14/16, indicated Resident 1 underwent a closed reduction (procedure to set or reduce a broken bone without surgery; this allows the bone to grow back together) of the left hip under general anesthesia (anesthesia that affects the whole body and induces a loss of consciousness) on 10/14/16.
d. During a record review of the clinical record for Resident 1 on 12/9/16, the Admission Progress Note dated 10/17/16, indicated Resident 1 was readmitted back to the facility with a left immobilizer (device to prevent left extremity from moving) and an abduction pillow (a pillow or cushioned wedge placed between the legs of a patient to maintain proper positioning and prevent dislocation of the hip joint).
During an interview with the director of rehabilitation department (OT), on 12/9/16, at 3:50 p.m., OT indicated he educated certified nursing assistants (CNAs) about hip precautions on 10/26/16. OT explained the in-service he provided about Resident 1's hip precautions and indicated CNAs were instructed to do the following when transferring Resident 1 from a wheel chair to the toilet and back:
*Transferring Resident 1 requires two CNAs.
*CNAs are supposed to space the wheel chair so that Resident 1 can grab the bar (supportive device in the bathroom) without leaning forward.
*CNAs are to use verbal cues to initiate the transfer and have Resident 1 stand up.
*CNAs are supposed to have a gait belt on Resident 1 (special belt used to assist with transfers which is placed around the patient's waist) which they need to hold on to when having Resident 1 rise from the wheel chair.
*One CNA is supposed to support Resident 1's back by placing hands on her back and the other CNA is to move the wheel chair away and wheel a commode (device which could be placed over the toilet) closer to Resident 1.
*Once in place, CNAs are supposed to cue Resident 1 to lower her buttocks onto the commode.
*Once Resident 1 is in the sitting position, a trash can is placed under the foot with an immobilizer.
*The abduction wedge is removed during transfers and is put back on when Resident 1 is back in the wheel chair after toileting.
*No other supportive devices or regular pillows are to be used, only the abduction wedge.
During an interview with CNA 2 who helps to take care of Resident 1, on 12/9/16, at 2:18 p.m., CNA 2 explained how she transfers Resident 1 from the wheel chair to the toilet and back. CNA 2 stated "...I help her (Resident 1) to get to the bathroom. She (Resident 1) reaches for the bar. I help her (Resident 1) stand and put her (Resident 1) on the commode. When she (Resident 1) is done, we (CNAs) have her (Resident 1) stand and sit back in the wheel chair..." When asked for more details, CNA 2 stated "We (CNAs) hold her (Resident 1) by her arms. I tell her (Resident 1) to make the leg straight, put the wedge, then we (CNAs) put her (Resident 1) in the wheel chair with the wedge in the middle and put a pillow underneath the wedge and second pillow above the wedge. This was in October after her (Resident 1's) surgery..." Both CNAs were not following instructions provided by the OT to prevent hip dislocation.
During an interview with CNA 3 who helps to take care of Resident 1, on 12/14/16, at 9:44 a.m., CNA 3 indicated when she and another CNA transfer Resident 1 from the wheel chair to the toilet and back, they hold Resident 1 "underneath armpits." CNA 3 also indicated once Resident 1 finished with toileting and assisted back into the wheel chair, CNA 3 places the abduction wedge and then places one pillow above the wedge and another pillow behind Resident 1's calves (back part of the human leg between the knee and ankle). CNA 3 indicated she was not aware of a hip precautions care plan or any other written instructions for hip precautions.
During an interview with CNA 4, on 12/14/16, at 9:21 a.m., CNA 4 stated "(Resident 1) doesn't have any hip precautions at the moment. I just try to follow them on my own anyway..." When asked about transferring Resident 1 after the surgery back in October 2016, CNA 4 indicated two people were required to transfer Resident 1 and stated "She (Resident 1) will hold on to bars. Each of us (CNAs) would be on each side of her (Resident 1). She (Resident 1) would stand on her own. We would hold her (Resident 1) on her lower back..." CNA 4 explained when Resident 1 was finished with toileting and was sitting back in her wheelchair, CNA 4 would place the wedge and then place one pillow under the wedge. CNA 4 indicated the names of two other CNAs who usually assist her with transferring Resident 1. Those two other CNAs are CNA 2 and CNA 3.
During a record review of the clinical record for Resident 1 on 12/14/16, the Order Summary Report indicated there is an active physician's order initiated on 10/17/16 for hip precautions "No hyperextension (excessive joint movement in which the angle formed by the bones of a particular joint is opened or straightened beyond its normal, healthy range of motion) or external rotation (rotation away from the center of the body)."
The Health Status Progress Note dated 11/23/16, indicated Resident 1 came back to the facility from a doctor's follow up appointment with new written orders from the physician indicating Resident 1 "has re-dislocated her left hip..."
During a record review of the clinical record for Resident 1 on 12/14/16, the surgeon's Progress Note dated 11/23/16, indicated Resident 1 had a "Recurrent dislocation left hip hemiarthroplasty (surgical procedure that replaces one half of the hip joint with a prosthetic, while leaving the other half intact). (Resident 1's responsible party-RP) does not desire further surgical intervention at this time."
During an interview with Resident 1's RP on 12/9/16, at 10:35 a.m., RP indicated Resident 1's second dislocation of the left hip was identified by the physician during a follow up appointment on 11/23/16. RP explained both the physician and the RP decided not to proceed with another surgical intervention due to high risks associated with exposing Resident 1 to general anesthesia.
During an interview with LN 2, on 12/14/16, at 11:32 a.m., confirmed Resident 1's second dislocation on 11/23/16.
Record review on 12/15/16 of Resident 1's Minimum Data Set (a comprehensive assessment), dated 10/24/16, indicated Resident 1 was no longer able to walk. A record review of the Order Summary Report, the physician's order dated 11/30/16, indicated "Non-ambulatory (not able to walk), transfer only WBAT (weight bearing as tolerated) every shift."
The facility should know or should have known not to leave Resident 1 unattended during toileting but failed to do so which resulted in Resident 1 falling and sustaining injuries. Additionally, the facility staff did not provide the needed hip precautions which resulted in Resident 1 sustaining dislocations of hip. The failures resulted in Resident 1 not being ambulatory.
The failure presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result. |
| 060000034 |
VICTORIA HEALTHCARE AND REHABILITATION CENTER |
060008910 |
B |
13-Jan-12 |
MOOO11 |
4008 |
72311. Nursing Service (a) Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (A) Identification of care needs based upon an initial written and continuing assessment of the patient's needs with input, as necessary, from health professionals involved in the care of the patient. Initial assessments shall commence at the time of admission of the patient and be completedwithin 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.Based on interview and closed health record review, the facility failed to provide ongoing assessment and implement Patient 1's care plan to identify the signs and symptoms of dehydration (lack of fluids in the body). This resulted in hospitalization for Patient l to treat severe dehydration.Review of the closed health record for Patient 1 was initiated on 11/4/11. Review of the face sheet showed Patient 1 was admitted to the facility on 6/5/11.The Minimum Data Set (MDS, an assessment tool) dated 6/11/11, showed Patient 1 was dependent on nursing staff for nutrition and hydration via a gastrostomy tube (GT - a tube inserted through the abdominal wall into the stomach to provide nutrition and hydration). The MDS showed Patient 1 is completely dependent on staff for all activities of daily living. Dehydration and nutrition was triggered as a care area (a problem or potential problem that should have a care plan problem/assessment developed in order to correct or prevent the problem).Review of the Nutritional Screening and Data Collection form dated 6/9/11, showed Patient 1 was being given nutrition and hydration via the GT. Review of Patient 1's care plan problem to address nutrition dated 6/5/11, showed an approach plan to monitor the patient daily for evidence of dehydration, observe/report signs and symptoms of fluid deficit such as poor skin turgor and dry oral mucosa. Review of Patient 1's care plan problem to address dehydration dated 6/15/11, showed an intervention to monitor fluid intake and output. An interview with the Director of Nurses (DON) was initiated on 11/4/11 at 0815 hours. She was asked for documented evidence the nursing staff was conducting monitoring of fluid intake and output and ongoing assessment for signs and symptoms of fluid deficit for Patient 1. The DON stated she was unable to find the documentation. She further stated the assessments for dehydration would be on the form she was unable to find.Review of a blank intake and output form showed a place to document weekly evaluations for dehydration, intake and output and a place to document comments/adequacy. Review of laboratory results dated 6/29/11, showed Patient 1's sodium was 155 milliequivalents/Liter (mEq/L). Normal sodium levels are 132-145 mEq/L.According to Laboratory Tests Implications for Nursing Care, Second Edition, hypernatremia (increased sodium) may be a sign of dehydration (excessive loss of body fluid). During the interview with the DON on 11/4/11 at 0815 hours, she stated Patient 1 had an appointment to go to the Gastroenterologist (a physician who specializes in diseases of the gastrointestinal tract) on 6/29/11.A nurse's note dated 6/29/11 at 0840 hours, showed Patient 1 had a temperature of 101.5 degrees Fahrenheit. Further documentation (no documented time) showed the facility received a call from the Gastroenterologist's office stating Patient 1 was sent from the doctor's office to the acute care hospital emergency department for evaluation. Review of the Physician Progress Note dated 6/29/11, from the emergency room physician of the acute care hospital, Assessment/Plan documentation showed severe dehydration with hypernatremia. Patient 1 was admitted to the intensive care unit at the acute care hospital.Violation of these regulations had an immediate and direct relationship to the patient's health, safety and security. |
| 070000092 |
Valley Convalescent Hospital |
070009541 |
B |
17-Oct-12 |
Z7VK11 |
8563 |
F 172 - 483.10(j)(1)&(2) RIGHT TO/FACILITY PROVISIONS OF VISITOR ACCESS The resident has the right and the facility must provide immediate access to any resident by the following: Any representative of the Secretary; Any representative of the State; The resident's individual physician; The State long term care ombudsman (established under section 307 (a)(12) of the Older Americans Act of 1965); The agency responsible for the protection and advocacy system for developmentally disabled individuals (established under part C of the Developmental Disabilities Assistance and Bill of Rights Act); The agency responsible for the protection and advocacy system for mentally ill individuals (established under the Protection and Advocacy for Mentally Ill Individuals Act); Subject to the resident's right to deny or withdraw consent at any time, immediate family or other relatives of the resident; and Subject to reasonable restrictions and the resident's right to deny or withdraw consent at any time, others who are visiting with the consent of the resident. The facility must provide reasonable access to any resident by any entity or individual that provides health, social, legal, or other services to the resident, subject to the resident's right to deny or withdraw consent at any time. The facility failed to provide visitation access to one of five sampled residents (1) by the resident's responsible party (RP, her durable power of attorney for all her health care needs). Resident 1 had a stroke, had memory problems and relied totally on staff for all her personal care needs. On 9/21/12 the RP had a verbal disagreement with facility staff regarding the transfer of Resident 1 from a wheelchair to her bed using a mechanical lift sling (a fabric hammock-like part of the lifting device which holds the resident). The RP stated the provided sling was dirty, was removed from a closet in the room and placed under a sink. During the disagreement, the RP refused to speak with the director of nurses (DON), and became upset and pointed a finger at and threatened to sue a staff member. The RP then apologized for the comment and stated she would not sue. The resident was transferred to bed using a different sling. Shortly after, the administrator (ADM) ordered the RP to leave the facility, stating she was disruptive. When the RP later that day tried to re-enter the facility to visit Resident 1, the ADM denied access. Resident 1 was admitted with diagnoses including cerebro-vascular accident (stroke). The Minimum Data Set (MDS, an assessment tool) assessment dated 7/13/12 indicated Resident 1 could not speak, was dependent on staff for all activities of daily living, and required assistance of two personnel to transfer from bed to chair with the use of a mechanical lifting device. On 9/26/12 at 8:18 a.m. Resident 1 was observed in her bed with the head of the bed up. She smiled when her name was said and made eye contact but did not answer questions.During record review on 9/26/12, a Durable Power of Attorney for Health Care document dated and notarized on May 24, 2004 indicated Resident 1 designated the RP as the agent to make health care decisions for her.Certified nurse assistant B (CNA B) was interviewed on 9/26/12 at 2:40 p.m. She stated on 9/21/12 at approximately 1 p.m., she answered a call light (a request for help) in Resident 1's room. CNA B stated the RP requested the resident, asleep in her wheelchair, to return to her bed since "she looked uncomfortable, so she can rest." CNA B stated she looked for the sling for the mechanical lift and found it under a sink inside the room. CNA B stated the RP told her the sling was "dirty and smelled like pee." CNA B stated she would get another sling and some help for the transfer of Resident 1 and left the room. CNA D was interviewed on 9/26/12 at 9:45 a.m. CNA D stated on 9/21/12, CNA B asked her for assistance to transfer Resident 1 back to bed. CNA D stated she and CNA B went back to the room. Licensed nurse A (LN A) also came to the room. CNA D stated LN A told the RP the DON wanted to talk to her in the office and if RP went, then they would transfer Resident 1 back to bed. CNA D stated the RP got very upset and asked a question to the effect of "What kind of nurses are you that you cannot do a simple thing without the DON's permission?" CNA D said LN A answered "The DON is our supervisor" and then asked CNA B to summon the DON to the room. CNA D stated the RP pointed her finger at CNA B and said "If you get the DON, I will sue you." CNA D stated the RP apologized to CNA B right away and said, "You know I really will not sue you. I'm sorry." CNA D said Resident 1 was transferred to bed using the lift with a fresh sling. CNA D stated the DON and ADM came and asked the RP to leave the building because the RP was disruptive. The DON was interviewed on 9/26/12 at 10:50 a.m. She stated on 9/21/12, staff reported the RP threw a lift sling on the floor, was rude to a CNA, argued with LN A, pointed her finger at staff and threatened to sue, so they called police. The DON stated this was private property and they could escort out anyone who was disruptive. The DON stated the RP returned in the afternoon of 9/21/12 around 5 p.m. but was not allowed in the building.The ADM was interviewed on 10/2/12 at 12:45 p.m. The ADM stated the RP would not follow visitation rules. He stated for this reason the RP was asked to leave on 9/21/12. The ADM said the RP came back that same afternoon with a police officer. The ADM stated he told the police officer the RP was disruptive and could not enter the building. He stated the RP did not enter the building. The RP was interviewed on 10/3/12 at 10:08 a.m. She stated Resident 1's wish when she was still able to make decisions was for the RP to make her health care decisions. The RP stated she wanted to ensure Resident 1 received good care, and stated she had a good rapport with most facility staff. However, she stated she had a strained relationship with the DON since last year. She stated she preferred not to speak with the DON in person, and instead preferred to use written notes when communicating to the DON to minimize the potential for a misunderstanding. The RP stated she visited Resident 1 at the facility on 9/21/12. The RP stated Resident 1 had been sitting in a wheelchair starting at 10:30 a.m. The RP stated Resident 1 was asleep in the wheelchair and she asked staff to transfer Resident 1 to bed at 12:55 p.m. The RP stated she requested a clean sling to be used in the mechanical lift to transfer Resident 1 back to bed. She stated a lift sling which was already in the room was soiled and smelled of urine. She stated CNA B said she would get a different sling and also to get more staff to help her with the transfer. CNA B then left the room. The RP stated a short time later LN A came to the room. The RP stated LN A told her she must go speak to the DON in her office at the front of the building before any care could be provided to Resident 1. RP stated she became upset and told LN A "for God's sake you are a nurse. What does it take for you to put {Resident 1} to bed?" The RP stated LN A said she would summon the DON to the room and the RP said, 'If you get the DON I will sue you.' The RP stated she regretted this comment and immediately said she did not mean it and would not sue. The RP stated staff assisted Resident 1 to bed with a lift around 1:40 p.m. The RP stated the DON and the ADM came to the room and the ADM asked her to leave the facility. She stated the ADM said the reason was the RP was disruptive and was on private property. The RP stated the ADM told her if she did not leave the premises, the police would be notified, so RP left the building. The RP stated later the same afternoon she returned to visit Resident 1 and was denied access to the building by the ADM. According to the facility's undated Visitor Policy, "Staff shall encourage visitors at VCH to assist in the health promotion and healing process of our patients." The policy indicated visitors who are disruptive or disturb patients, staff, or others will be asked to stop the disruptive behavior or be escorted off the premises by law enforcement. The facility failed to provide reasonable visitation access to Resident 1. Resident 1 was non-verbal, physically disabled and depended on the RP to represent her interests. The facility failure caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety, or other emotional trauma to residents. |
| 070000003 |
VASONA CREEK HEALTHCARE CENTER |
070013135 |
B |
19-Apr-17 |
MWR711 |
4572 |
F226--483.12(b)(1)-(3), 483.95(c)(1)-(3) DEVELOP/IMPLEMENT ABUSE/NEGLECT, ETC. POLICIES
483.12
(b) The facility must develop and implement written policies and procedures that:
(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property,
(2) Establish policies and procedures to investigate any such allegations, and
(3) Include training as required at paragraph ?483.95,
483.95
(c) Abuse, neglect, and exploitation. In addition to the freedom from abuse, neglect, and exploitation requirements in ? 483.12, facilities must also provide training to their staff that at a minimum educates staff on-
(c)(1) Activities that constitute abuse, neglect, exploitation, and misappropriation of resident property as set forth at ? 483.12.
(c)(2) Procedures for reporting incidents of abuse, neglect, exploitation, or the misappropriation of resident property
(c)(3) Dementia management and resident abuse prevention.
The facility failed to report to the California Department of Public Health (CDPH), the Ombudsman, or police, when Resident 1 reported to facility staff regarding an incident of Resident 15 grabbing Resident 1's hand and not letting the hand go on 4/2/17.
During an interview with Resident 1 on 4/4/17 at 12 p.m., she stated her roommate, Resident 15, was "crazy and not rational." Resident 1 stated Resident 15 "suddenly" grabbed her hand and did not let her hand go when she passed by Resident 15 on 4/2/17. Resident 1 stated she felt "irritated and a little scared" when Resident 15 grabbed her hand. Resident 1 stated her hand was hurt when Resident 15 grabbed it. Resident 1 stated she reported the incident to facility staff right away.
A review of Resident 1's minimum date set (MDS, an assessment tool) dated 2/8/17 indicated Resident 1 had no cognitive impairment.
During an interview with Resident 15, on 4/4/17, at 1:22 p.m., she stated Resident 1 grabbed her cubicle curtain without her permission. Resident 15 stated she was "angry" and grabbed Resident 1's hand and pulled Resident 1's wrist away the previous Sunday.
A review of Resident 15's MDS dated 3/8/17 indicated Resident 15 had no cognitive impairment. Resident 15's clinical record indicated she had a diagnosis of psychotic disorder with delusion (false belief or opinion against the fact) due to known physiological condition.
During an interview with licensed vocational nurse X (LVN X) on 4/4/17 at 4:26 p.m., he stated Resident 1 reported to him that Resident 15 grabbed Resident 1's hand when Resident 1 passed by Resident 15 around six to seven o'clock on 4/2/17 . LVN X stated Resident 1 was alert, forgetful at times and able to tell staff what she needed. LVN X stated he reported the incident to the director of nursing (DON) right away on 4/2/17.
During an interview with the administrator (ADM), the facility abuse coordinator, on 4/4/17 at 9:45 a.m., he stated the evening nurse reported the incident to the DON, and the DON reported the incident to the ADM on 4/2/17. The ADM stated the facility did not report this alleged resident to resident incident to CDPH, or the Ombudsman, or the police. The ADM stated the facility did not consider this incident as resident to resident abuse after facility staff interviewed both residents and staff.
During an interview with the ADM on 4/4/17 at 12:35 p.m., he stated social service "just" followed up with Resident 1 approximately 20 minutes prior. Per social service, Resident 1 stated Resident 15 grabbed her hand on 4/2/17 and did not let her hand go. The ADM stated that, based on social service's new information from Resident 1's interview, the facility should have reported this alleged incident to CDPH, the Ombudsman and the police department.
A review of the facility's revised policy dated March 2013, "Reporting abuse to Facility Management," indicated when alleged or suspected abuse is reported, the facility administrator or their designee should "immediately" (within 24 hours of the alleged incident) report to CDPH, the Ombudsman and law enforcement officials.
The facility failed to report this resident to resident abuse incident to CDPH, or the Ombudsman or the police per the facility's policy.
Failure to report the alleged abuse prevented an analysis of the occurrence to determine any changes necessary to prevent future abuse and could potentially have allowed the abuse to continue.
This violation had direct or immediate relationship to the health, safety or security of the residents. |
| 220001018 |
VALLEY HOUSE REHABILITATION CENTER |
070013208 |
B |
31-May-17 |
2F7911 |
6294 |
F314 -- 483.25(b)(1) TREATMENT/SCVS TO PREVENT/HEAL PRESSURE SORES
(b) Skin Integrity -
(1) Pressure ulcers. Based on the comprehensive assessment of a resident, the facility must ensure that-
(i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and
(ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing.
The facility failed to ensure appropriate care and treatment for Resident 5 when an identified pressure ulcer (skin injury caused by unrelieved pressure resulting in damage to the underlying tissues) of the left buttock was (1) unreported to Physician 1 (P1), (2) not fully assessed by a nurse, (3) not care planned in a timely manner, and (4) left untreated for over a week. Resident 5 also had stage I and II pressure sores (a localized skin area of non-blanchable redness - usually over a bony prominence) on the left buttock.
These failures resulted in letting Resident 5's left buttock pressure ulcer evolve into a deep tissue injury (DTI, a localized area of pressure damaged underlying soft tissue often viewable from the skin's surface as a purple or maroon discoloration).
Review of Resident 5's clinical record indicated he was admitted on XXXXXXX17 with the following diagnoses: dementia (memory problem), muscle weakness, and seizures (uncontrolled electrical activity in the brain). His Minimum Data Set (MDS, an assessment tool) dated 5/31/17, indicated he was at risk for developing pressure ulcers, cognitively impaired (memory loss), and required assistance for bed mobility and transfers.
Review of Resident 5's Admission Data Collection tool, dated 1/30/17, indicated he had wounds on his scalp, right ear, and redness of the skin over his sacrum (a large and triangular bone at the base of the spine). There was no documentation of pressure ulcers to the left buttock.
Review of Resident 5's Braden scale (a tool can be used to identify residents at-risk for pressure ulcer), dated 2/13/17, indicated he had a score of 11 (a score of 10-12 represents a high risk for developing pressure ulcers).
Review of Resident 5's skin integrity care plan, dated 10/19/16, indicated he had the potential for impaired skin integrity related to fragile skin and a history of skin cancer. The interventions to prevent pressure ulcer included keeping his skin clean and dry.
During an interview with certified nurse assistant D (CNA D) on 5/9/17 at 8:10 a.m., he stated he reported to the charge nurse last week that Resident 5 had an open area on his buttock.
During a wound care observation and interview with Treatment Nurse A (TN A) on 5/9/17 at 10:25 a.m., she stated Resident 5's left buttock had a facility acquired (developed during the resident's stay at the facility) DTI, a stage II pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a pink wound bed), and a stage I pressure sore. TN A stated she was not previously aware of Resident 5's stage II pressure ulcer to the left buttock and that it should have been treated to promote healing. TN A confirmed there was no daily treatment on the treatment administration record (TAR).
During an interview with Licensed Vocational Nurse B (LVN B) on 5/9/17 at 1:45 p.m., she stated CNA D informed a treatment nurse about an open area on Resident 5's left buttock on 4/30/17.
Review of Resident 5's treatment administration record (TAR), dated 5/2017, indicated no evidence of treatment for Resident 5's left buttock open area.
Review of Resident 5's progress note, dated 4/30/17, indicated no evidence that Resident 5's left buttock open area was assessed by a licensed nurse or that the physician was informed of it.
Review of Resident 5's pressure ulcer care plan, dated 4/30/17, indicated there was no evidence a care plan was initiated regarding Resident 5's left buttocks open area.
During an observation and interview with Licensed Vocational Nurse C (LVN C) on 5/10/17 at 8:10 a.m., Resident 5 wore a disposable brief soaked with dark yellow urine while he lay on his back. LVN C stated Resident 5's disposable brief should not be soaked with dark yellow urine to prevent pressure sore.
During an interview and record review with the Assistant Director of Nursing (ADON) on 5/10/17 at 10:35 a.m., she stated she was unaware of Resident 5's left buttock open area. The ADON confirmed, in regards to Resident 5's left buttock open area, there was: (1) no involvement by the interdisciplinary team (IDT, team composed of members from different departments involved in a resident's care), (2) no registered dietician (RD) referral, (3) no care plan, (4) no initiation of daily treatment, and (5) the physician was not informed. The ADON stated, in regards to Resident 5's left buttock, the licensed nurse should have assessed the wound, initiated a care plan, and informed the physician. The ADON stated that daily treatment to Resident 5's left buttock open area should have been started to prevent the wound from worsening.
During an interview with P1 on 5/11/17 at 10:50 a.m., he stated he should have been informed of any changes to Resident 5's skin. He stated that when the left buttocks open area was identified, the licensed nurse should have addressed and treated it to prevent it from worsening.
Review of the facility's policy, "Wound And Skin Management," dated 11/2015, indicated any resident who had a pressure sore will receive the necessary treatment and services to promote healing, prevent infections, and prevent new ulcers or sores from development. A licensed nurse will refer newly identified pressure ulcers to the IDT for further assessment and care planning. The licensed nurse shall report any changes in a resident's condition to the attending physician. The IDT and licensed nurse will assure care plans and progress notes reflect a resident's current status and that appropriate interventions are carried out.
This failure had a direct relationship to the health, safety, or security of residents. |
| 220001018 |
VALLEY HOUSE REHABILITATION CENTER |
070013236 |
B |
31-May-17 |
2F7911 |
7225 |
F313 -- 483.25(a)(1)(2) TREATMENT/DEVICES TO MAINTAIN HEARING/VISION
(a) Vision and hearing
To ensure that residents receive proper treatment and assistive devices to maintain vision and hearing abilities, the facility must, if necessary, assist the resident-
(1) In making appointments, and
(2) By arranging for transportation to and from the office of a practitioner specializing in the treatment of vision or hearing impairment or the office of a professional specializing in the provision of vision or hearing assistive devices.
The facility failed to recognize and address Resident 21's hearing deficit issues when licensed nurses did not carry out the physician order and care plan was not implemented. This practice resulted in Resident 21 became emotionally upset and had loss interest in group activities.
During the initial tour on 5/8/17 at 8:45 a.m., Resident 21 was lying in bed.
During a concurrent interview, Resident 21 stated in a loud voice that he can't hear while pointing to both of his ears. He stated the nurses keep his hearing aids and had requested staff to bring his hearing aids.
During a follow up observation on 5/8/17 at 1:40 p.m., Resident 21 was still not wearing hearing aids. He stated likes watching television (TV) and live music and talking with other residents when his hearing aids were on.
During another observation on 5/9/17 at 8:20 a.m., Resident 21 was seen watching TV. The TV sound could be heard in the hallway and at the nurses' station. Resident 21 was not wearing hearing aids. Resident 21 stated he likes to watch the news in the morning. The TV volume was set at the maximum level of 100/100. He stated he already asked staff to get his hearing aids.
A review of Resident 21's clinical record indicated he was admitted with hypertension (high blood pressure), anemia (low red blood cell count), and cataract (eye disorder). His minimum data set (MDS-an assessment tool), dated 4/2/17 indicated he had no cognitive impairment but had severe hearing difficulty. There was a physician order, dated 7/13/15 to apply hearing aid in both ears in the morning and remove at bedtime. An inventory belongings form, dated 7/13/15 indicated he had bilateral hearing aids.
A review of Resident 21's care plan entitled "The resident has a communication problem related to poor hearing" indicated nurses to make sure he wears bilateral hearing aids at daytime and remove at night.
During an interview with Minimum Data Set Coordinator (MDSC) on 5/10/17 at 3:09 p.m. she confirmed there was an inaccurate MDS assessment. The MDSC stated it did not reflect Resident 21's need of bilateral hearing aids.
During an interview with Certified Nursing Assistant L (CNA L) on 5/9/17 at 8:20 a.m., she stated Resident 21 had hearing difficulty but she was not aware if he had hearing aids. CNA L stated she would inform the nurse.
During an interview with Licensed Vocational Nurse B (LVN B) 5/9/17 at 12:56 p.m., she stated Resident 21 had hearing aids. LVN B checked the medication cart and found few hearing aids that belonged to other residents but could not locate Resident 21's.
During another observation on 5/10/17 at 7:32 a.m., Resident 21 was watching TV in a very loud volume. He was not wearing hearing aids. He stated he was very upset as staff could not find his hearing aids.
During an interview with Assistant Director of Nursing (ADON) on 5/10/17 at 8 a.m., she confirmed Resident 21 had a communication problem due to his hearing difficulty. The ADON stated she revise the care plan to include wearing of bilateral hearing aids daytime and remove bedtime. She was surprised licensed nurses were not implementing the care plan as well as carrying out physician order. ADON stated no licensed nurses reported any hearing aids issue during their daily meeting. ADON was not aware if the hearing aids were missing or broken.
During an interview with LVN M on 5/10/17 at 8:15 a.m., she found Resident 21's hearing aids in the treatment cart.
On 5/10/17 at 8:30 a.m., the ADON visited Resident 21 and tried to talk to him. Resident 21 stated, "I can't hear you!" while nodding his head sideways. Resident 21 looked very upset and frustrated. ADON acknowledged Resident 21's frustration and walked towards the nurses' station and spoke to LVN C.
During an interview with LVN C on 5/10/17 at 1:50 p.m., Resident 21 had hearing difficulty. LVN C stated hearing aids should be place daily in the morning and remove at bedtime as care planned. LVN C stated he tried to apply bilateral hearing aids but both of them were not working.
During an interview with the Social Services Assistant (SSA) 5/9/17 at 3:10 p.m., she stated that their department was responsible for following up appointments on issues with hearing aids. The SSA stated they never received reports from licensed nurses that Resident 21's hearing aids were missing or broken.
During an interview with Social Services Director (SSD) on 5/11/17 at 8:40 a.m. she stated nurses should notify them if hearing aids were missing or broken so they can contact the audiologist (a hearing doctor) as soon as possible.
During an interview with Activities Assistant N (AA N) on 5/10/17 at 1:35 p.m., she stated Resident 21 used to attend special events like live music. She stated that he was not attending group activities lately. AA N stated Resident 21 seemed to be withdrawn from group interaction.
During an interview with AA O on 5/10/17 at 1:47 p.m., she stated Resident 21 had a hearing difficulty. AA O stated she was not aware that he had hearing aids.
During an interview with AA R, on 5/11/17 at 9:10 a.m. she stated Resident 21 likes live music but she noticed he was not attending lately.
During an interview with the Activities Director (AD) on 5/11/17 at 9:30 a.m., she stated Resident 21 used to attend special events like concerts. AD reviewed the Activities Assessment, dated 4/3/17, indicated Resident 21's activities plan was not modified to accommodate his hearing deficit and did not address Resident 21's use of hearing aids.
During an interview with Director of Nursing (DON) on 5/11/17 at 1:55 p.m. she stated to ensure quality of life and quality of care, they should address the needs of any hearing impaired residents including Resident 21. DON stated licensed nurses should have communicated if Resident 21's hearing aids were missing or broken so they could address the issue. DON stated licensed nurses should communicate the issue through their daily 24 hour report.
Review of facility's undated "Twenty Four Hour Report" policy indicated the form would "provide a communication system that will alert facility staff of changes in resident's condition and other important aspects of care and treatment."
Review of facility's undated "Hearing Services" policy indicated to ensure all residents have access to hearing services. All resident's hearing will be assessed upon admission and quarterly and will be referred as needed for a hearing evaluation.
Therefore, the facility failed to recognize and address Resident 21's hearing deficit issues.
The above violation had a direct or immediate relationship to the health, safety, or security of the resident. |
| 220001018 |
VALLEY HOUSE REHABILITATION CENTER |
070013287 |
B |
16-Jun-17 |
8OI611 |
7043 |
F323-483.25(d)(1)(2)(n)(1)-(3) FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES
(d) Accidents.
The facility must ensure that -
(1) The resident environment remains as free from accident hazards as is possible; and
(2) Each resident receives adequate supervision and assistance devices to prevent accidents.
(n) - Bed Rails. The facility must attempt to use appropriate alternatives prior to installing a side or bed rail. If a bed or side rail is used, the facility must ensure correct installation, use, and maintenance of bed rails, including but not limited to the following elements.
(1) Assess the resident for risk of entrapment from bed rails prior to installation.
(2) Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation.
(3) Ensure that the bed's dimensions are appropriate for the resident's size and weight.
The facility failed to provide a safe environment for Resident 1 when the facility failed to provide a foot rest while transporting Resident 1. This resulted in a fall with injury. Resident 1 sustained a mildly displaced fracture of the cervical 1 vertebra (C1, neck).
Resident 1 was admitted with diagnoses including muscle weakness and cerebral palsy. The MDS (Minimum data set, an assessment tool) dated 5/14/17, indicated he had a BIMS (Brief interview of mental status) score of 4 (ranging from 0 to 15, 15 being alert and oriented).
During an observation on 5/30/17 at 8:35 a.m., Resident 1 was seen in the hallway across from Nursing Station A sitting in his wheelchair with his feet on the floor wearing a pair of non-skid socks.
During an interview with the activities aide (AA) on 5/30/17 at 9:05 a.m., he stated on 5/14/17 sometime after lunch, he assisted certified nursing assistant A (CNA A) in transporting Resident 1 to the bathroom for a brief (a protective adult undergarment used for incontinence) change. The AA was in the front of Resident 1 and saw Resident 1 had his feet on the ground. CNA A pushed the wheelchair forward and Resident 1 fell with his arms folded across his chest and hit his forehead on the floor. He stated Resident 1 was not using the foot rest at that time.
During an interview with CNA A on 5/30/17 at 9:20 a.m., she stated she saw Resident 1 in front of Nursing Station 3 in a wheelchair requesting a brief change. CNA A requested the AA to assist with the transport. At the time of the transport, Resident 1 was seen leaning forward and his feet were on the ground. CNA A heard the AA yell, "hey, hey, hey" and saw Resident 1 fell from the wheelchair with his face landing on the floor first. Resident 1 ended up with a little bump on his forehead above his eyebrow.
During an interview with the director of staff development (DSD) on 5/30/17 at 11:37 a.m., he stated he had given staff inservice on how to transport and/or assist residents in wheelchairs. Instructions included use of foot rests for all residents with mobility issues including muscle weakness. Foot rests are not required for residents who are able to lift their feet.
During an observation on 5/30/17 at 11:45 a.m., Resident 1 was in the physical therapy (PT) room sitting in a wheelchair with a foot rest attached to the wheelchair. The physical therapist was doing passive foot lift exercises with Resident 1. Resident 1 was barely able to lift one foot at a time and with much difficulty.
During a telephone interview on 6/2/17 at 9:00 a.m., the Rehabilitation Director (RD) stated Resident 1 was initially on physical therapy 8/16/13 and was discontinued from therapy on 9/28/13 with recommended 24 hour assist upon discharge from the facility. The RD also stated Resident 1 was again referred to PT on 5/18/17 after the fall.
During a telephone interview on 6/2/17 at 1:08 p.m., the physical therapist stated Resident 1 had the tendency to lean forward and his leg position was always on knee flexion (bending the lower leg toward the back of the thigh). She stated with Resident 1's posture, use of a foot rest is highly recommended for safety purposes and to prevent falls.
Record review of the PT evaluation and plan of treatment dated 5/18/17, indicated Resident 1 was referred to PT due to a new onset of decrease in strength, reduced balance, reduced functional activity tolerance and decreased postural alignment indicating the need for PT to promote safety awareness, enhance rehabilitation potential, increase functional activity tolerance, increase lower extremity range of motion and strength, and facilitate with all functional mobility. Initial assessments including prior level of function indicated maximum assist for wheelchair mobility and fixed position of muscle tone on both upper and lower extremities. Plan of care included passive range of motion (ROM) and gentle stretching of tight muscle on bilateral lower extremities (BLE).
A review of the Nursing Fall Incident Report dated 5/14/17, indicated CNA A attempted to push Resident 1 to his room for a brief change. The moment CNA A pushed the wheelchair forward, Resident 1 fell forward hitting his head on the floor. Head to toe assessment was performed and a small bump was found on the left side of his head. Acetaminophen (analgesic used for pain relief) was given for pain scale (level of pain severity ranging from 0-10, 10 being the worst) of 3/10. The attending physician was notified and ordered to send Resident 1 to the hospital for a computerized axial tomography scan (CT scan - a form of diagnostic imaging) of the head.
A review of the CT of the cervical spine diagnostic imaging report dated 5/14/17 indicated a mildly displaced fracture was present through the right posterior ring of C1 and a mildly displaced fracture was also noted through the left anterior ring of C1.
During record review, the care plan for Resident 1 dated 5/30/17 indicated Resident 1 was a high risk for falls related to history of falls, depression, anxiety, incontinence, cardiovascular medication, diuretic use, poor safety awareness, impaired vision, decreased ROM, and cerebral palsy.
According to "Physical Medicine and Rehabilitation: Principles & Practice" Volume 1 Fourth Edition, Lippincott Williams & Wilkins, "The foot rest must provide sufficient support for the lower legs and feet and must hold the feet in proper position to prevent foot drop or other deformities. The feet must remain on the foot rest at all times during propulsion.
Review of the facility's policy and procedure titled "Fall Prevention Program" dated 9/1/10, indicated that "all residents' environment shall remain as free of accident hazards as is possible and all residents will receive adequate supervision and assistive devices to prevent accidents."
Therefore, the facility failed to provide a safe environment when a foot rest was not used when transporting Resident 1 which resulted in a fall with injury.
This violation had a direct relationship to the health, safety, or security of Resident 1. |
| 080000761 |
VISTA HEALTHCARE CENTER |
080009028 |
B |
17-Feb-12 |
RKZW11 |
5655 |
72313. Nursing Service-Administration of Medications and Treatments (a) Medications and treatments shall be administered as follows: (2) Medications and treatments shall be administered as prescribed.The facility failed to medicate Patient A with Morphine (a strong narcotic medication) as ordered. As a result, Patient A experienced constant, severe pain for more than 15 hours.Patient A was admitted to the facility on 1/14/12 with diagnoses that included fibromyalgia (chronic widespread pain of muscles and ligaments) and hospice care for end stage chronic obstructive pulmonary (lung) disease per the History and Physical dated 1/16/12. Patient A was capable of making her own decisions, per the same History and Physical. On 2/8/12 at 6:15 P.M., Patient A stated, she had been in severe pain, all over her body, since about 3 A.M. The patient said she usually received pain medication every couple of hours, but her last dose of pain medication (Morphine) was at 2 A.M. and then not again until 5:10 P.M., more than 15 hours later. Patient A said that all day she reported frequently to the nursing staff that she was experiencing severe pain, rated as 8-9 on a scale of 10, and asked the nursing staff if her pain medication had arrived. (Pain is rated on a scale of 1 to 10, with 1 being mild pain and 10 being severe pain.) Patient A said she contacted the Department for assistance when the facility failed to respond timely to her requests for pain medication.According to the physician's orders, dated 1/14/12, Patient A was prescribed liquid Morphine (strong narcotic pain medication) every 2 hours as needed for pain. The orders indicated the patient was to receive Morphine 5 mg for mild pain, 10 mg for moderate pain and 20 mg for severe pain.Documentation on the Medication Administration Records (MARs) indicated Patient A received Morphine 20 mg on 2/5/12 at 5 A.M., 9 A.M., 11 A.M., 1 P.M., 8 P.M. and 11:30 P.M., for pain rated as 8 out of 10.On 2/6/12, Patient A received Morphine 20 mg at 3 A.M., 6 A.M., 9:30 A.M., 11:30 A.M., 1:30 P.M., 3:30 P.M., 8:30 P.M. and 11:30 P.M., for pain rated as 7-9 out of 10.On 2/7/12, Patient A received Morphine 20 mg at 2 A.M., 6 A.M., 9 A.M., 11 A.M., 2 P.M., 5:30 P.M. and 7:30 P.M. At 10:30 P.M., the nurse administered 10 mg of Morphine (half of the prescribed dose), even though the patient's pain level was documented as 8 out of 10, indicating the patient was experiencing severe pain.On 2/8/12 at 2 A.M., the nurse administered 10 mg of Morphine (half of the prescribed dose), even though the patient's pain level was documented as 8 out of 10, indicating the patient was experiencing severe pain. According to the MAR, the patient did not receive any further Morphine or narcotic pain medication until 5:10 P.M., more than 15 since the last dose. On 2/8/12 at 6:45 P.M., Registered Nurse (RN) 1 said she faxed over a request to the pharmacy, on 2/7/12 at about 4 A.M., to refill the Morphine. RN 1 said she sent the request as a routine refill and did not make a follow-up phone call to the pharmacy. RN 1 then reported off to the next shift, informing them the Morphine was ordered. During a subsequent interview with RN 1, on 2/9/12 at 7 A.M., she said, "I faxed the request over to the pharmacy between 2-4 A.M. on 2/7/12. I spoke to the pharmacy service between 2-4 A.M. I told them the patient was on this medication every 2-3 hours and we were completely out of the medication. I should have ordered the medication on 2/6/12 when there were 8 ml's (20 mg = 1 ml) left in the bottle, or ordered it stat." On 2/8/12 at 6:55 P.M., RN 2 stated he called the pharmacy at 9:30 A.M. on 2/8/12 and was informed the medication would arrive at 1 P.M. RN 2 stated he did not inform the pharmacy that Patient A had been out of the Morphine since 2 A.M.On 2/14/12 at 10 A.M., Licensed Vocational Nurse (LVN) 3 stated, "I gave 10mg on 2/7/12 at 10:30 P.M., because there was only 20 mg left in the bottle." LVN 3 said the patient rated her pain level as 8 out of 10, which was considered severe pain. She acknowledged she should have administered 20 mg of Morphine for severe pain.She said she wanted to save some of the Morphine for the next shift. LVN 3 stated, "I did not call the pharmacy, but I did notify the RN." She acknowledged she did not administer the medication as ordered.On 2/9/12 at 9:55 A.M., the Assistant Director of Nursing stated her first knowledge of a problem with the pain medication was not until 1 P.M. on 2/8/12, when she was informed the medication did not arrive with the 1 P.M. delivery from the pharmacy.On 2/10/12 at 4:10 P.M., Patient A was interviewed by telephone. Patient A stated, "I was in extreme, severe pain. I felt out of my mind with pain." The patient said that all day she complained to the staff that she had severe pain and requested to know when her pain medication would arrive.According to the Quick Reference from the pharmacy, pharmacy hours were Monday to Friday, 9 A.M. to 9 P.M. In addition, an after-hours process was listed, as follows: "Please fax order and call the pharmacy phone number and ask the Answering Service to page the On-Call Pharmacist for meds needed that night." For refills, the process included, "Please allow 5 days for narcotic refills as Physician Authorization is required before dispensing." The facility failed to obtain narcotic pain medication (Morphine) for Patient A in a timely manner. As a result, Patient A, a patient receiving end of life care, suffered constant severe pain for more than 15 hours. The above violation had a direct or immediate relationship to the health, safety or security of patients. |
| 080000694 |
VILLA RANCHO BERNARDO CARE CENTER |
080009310 |
B |
17-May-12 |
1RH911 |
5119 |
CFR 483.13(c) F 224 The facility must develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. The facility failed to protect Resident A from financial abuse when a CNA (certified nursing assistant) misappropriated money from the patient. Resident A gave CNA 1 her debit card to purchase cigarettes on her behalf and the CNA used the card to put gas in his car. The facility also failed to ensure that a physical therapist aide (PTA 1) reported the allegation of abuse to the Administrator within the time frame required per policy. As a result of the financial abuse, Resident A suffered unnecessary worry over a nine day period during which time the resident was afraid to report the CNA for fear of retaliation.Resident A, a 51 year old female, was admitted to the facility on 11/17/11, per the Face Sheet. The resident was assessed as independent in daily decision making and had no problems with long-term or short-term memory, per the Minimum Data Set dated 12/15/11. Resident A was alert and oriented to person, place and time, was her own responsible party, and handled her own finances. On 1/6/12 at 9:30 A.M., Resident A stated that on 12/13/11, CNA 1 told her that he was going to get cigarettes. Resident A said she handed CNA 1 her debit card and asked him to get 2 packs of cigarettes for her and get a pack for himself. When CNA 1 returned, about half an hour later, he told Resident A that in addition to buying the cigarettes he put $10.00 of gasoline into his gas tank.Resident A said that she had a, "bad feeling" about what CNA 1 told her so she called the bank to check her account balance. Resident A said she discovered that CNA 1 spent $15.96 for cigarettes and $20.00 for gasoline. Resident A stated that when she asked CNA 1 why he lied about how much he spent, CNA 1 told her he actually thought it was only $10.00 and that he would pay her back on payday. He also told Resident A not to tell anyone that he bought gasoline with her debit card. Resident A said she was afraid to say anything about the incident because she was afraid that CNA 1 might hurt her. The resident stated that CNA 1 had over a week to pay her back but he never did. Resident A said that she finally told the physical therapist aide (PTA 1) about the incident on 12/22/11 because she was worried that CNA 1 was not going to pay her back.On 1/6/12 at 11:30 A.M., PTA 1 stated that on 12/22/11, during a physical therapy treatment, Resident A told her that CNA 1 used her debit card to buy cigarettes and bought gasoline for his car without her permission. The resident told PTA 1 she was worried that the CNA was not going to pay her back. PTA 1 said she didn't think it was a true story and did not report it to her supervisor, as required per policy. PTA 1 said that after Resident A repeated the allegation the next day, on 12/23/11, she reported it to the DSD (Director of Staff Development). PTA 1 admitted that she should have told her supervisor or the DON (Director of Nursing) the first time Resident A told her about the abuse with the debit card. The DSD was interviewed on 3/9/12 at 10:45 A.M. He stated that all employees received abuse training in orientation. The DSD stated it was facility policy for staff to refer requests from residents for purchasing items, to the social worker. The DSD also stated that employees were expected to report abuse allegations immediately to the Administrator. CNA 1's personnel file was reviewed. According to the file, CNA 1 was hired on 9/30/11 and the CNA signed to say he received the abuse training on the day he was hired. CNA 1 was interviewed on 3/22/12 at 12:50 P.M. He stated he knew he was going against the facility's policy by using Resident A's debit card to make purchases for the resident and for himself. CNA 1 said, "I was just trying to be nice."Per the facility Abuse Prevention Policy Program, revised 7/09, "Employees, facility consultants and/or Attending Physicians must immediately report any suspected abuse or incidents of abuse to the Administrator of the facility or his/her designee. In the absence of the Administrator such reports may be made to the Director of Nursing Services or the Nurse Supervisor on duty." PTA 1's personnel file was reviewed. According to the file, PTA 1 was hired on 7/20/11 and received abuse training on 8/15/11. On 12/13/11, CNA 1 took Resident A's debit card to purchase cigarettes for her against facility policy. The CNA used the card, without the patient's knowledge, to put $20 of gasoline in his car. The CNA later lied to the patient about the amount of money he spent on gasoline. Resident A was afraid to report the incident, for nine days, for fear of retaliation. On 12/22/11, Resident A told PTA 1 about the abuse after the CNA failed to pay back the money. PTA 1 failed to report the allegation of financial abuse to her supervisor until the following day when Resident A repeated her story to PTA 1. The above violation had a direct relationship to the health, safety, or security of patients. |
| 080000694 |
VILLA RANCHO BERNARDO CARE CENTER |
080009783 |
AA |
13-Mar-13 |
9EL211 |
8417 |
F365 (CFR 383.35(d) Food prepared in a form designed to meet individual needs.The facility failed to follow the physician's orders for a chopped diet. The Cook, the Dietary Line Checker, the Licensed Nurse and the Certified Nursing Assistant did not verify that the prescribed diet, in the correct consistency, was checked prior to bringing the meal tray into Resident 1's room. Resident 1 was known to have behaviors, in which he immediately grabbed for food and stuffed the food into his mouth. As a result, Resident 1 grabbed 2 pancakes and 2 uncut whole sausage patties from his breakfast tray and put all 4 items into his mouth. The resident choked on the food and died. Resident 1, a 61 year old male resident, was admitted to the facility on 9/26/12 with a diagnosis of dementia (memory loss) per the Record of Admission. According to the Physician's Orders dated 9/26/12, Resident 1 had cognitive/behavior impairment (decreased mental status). Resident 1's clinical record was reviewed on 10/31/12. The resident was unable to make medical decisions for himself per the Advanced Healthcare Directive, signed and dated by the physician on 9/28/12. According to the Minimum Data Set (MDS) assessment, dated 10/3/12, the facility assessed Resident 1 with unclear speech, unable to understand others or be understood by staff, and unable to make daily decisions due to severe cognitive impairment. Per the same document, the facility assessed Resident 1 as requiring limited assistance with feeding himself and the assistance of one staff member for supervision. According to the Social Services assessment dated 9/26/12, Resident 1, "Speaks with few words: yes, no, eat, hungry...Can become aggressive especially when eating." Resident 1 was prescribed a mechanical soft, chopped diet, according to the Physician's Orders dated 9/26/12. The Physician's Orders were updated on 10/5/12 to include, "Feeding 1:1 (one staff to one resident) w/ (with) all meals re: at choking risk." An Interdisciplinary Team (IDT) review was completed on 10/5/12. According to the IDT notes, staff were instructed to watch the food trays and the food cart, as Resident 1 was, "Always looking for more food," and needed to be redirected frequently. The resident was placed on 1:1 (one staff member to one resident) during meals due to his behaviors. On 10/30/12 at 1 P.M., the Cook was interviewed by phone. The Cook said he worked the breakfast meal on 10/28/12. He said it was his responsibility to match the food ticket (diet order) and plate the food on the kitchen line. The cook said he prepared a chopped diet of sausage and pancakes for Resident 1. He said he would usually cut the sausage patty into 9 pieces. The pancakes were not cut, as they were soft.The Food Line Checker, a second person that reviewed the diet for correctness, said on 10/30/12 at 1:15 P.M., she was quite busy on 10/28/12. She said since it was a Sunday, she was responsible for answering the phone and responding to requested food changes. She said she was also responsible for checking the trays before the trays were loaded onto the service cart and taken to the nursing station. The Food Checker said the phone rang frequently on 10/28/12. She was uncertain if she reviewed all of the trays on the line that morning. Licensed Nurse (LN) 1 said on 10/31/12 at 1:30 P.M., she was the Charge Nurse on the day shift on 10/28/12. She said she was aware that Resident 1 was a compulsive food seeker. She said Resident 1 grabbed and ate the applesauce when it was left unsupervised on the top of the medication cart. She said she was responsible for checking each tray on the cart before the Certified Nursing Assistants (CNAs) delivered the trays.LN 1 said at about 8 A.M. on 10/28/12, "I was in a hurry." Resident 1, "Stood in front of the food cart. I wanted to make sure he did not grab any other resident's food. I made a mistake. I was not careful to match the diet card with the food on the plate, when I checked the tray," for Resident 1. LN 1 said she handed Resident 1's tray to CNA 1 to move Resident 1 away from the other food trays.CNA 1 said on 10/31/12 at 12:30 P.M., she was assigned to care for Resident 1 on the day shift on 10/28/12. CNA 1 said she was aware Resident 1 wandered throughout the facility and grabbed food from others. She said she was aware Resident 1 was only to have chopped food. CNA said she knew Resident 1 was on 1:1 supervision for meals.CNA 1 said LN 1 handed her Resident 1's breakfast tray from the cart on 10/28/12 at about 8:05 A.M. She told Resident 1 she had his food and he immediately followed her to his room. CNA 1 said she usually checked the trays when she got into the rooms. She said as she lifted the plate cover, Resident 1 grabbed 2 pancakes and 2 uncut sausage patties and stuffed them into his mouth. CNA 1 said Resident 1 walked out of his room and into the hallway. CNA 1 followed behind him with some milk, intending to encourage Resident 1 to drink the milk. CNA 1 said she immediately told LN 1 that Resident 1 grabbed his food and put it into his mouth. Within a minute or two, Resident 1 collapsed on the floor in the hallway, in front of his room. CNA 1 said she called for help.LN 1 said on 10/31/12 at 1:35 P.M., she was in the hallway on 10/28/12 at about 8:10 A.M. and saw Resident 1 fall to the floor. She rushed to Resident 1. He was foaming at the mouth and he looked pale. LN 1 she said she put on gloves and swept the Residents mouth. Some food was removed. LN 1 said she tried to do the Heimlich maneuver (emergency technique to unblock the airway) on the floor, but it was not successful. Resident 1 was not breathing and his skin color was blue. LN 1 said she started CPR (cardiopulmonary resuscitation - mouth to mouth breathing and chest compressions). Another staff member called a "code blue" (resident not breathing and CPR initiated). Other staff members arrived and Resident 1 was carried from the hallway, outside of his room, to his bed. The physician was notified and 9-1-1- was called, while the CPR continued.According to the facility records, the Emergency Medical Technicians (EMTs) arrived at 8:20 A.M. and took over the care of Resident 1. The EMTs transported Resident 1 to the acute care hospital. According to the hospital records, the Emergency Room (ER) physician removed food from the throat of Resident 1, to establish an airway. Resident 1 was unable to be resuscitated and was pronounced dead, due to airway obstruction.On 10/31/12 at 12:30 P.M. the Registered Dietician and Food Services Manager cooked a sausage patty, the same sausage as prepared on 10/28/12 for Resident 1. The patty was circular and measured 3 inches by 3 inches.According to the facility undated policy titled, Choking Prevention, "Prior to serving the trays to the Residents have the license nurse assigned to the dining room to check that all the meal matches the diet slip...Certified Nursing Assistants (CNAs), are to double check meals after the nurse has checked the tray for any missed items or wrong diet in the tray that the nurse may have over looked." According to the facility diet manual, Healthcare services Group I, Diet Manual Third Edition 2011, a Mechanical Chopped Diet consists of: Meats chopped to the consistency of small dice (1/2 inch).According to the Medical Examiner's report dated 12/24/12, Resident 1 expired due to airway obstruction and aspiration (inhalation) of food. The facility failed to follow the physician's orders for a chopped diet. The Cook, the Dietary Line Checker, the Licensed Nurse and the Certified Nursing Assistant did not verify that the prescribed diet, in the correct consistency, was checked prior to bringing the meal tray into Resident 1's room. Resident 1 was known to have behaviors, in which he immediately grabbed for food and stuffed the food into his mouth. As a result, Resident 1 grabbed 2 pancakes and 2 uncut whole sausage patties from his breakfast tray and put all 4 items into his mouth. The resident choked on the food and died.This violation presented an imminent danger that death or serious harm to the patients or residents of the long-term health care facility would result therefrom, or a substantial probability that death or serious physical harm to patients or residents of the long-term health care facility would result therefrom, and was a direct proximate cause of the death of the a patient. |
| 080000761 |
VISTA HEALTHCARE CENTER |
080010344 |
B |
19-Dec-13 |
HL8W11 |
10455 |
F 201 483.12(a)(2) Transfer and Discharge Requirements The facility must permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless-- (i) The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility; (ii) The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility; (iii) The safety of individuals in the facility is endangered; (iv)The health of individuals in the facility would otherwise be endangered; (v) The resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at the facility. For a resident who becomes eligible for Medicaid after admission to a nursing facility, the nursing facility may charge a resident only allowable charges under Medicaid; or (vi) The facility ceases to operate. The facility failed to allow 1 of 3 sampled residents (1) to return to the facility after the resident went out on a routine outing with her family. When Resident 1 returned from the outing, her personal belongings were packed, and she was told she was discharged from the facility against medical advice (AMA).As a result, the resident had nowhere to go, called for police assistance, developed chest pain, called 911 emergency, and was taken by ambulance to the hospital, where she remained for 5 days. Resident 1 was originally admitted to the facility on 7/19/12, and was responsible for herself, per the Admission Record. Resident 1's clinical record was reviewed on 7/25/13. Resident 1 had the capacity to understand and make her own decisions, per a physician's history and physical examination (H & P) report, dated 7/8/13. Per the H & P, Resident 1's diagnoses included history of an above the knee amputation (removal of limb), depression and coronary artery disease (damaged or diseased major blood vessels that supply your heart with blood, oxygen and nutrients) with previous stent placement (a tube placed in blood vessels to help keep them open), and insulin dependent diabetes mellitus (a condition where the body can't process sugar normally, and requires medication for regulation). According to the resident's Alteration in Mood care plan, last reviewed 4/2013, interventions listed to reduce the resident's episodes of depression included, "Encourage activities of choice"..., and, "Allow as much independence as possible." According to an Interdisciplinary Team (IDT) Care Conference (a meeting by a team of staff and the resident or responsible party to discuss all aspects of care), dated 4/19/13, Resident 1's activities were, "Independent/Self Directed." The IDT documented the same activities should continue. There were 4 Release of Responsibility For Leave of Absence forms (a form for the residents and/or responsible party to sign out when they left the facility, with a section for the licensed nurses (LN) to co-sign) in Resident 1's clinical record. Between 7/24/12 and 4/30/13, Resident 1 signed herself out of the facility on 73 different occasions. The most common destinations listed were local stores and fast food restaurants. The 4th, and most recent form, indicated the last time Resident 1 signed herself out was on 4/30/13. A LN co-signed only 7 of the 73 occasions when Resident 1 signed herself out.On 7/24/13 at 3:35 P.M., Resident 1's family member (FM) 1 stated in a telephone interview, that over the past year while Resident 1 lived at the facility, she and FM 2 routinely took Resident 1 on a lunch outing every Sunday. FM 1 said that on Sunday, 7/21/13, around 11:30 A.M., she and FM 2 picked up Resident 1 for lunch as usual. After lunch, FM 1 said she & FM 2 dropped Resident 1 off at the front door of the facility, and left as usual. FM 1 said she later learned that when Resident 1 went back in to the facility she was told she was evicted. In a follow up interview, on 10/30/13 at 9:47 A.M., FM 1 stated that they routinely picked Resident 1 up every weekend. FM 1 stated either she or FM 2 would enter the facility to pick up Resident 1 for lunch. FM 2 said Resident 1 would always tell a staff member they were leaving the facility, and no staff members ever tried to stop them or instructed them to sign out, and further stated, "On the contrary," the staff would tell us, "Ok - have a good time." On 7/25/13 at 8:45 A.M., Certified Nursing Assistant (CNA) 1 stated, every weekend Resident 1's family would take her to lunch. CNA 1 said the staff would tell Resident 1 to sign out and Resident 1, "Often just kept on going in her wheelchair when you'd tell her to do something." CNA 1 said, Resident 1 going out on a weekend day with her family was, "Her routine."On 7/25/13 at 9:45 A.M., the facility Activity Coordinator (AC) stated Resident 1 was independent in her activities. The AC said Resident 1 went, unaccompanied, to local stores 1 - 2 times per week. Additionally, the AC said Resident 1 went out with her family on the weekend. The AC said Resident 1 was able to go out of the facility on her own.On 7/25/13 at 11:15 A.M., LN 2 stated that on 7/21/13, Resident 1 informed her she was going out to lunch that day. LN 2 said when she returned from her lunch break, LN 3 informed her that Resident 1 did not have physician's orders to go out on a pass, didn't sign out, and those issues meant the resident left AMA. LN 3 stated on 9/3/13 at 10:51 A.M., during a telephone interview, he worked with Resident 1 infrequently and was not familiar with her routine. LN 3 said on 7/21/13, an unknown CNA told him Resident 1 was leaving with her family. LN 3 said Resident 1 refused to tell him where she was going or when she would return.LN 3 stated when Resident 1 left the facility on 7/21/13 without telling him where she was going or when she would return, he contacted the Director of Nursing for direction. LN 3 said the DON instructed him to check Resident 1's clinical record for a physician's order to go out on pass. LN 3 said when he told the DON there wasn't a physician's order to go out on pass, the DON informed him Resident 1's actions meant the resident left AMA. LN 3 said he was instructed by the DON to pack Resident 1's belongings and discharge her from the facility.LN 3 said no one at the facility informed Resident 1, prior to her leaving, that if she left the facility without signing out, she would be discharged AMA.During an interview on 9/4/13 at 11:35 A.M., Resident 1 stated for the past year, every weekend, "Like clockwork," she would go out to lunch with her family. Resident 1 stated she was aware of the sign out book, and utilized it previously, but after 4/30/13, the sign out sheet was full, so she stopped signing out. Resident 1 said she routinely left the facility on a daily basis to go to the store, and, "I always told them where I was going - they never made me sign out." Resident 1 said on 7/21/13, she informed her medication nurse she would be going to lunch that day. Her family arrived to pick her up as usual, and as they were leaving she said aloud, "I'm going to lunch now - see everyone in a little while." Resident 1 said as she was exiting the front door a CNA came running out and told her LN 3 said she had to sign out. Resident 1 said she told the CNA there was no room on the sheet for her to sign out. Resident 1 said she told the CNA, she hadn't signed out in 6 months and, "Wasn't going to now."Resident 1 said when she returned, approximately 45 minutes later, and proceeded down the hall to her room, LN 3 was waving a piece of paper (AMA form) and said, "You no longer live here," and said she was being, "Evicted." Resident 1 said she refused to sign the form, told LN 3 he couldn't evict her, and that the facility was required to provide notice before discharging her. Resident 1 said all of her belongings were packed, and LN 3 told her she needed to leave the premises. According to the facility policy, revised 1/1/13, entitled Pass Procedure (Sending Resident Out On Pass), "It is the policy of this facility to send residents out on pass with a responsible adult and a physician order." Listed as a procedure for the policy was, "Obtain order from physician to allow resident to leave the facility." Included in the policy was the resident or responsible party should sign in/out, indicate where they are going and, "The licensed Nurse is to document that the resident is out on pass per facility policy." The policy did not include any procedure to follow when a resident refused to sign out when leaving the facility. During the past year, 7/19/12 to 7/21/13, the facility did not obtain a physician's order for Resident 1 to go out on pass from the facility. The facility consistently allowed Resident 1 to leave the facility without an order and inconsistently required her to sign out when she left. When Resident 1 returned to the facility on 7/21/13 to find she had been, "Evicted," she attempted to contact her family by telephone, and couldn't reach them. Resident 1 said she called the police and eventually called a 911 ambulance because she developed chest pain and was transported to the hospital.According to the hospital (where Resident 1 was taken to by the paramedics), physician's H & P, dated 7/21/13, Resident 1's chief complaint was, "...evicted from her skilled nursing facility today with no place to go...with chest pain and is being admitted for further evaluation." Additionally, per the H & P, "There may well be a very significant emotional or psychosocial component to the patient's symptoms. The chest pain occurred after eviction from (facility) and occurred at a time when the patient had no place to go." Resident 1 lived in the facility for over one year, left the facility for routine Sunday lunches nearly every weekend with her family members, and went to the store unescorted, all without routinely signing out or having a physician's order. Upon return from a routine Sunday lunch outing on 7/21/13, was told she no longer lived in the facility, was being discharged AMA, and was not allowed to return to her room. Resident 1, after remaining for hours onsite at the facility and with nowhere to go, developed chest pain, called 911, and was subsequently hospitalized for 5 days.The violation of this regulation had a direct relationship to the health, safety or security of patients. |
| 080000761 |
VISTA HEALTHCARE CENTER |
080011922 |
B |
29-Dec-15 |
4Y6B11 |
7801 |
F-241 483.15(a) Dignity and Respect of Individuality The facility failed to ensure two CNAs (Certified Nursing Assistants) followed the facility policy and procedure, designed to protect residents' privacy, with regard to the use of using cell phones and photographing residents. The CNAs used a personal cell phone to videotape 1 of 1 sampled residents (Resident A), partially unclothed from her neck to her waist in a shower chair, made fun of the resident's unwillingness to shower, and posted the video on an internet website. As a result the resident's dignity was compromised when the video of her naked to the waist in the shower, was viewed by an undisclosed number of people on the social media website.On 10/16/15, at 8:15 AM, the Department received a notification from the facility of an incident regarding a resident in the facility who was videotaped nude from the neck to the waist. According to the report, the videotape was posted on a social media website where users could post pictures and short videos which would be deleted within 24 hours.On 10/16/15 at 1:07 PM, the Department entered the facility to investigate the incident. On 10/16/15 at 1:10 PM, the Administrator stated she was approached by a television news reporter on 10/15/15 at 5:20 PM. The news reporter produced a picture for the Administrator which showed CNA 2, standing next to an elderly lady sitting in a shower chair undressed from the neck down to her waist. The Administrator identified CNA 2 as one of her employees. The Administrator and the Director of Nursing (DON) identified the elderly lady in the picture as one of the residents living in the facility, (Resident A). The Administrator stated the television news reporter told her the picture was provided to the television station by an informant who saw the video of the CNAs and the informant took a screen shot (an image taken by a person to record the visible items displayed on a mobile telephone screen) of the video. The Administer stated the screen shot was dated 10/9/15, and contained the name of the person who posted the video on the social media website. The Administrator identified the individual as CNA 1, who was employed at the facility. During an observation of the television newscast on 10/16/15 at 11 PM, the news reporter stated the video posted on the website included the two CNAs mocking and laughing about the resident saying the resident was afraid of taking a shower and they were ready to shower her.On 10/16/15 the resident's record was reviewed. Resident A was readmitted to the facility on 3/9/14, with diagnoses to include dementia, major depression and cataracts, per the Admission Record. According to a her latest MDS ((Minimum Data Set)--[a standardized, primary screening and assessment tool of health status], dated 8/11/15, Resident A's BIMS (Brief Interview of Mental Status) was scored at 10 out of 15, indicating the resident's cognition was moderately impaired. According to a review of the Assignment Sheet -Station 2, dated 10/9/15; both CNA 1 and CNA 2 were listed on duty that day. In addition CNA 2 was assigned shower detail for Station 2. On 10/16/15 at 1:55 PM, Resident A was observed and interviewed in her room. Resident A was lying in bed with her covers over her. Resident A could not state the day or month. Resident A was asked if she had been given a shower recently. Resident A adamantly stated, "I hate showers. I like a tub bath."On 10/16/15 at 2:03 PM, Licensed Nurse (LN) 3 stated prior to 10/16/15, people had their cell phones with them on the unit.A review of the employee files for both CNA 1 and CNA 2 was conducted on 10/16/15.Both of the employee files contained acknowledgements of the Code of Conduct Policy, Resident Rights Policy, Dependent Adults/Elder Abuse Reporting requirements, and dementia training.In addition, both CNAs acknowledged receipt of the facility's Employee Handbook. CNA 1's acknowledgements were signed on 5/12/15, and CNA 2's acknowledgements were signed on 7/31/14 and 8/1/14 respectively.At 12 noon on 10/23/15, CNA 2 was interviewed via telephone. CNA 2 acknowledged working on 10/9/15 and being assigned to shower Resident A on that specific day. CNA 2 stated, "To be honest, I didn't know what was going on. I didn't know anyone was taking my picture." When asked if she remembered CNA 1 helping her shower Resident A on 10/9/15, CNA 2 stated, "I think she was in there with me." CNA 2 again stated, "I did not know she was taking video." When asked if she remembered seeing a phone in CNA 1's hand, she stated, "Most likely she would have been with her phone." CNA 2 stated she did not carry a cell phone, she kept it in her bag.When asked if she saw other staff with cell phones, CNA 2 stated, "Everybody's on their phone all the time. Nobody is supposed to have them."CNA 2 also stated she did not remember anyone being reprimanded for carrying their phones on the unit. The Administrator was interviewed on 10/23/15 at 3:35 PM. The Administrator stated she could not remember about staff members being reprimanded for carrying their cell phones on the units. The Administrator stated, "We've talked about it in staff meetings..." When asked if she knew employees were carrying cell phones with them on the units prior to 10/16/15, she stated, "I won't say it was uncommon. A lot of employees carried them in their pockets." When asked if she remembered telling staff they could not have phones on them, the the Administrator stated, "Honestly, I don't think they were ever told."On 10/23/15, at 3:47 PM, the DSD stated she did not specifically tell staff they could not take pictures of residents in patient care areas. She stated, "I never felt it was necessary for me to tell them you shouldn't photograph a resident. Everyone should know that."Per the facility's Employee Handbook (California) Revised June 1st, 2011, Resident Privacy, "The Company strongly protects the privacy of the Community Residents both as a moral and legal matter including compliance with the Health Insurance Portability and Accountability Act (HIPAA) of 1996 [P.L. 104-191].""Also included in resident privacy is freedom from having their photograph image taken without approval. Employees shall not permit photography of residents unless: (1) the photography is approved as a part of an activity approved in this Employee Handbook (i.e. resident identification purposes; inclusion in the resident's medical records, support for Community activities programs, etc.; (2) the photography is performed as part of an activity approved in writing by the Executive Director; or (3) photography by the resident's family members and the resident's visitors. In the event that the photography is conducted in association of an approved activity, the employee is taking and/or using the photographs are required to ensure that a release to use the photography is present in the resident's file..." "Employees may not post on a blog or social media website during work time, or at any time with Company equipment or property, unless specifically authorized by your Executive Director.........." Cameras and Camera Phones: "Your Community prohibits the use of personal cameras and personal cellular phones with photographic capabilities in any area of the workplace. Employees should not bring cameras or camera phones to the workplace for any reason." The photographing and subsequent posting of a video of two staff mocking Resident 1 who was partially naked in the shower, was a violation of the resident's right to privacy, her dignity and the facility's policies and procedures prohibiting this behavior. The above violations caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety, or other emotional trauma to residents. |
| 080000795 |
VISTA KNOLL SPECIALIZED CARE FACILITY |
080012899 |
A |
25-Jan-17 |
55X711 |
18300 |
483.25 Quality of Care The following reflects the findings of the California Department of Public Health during an annual re-certification survey, conducted from 12/5/16 through 12/12/16. Represented the Department was Health Facilities Supervisors 29509 and 33922. Glossary of Terms: DON - Director of Nursing ADON - Assistant Director of Nursing MD 1 - Medical Director LN - Licensed Nurse CNA - Certified Nurse Assistant Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. The facility failed to: 1. Ensure Licensed Nurses (LN2) notified the physician (MD 1) they changed 1 of 23 sampled resident's (73) g- tube (feeding tube) site dressing 11 times in 8 hours due to the dressing being saturated with blood and failed to document these dressing changes in the resident's record. The LNs also failed to assess, and notify the physician when Resident 73 had black tarry stools (black tarry stools indicate internal bleeding) and failed to document assessments in the resident's record. 2. Follow up on physician's orders to obtain an orthopedic specialist visit for 1 of 23 sampled residents (39), who suffered an injury after a fall at the facility. These deficient practices resulted in: 1. Resident 73 was transferred to the hospital 48 hours after the bleeding began and required fluid resuscitation due to abnormal laboratory values; and 2. Resident 39 has decreased and limited mobility to her dominant right upper extremity. Findings: 1. Resident 73 was admitted to the facility on XXXXXXX, with diagnoses which included a history of difficulty swallowing after a stroke, per the History and Physical (H&P) dated 11/28/16. Resident 73 received his nutrition through a GT, per the same H&P. On 12/6/16 at 8 A.M., Resident 73's clinical record was reviewed. According to the physician's (MD) order, dated 11/28/16, Resident 73 received continuous feeding though a GT with no solid or liquid foods by mouth. According to the MD's order, dated 11/29/16, Resident 73 received 5 milligrams (mg) of Eliquis (blood thinner) twice daily. According to the MD's order, dated 11/30/16, Resident 73 received 1 Aspirin daily (used as a blood thinner for stroke patients). On 12/2/16 at 4:31 P.M., LN 2 documented, "... Around 4 P.M., [Resident 73] was bleeding due to pulling his GT. Dressing applied and observed... At 7 P.M. meds were given (though the GT) without any problem. After an hour, resident again pulling his GT and bleeding again...Redressing again..." LN 2 documented, "MD and Responsible Party [RP] informed". LN 2 documented she stopped the tube feeding due to the resident pulling at the tube. On 12/3/16 at 1:43 A.M., LN 3 documented, "... Per report resident (73) had been bleeding from GT site and pressure dressing applied. Dressing had to be changed three times since beginning of shift (11 P.M.). Dressing was saturated in blood seeping onto clothing..." LN 3 documented she was unable to verify placement of the GT and she received orders from the MD to stop the GT feedings and for IV fluid hydration. On 12/5/16 at 7:09 A.M., LN 4 documented Resident 73 was given a shower at 6:30 A.M., due to a large loose, black stool (black colored stools can indicate internal bleeding). She further documented, while in the shower, Resident 73 continued to have loose black stools and vomited coffee ground consistency fluid (coffee ground vomit indicates internal bleeding). 911 was called and the resident was transported to the hospital. On 12/8/16 at 9 A.M., the hospital provided the documentation from the Emergency Department (ED) and subsequent hospital admission on XXXXXXX. According to the ED MD's documentation dated 12/5/16 at 8:21 A.M., the resident was examined at 7:46 A.M., when he was brought to the ED by ambulance. The ED MD documented, "...Paramedics arrived [at the nursing home] and he was very lethargic [sluggish]... was noted to be hypotensive (low blood pressure) and transported here. On arrival, per the paramedics, during the transport he became more hypotensive and since that time is not speaking. Certainly on arrival he's not able to communicate. His blood pressure is quite low and he [is] very lethargic..." According to the Nursing Notes dated 12/5/16, Resident 73 presented to the ED in a soiled brief with a large amount of black tarry stool. The resident's blood pressure was 80/56 (normal is 120/80). Resident 73 received intravenous (IV-a tube inserted through the vein) fluid resuscitation upon admission to the ED and received 3 blood transfusions throughout the date of 12/5/16. Resident 73 was transferred from the ED to the Intensive Care Unit. According to the hospital's Discharge Summary, dated 12/8/16, "... He came back [to the hospital] with maroon-colored stool and coffee-ground emesis (vomit). He was found to have a hemoglobin of 8.7 grams per deciliter (normal hemoglobin levels for males is 14 to 18 grams per deciliter). He was also initially hypotensive with a systolic blood pressure in the 80's, consistent with hemorrhagic shock (poor blood circulation). He was fluid resuscitated (fluid replacement). He got blood transfusions as well...Final Diagnoses: Severe anemia of acute blood loss...Initial Hemorrhagic Shock, resolved... Acute Gastrointestinal (GI) Bleed secondary to GT site ulcer..." During an interview on 12/8/16 at 3 P.M., LN 2 stated she was Resident 73's nurse on 12/2/16 during the evening shift (3 P.M.- 11 P.M.). LN 2 stated, at the beginning of her shift, she noticed blood on Resident 73's bed sheet and clothing and the resident told her he had pulled on his GT. LN 2 stated she cleaned the GT site and placed a dressing over the site. LN 2 stated Resident 73's GT site continued to bleed throughout the shift and she changed the dressing 6 times on her shift. LN 2 stated the dressings were "soaked." LN 2 stated she did not notify the MD or Nurse Practitioner (NP) [as she documented]. She stated she notified LN 5 and thought he called the MD. LN 2 confirmed she did not document the dressing changes. During an interview on 12/8/16 at 3:30 P.M., LN 5 stated he was the charge nurse on 12/2/16 evening shift. LN 5 stated he remembered Resident 73 had bleeding from the GT site around 4 P.M. LN 5 remembered the ADON changed Resident 73's GT site dressing at approximately 6 P.M. LN 5 stated he was unaware of the number of times the resident's dressing was changed during the shift. LN 5 stated, "No one told me the number of times the dressing was changed during the shift. That would be something the MD would need to know." During an interview on 12/8/16 at 3:45 P.M., LN 3 stated she worked the night shift (11 P.M.- 7: A.M.) on 12/2/16. LN 3 stated, "During shift report, they [the evening shift nurses] told me they applied pressure dressings [to the GT site] but it would bleed though the dressing and onto gown (Resident 73's clothing). She stated, "They said it was bleeding a lot and they had changed the dressing three times in the past hour." LN 3 stated at the beginning of her shift she noticed the resident was bleeding through the dressing and she applied a new dressing. LN 3 stated she changed the resident's dressing 3 times in two hours and was unable to flush the GT. LN 3 stated she notified the MD the resident's GT was not patent (open and unobstructed). LN 3 further stated she notified the MD the GT site was bleeding, but she did not inform him of the number of dressing changes over the past 2 shifts (8 hours) or the amount of blood saturating the dressings. LN 3 confirmed she did not document the dressing changes. During an interview on 12/8/16 at 5:25 P.M., the Assistant Director of Nursing (ADON) stated, on 12/2/16, she helped LN 2 change Resident 73's GT site dressing since LN 2 was busy with another resident. The ADON stated she noticed blood on the Resident's gown and observed "a trickle" of blood from the GT site. The ADON further stated, "LN 2 called me [to the resident's room] worried because it was wet again after 10 minutes." The ADON stated she applied a new dressing. (at which point the resident's dressing was changed a total of 8 times during the 3-11 shift). The ADON confirmed she did not document the dressing changes. The ADON further stated, she expected the LNs to notify the MD when the resident's dressing was saturated 6 more times during the shift. The ADON was unaware of the amount of dressing changes the resident required over the evening and night shift and stated she expected the LNs to document the dressing changes. During an interview on 12/12/16 at 8:05 A.M., Certified Nurse Assistant (CNA) 1 stated she provided care for Resident 73 during the night shift on 12/4/16. CNA 1 stated Resident 73 was incontinent of both bowel and bladder and she checked his brief when she performed rounds every 2 hours during her shift. CNA 1 stated, on her first round, the resident did not have a bowel movement. CNA 1 further stated, on her second and third round, the resident had large black tarry stools. CNA 1 stated she reported the black stools to the nurses each time. CNA 1 stated, on the last round (approximately 6 A.M.) the resident had another large black stool. CNA 1 stated she notified the charge nurse and took the resident to the shower room to clean him. CNA 1 further stated, while in the shower, Resident 73 continued to have loose black stools and had coffee ground vomit leaking from his mouth. During an interview on 12/12/16 at 8:40 A.M., LN 15 stated she was the charge nurse for the night shift on 12/4/16. LN 15 stated, at approximately 6 A.M., the CNA requested she come to Resident 73's room because "she thought he looked pale." LN 15 stated she assessed the resident's GT site and noted there was dried blood on the site so she changed the dressing. LN 15 stated, a short time later, she observed Resident 73 in the shower chair and noticed he had a black stool. LN 15 stated the CNA reported the resident also had coffee ground vomit. LN 15 stated, she was unaware Resident 73 had any black stools during the shift. LN 15 stated she would notify the MD the first time the resident had a black stool since it could be a symptom of a GI bleed. LN 15 stated the resident was at risk for a GI bleed because he was on blood thinners. LN 15 confirmed she did not document as assessment of the resident during her shift. During an interview on 12/12/16 at 12 P.M., MD 1 stated LN 3 notified him on the night shift of 12/2/16 Resident 73 had been pulling at his GT, the site was bleeding, and the GT did not flush. MD 1 stated he was unaware of the frequency of dressing changes the Resident's GT site required over the evening shift. MD 1 further stated he was not notified Resident 73 had black stools prior to the 6:30 A.M. phone call on 12/3/16. MD 1 stated the LNs should have notified him when Resident 73 had the first black stool as this was critical information and he would have sent the resident to the hospital for evaluation immediately. The LNs failed to recognize and assess the amount of bloody drainage from Res 73's GT site. This failure resulted in a change in condition and transfer to the hospital. In addition, the LNs failed to notify the MD of the amount of dressing changes (11 dressing changes), they provided to Res 73. 2. Resident 39 was admitted to the facility on XXXXXXX, with diagnoses which included liver disease, according to the facility's Admission Record. During an observation and interview on 12/7/16 at 3 PM, Resident 39 stated several months ago she tripped and fell and landed on her right shoulder. She did not know the exact date of her fall. She stated she was sent to the hospital Emergency Room and further stated she was supposed to get a Computerized Axial Tomography (CAT a computerized scan of structures in the body) scan and surgery but did not know when the procedures were scheduled. Resident 39 complained of pain to her right arm and demonstrated she was unable to lift or move it normally. On 12/7/16, a record review was conducted. According to the LN documentation dated 9/3/16, Resident 39 was walking back to her room in the hallway near the shower room, and Resident 39 tripped and fell. The LN assessed Resident 39 for injury, and contacted her physician. The physician ordered an x-ray of the right shoulder be taken at the facility. The LN reported the x-ray results to Resident 39's physician. The x-ray results revealed, "A fracture involving the neck of the humerus (upper arm bone from shoulder to elbow) with minimal displacement." The physician ordered the resident be transferred to the hospital for further evaluation. Resident 39 was evaluated in the hospital and repeat x-rays were taken. On 9/3/16 at 4:47 PM, the x-rays confirmed a diagnosis of a, "Closed transverse fracture (a crack extending from a surface into, but not through, a long bone) of the proximal (closest to the body) end of the right humerus." According to the hospital physician's Discharge Summary dated 9/3/16 at 4:47PM, it was recommended Resident 39 return to the facility and for the facility to schedule a follow-up appointment with an orthopedic surgeon (bone surgeon). The LN contacted Resident 39's physician on 9/3/16 at 11:55 PM and relayed the hospital physician's recommendation. The physician ordered a follow up with an orthopedic physician for surgical evaluation of the right shoulder. On 9/7/16 at 10:12 AM Resident 39's physician ordered an OT (Occupational Therapy) evaluation for treatment recommendations of the fracture. According to the OT evaluation note, dated 9/7/16 at 16:05 PM, "Pt (Patient/Resident) has not been seen by Ortho (Orthopedics) prior to eval (evaluation) and tx (treatment); to clarify RUE (Right Upper Extremity) ability. Will await ortho (Orthopedic) consult prior to OT eval and tx" On 9/15/16 (nine days later), Resident 39 was seen by the orthopedic surgeon. The surgeon recommended surgical intervention for Resident 39. He documented "I do not perform this procedure and therefore referred the patient back to her primary care physician for further treatment." He further documented... "We discussed the possibility of non-operative treatment. But the patient would like to seek out surgical intervention." On 9/15/16 at 2:41 P.M., the LN noted Resident 39 returned from the orthopedic referral from the surgeon's office with orders to, "Refer to Ortho trauma surgeon for possible ORIF (Open Reduction and Internal Fixation, a treatment for bone fractures)." On 9/24/16 at 10:18 AM, Resident 39 returned to the hospital radiology department for a follow up x-ray. The x-ray revealed, the fracture was still present with signs of displacement (abnormal position). On 9/28/16, Resident 39's physician ordered an appointment with another orthopedic surgeon. This appointment was scheduled for 10/3/16 (30 days after the initial injury). On 9/30/16, an x-ray of Resident 39's shoulder, ordered by facility's physician showed, "Slight increase in the lateral displacement of healing fracture proximal humerus compared with prior exam... some healing however no bony union." There was no documentation in Resident 39's record of the reason for the repeat x-ray. On 10/3/16, Resident 39 was evaluated by an orthopedic surgical specialist, who documented, "...the patient's proximal humerus fracture is significantly displaced." The orthopedic surgical specialist documented Resident 39 was, "...not able to use right arm for activity." In addition, he documented, "The treatment listed in the evaluation so far: sling. The ROM (range of motion) right shoulder: almost no ROM due to pain." He further documented, "As this is quite a complex problem, I would like to obtain a second opinion from a shoulder subspecialist. I would like to refer her to my associate...for this." On 11/28/16, the primary physician ordered a portable x-ray on Resident 39"s right shoulder. After a review of the Nurses Progress Notes, it was unclear as to why the x-ray was ordered. The x-ray revealed an, "Angulated displaced fracture of the humerus surgical neck probably with evidence of early healing." An appointment with a third orthopedic specialist was scheduled on 11/30/16, (89 days after the resident's fall). The orthopedic specialist ordered a CT of the right shoulder and documented, "...possible surgery soon." On 12/7/16 at 3 PM, Resident 39 was interviewed and confirmed the inability to move without great pain in her RUE (right upper extremity) injury since her fall, which made daily activities difficult as she confirmed she was right handed. Per the facility Policy and Procedure dated 6/2013 entitled, Care and Treatment, Section 2, "Residents with acute medical changes or change of condition (and some routine changes) will be identified as high risk progress notes in the PCC Documentation. Changes will be communicated each shift." On 12/12/16 at 10:06 A.M., the DON stated the LNs documentation in the weekly summaries regarding the status of Resident 39's shoulder; regarding pain, treatment, and progress were inconsistent with the acute high risk medical changes Resident 39 experienced. In summary, Resident 39 sustained a fall with a right shoulder fracture on 9/3/16. The initial radiography indicated a fracture involving the neck of the humerus with minimal displacement. The only treatment provided to the resident was pain medication and a sling. The resident had three evaluations by the orthopedic surgical specialist and numerous x-rays which revealed the right shoulder fracture had now become significantly displaced. In addition, the resident had nearly no range of motion to her arm due to the pain. A surgical intervention was recommended by the third orthopedic surgeon and had not been performed as of 12/12/16 (100 days since the injury). An Interdisciplinary Team(IDT) did not effectively address the delay in treatment and did not facilitate the scheduling of the recommended surgery in a timely manner. The cumulative effects of these failures presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result. |
| 090000104 |
Victoria Post Acute Care |
090013233 |
B |
31-May-17 |
HT9L11 |
10327 |
Federal Regulation, Long Term Care Facilities 483.13 Resident Behavior & Facility Practice, F 223 Free of Abuse - Verbal, Sexual, Physical, Mental. The resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. The facility must not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion.
The facility failed to ensure Resident 1 was kept free from abuse when certified nursing assistant (CNA) 1 tapped Resident 1's hand when Resident 1 attempted to remove a juice from the nourishment cart. This failure had the potential to compromise Resident 1's physical and mental well-being and potentially cause undue stress to a resident with a diagnosis of anxiety (a mental health disorder characterized by worry or fear that interferes with daily functioning). In addition, the facility allowed CNA 1 to return to the facility prior to conducting a thorough investigation by interviewing other residents or staff to make sure there was not a pattern of behavior or other incidents by CNA 1, which put Resident 1 and other residents at risk for physical or mental harm.
Findings:
On 1/24/17 at 11 A.M., an entity reported incident was investigated regarding CNA 1 who tapped the wrist of Resident 1 when Resident 1 attempted to remove apple juice from the nourishment cart on 1/6/17 at 7:40 P.M. According to the Report of Suspected Dependent Adult/Elder Abuse, dated 1/7/17, documented by the Administrator (Admin), it indicated "Reported type of abuse: Physical...CNA tapped resident on top of her hand as she was reaching for a nourishment..."
Resident 1 was admitted to the facility XXXXXXX/16 with diagnoses which included dementia (impaired memory and thinking that interferes with daily functioning) and anxiety per the facility's Admission Record.
A review of Resident 1's history and physical, dated 9/12/16, was conducted. This document indicated, "The Resident (Resident 1) does not have capacity to understand and make decisions... can make needs known but cannot make medical decisions..."
A review of Resident 1's progress notes, by the director of staff development, dated 1/7/17, was conducted. This document indicated, "...Resident had incident at HS (bedtime) snack cart 1/6/17. Resident attempting to reach on cart was asked to wait for staff. Resident's hand may have had hand to hand contact with CNA..."
A review of the facility's policy and procedure titled Nursing Administration, Section: Resident Rights, Subject: Abuse Prevention, dated 11/28/16, was conducted. This policy indicated, "...Mental Abuse- This includes, but is not limited to humiliation (make someone feel ashamed and foolish by injuring their dignity and self-respect, especially publicly), harassment, and threats of punishment or deprivation (the denial of something considered to be a necessity)... Physical Abuse: This includes but is not limited to hitting, slapping, pinching, and kicking. It also includes controlling behavior through corporal punishment (physical punishment to discipline or control other people's behavior by hitting, spanking, which physical force is used and intended to cause some degree of pain or discomfort)..."
An interview with the Admin on 1/25/17 at 11 A.M. was conducted. The Admin stated CNA 1 was back on duty and that she returned four days after the incident occurred. There was no documented evidence provided to the Department that other residents were interviewed regarding the care and treatment provided by CNA 1 before she returned to the facility.
A review of the facility's policy and procedure, dated 11/28/16, titled Abuse Prevention, was conducted. This policy indicated, "...Identification of Abuse... 3. Occurrences, patterns and tends will be assessed by License3d staff and/or Interdisciplinary Team to determine the direction of the investigation... Investigation: All identified events are reported to the Administrator/Designee immediately and will be thoroughly investigate...The investigation shall consist of:.. 3. Interviews with any witness to the incident, including the alleged perpetrator... 6. Interviews with other residents to whom the accused employee provides care or services..." This facility's policy was not implemented, when the facility allowed CNA 1 to return to the facility prior to conducting a thorough investigation by interviewing other residents or staff to make sure there was not a pattern of behavior or other incidents by CNA 1, which put Resident 1 and other residents at risk for physical or mental harm.
On 1/25/17 at 11:47 A.M. Resident 1 was observed in bed, in her room. An attempt to interview Resident 1 about the incident was made. Resident 1 stated, "I can't recall incident."
A review of Resident 1's social service plan of care, created on 1/9/17 [two days after the incident], by the social service supervisor, indicated "Focus: Potential for a psychosocial well-being problem r/t (related to) possible hand to hand contact with CNA on 1/6/17. Goal: Will demonstrate adjustment to nursing home placement... Interventions/tasks: Allow time to answer questions and to verbalize feelings perceptions, and fears..." There was no nursing care plan related to physical abuse (employee to the resident), developed or initiated by nursing on 1/6/17 to instruct the staff on how to treat, support, and monitor Resident 1 (victim) who had a diagnosis of anxiety disorder.
A telephone interview with the Admin on 5/23/17 at 11 A.M. was conducted. The Admin stated CNA 1 was not available to interview and was no longer an employee at the facility. The facility did not obtain an interview statement from CNA1 for Department review. CNA 1's contact information was requested and received.
An attempt to contact CNA 1 for an interview was made on 5/23/17 at 1:36 P.M. and 4:28 P.M., and on 5/25/17 at 8:30 A.M. Upon each attempt, an automated message was received that the caller did not accept incoming calls and a message could not be left.
A telephone interview with the Admin on 5/25/17 at 11:09 A.M. was conducted. The Admin stated CNA 2 witnessed the incident.
A telephone interview with CNA 2 on 5/25/17 at 11:17 A.M. was conducted. CNA 2 acknowledged she witnessed the incident that occurred on 1/6/17 between CNA 1 and Resident 1. CNA 2 stated CNA 1 was passing out nourishments when she heard Resident 1 say, "I want a juice," and CNA 1 did not respond to the resident. CNA 2 stated she heard Resident 1 say again, "I want a juice...I'm hungry" and CNA 1 did not respond to the resident. CNA 2 stated she saw Resident 1 touch the nourishments and CNA 1 tapped the resident on the hand and told the resident, "Don't touch the nourishments." CNA 2 stated Resident 1 told CNA 1, "Don't you ever put your hands on me again, or I will..." CNA 2 could not remember exactly what Resident 1 said she would do to CNA 1, but both CNA 1 and the resident were serious. CNA 2 acknowledged CNA 1 tapped Resident 1's hand in a scolding (an angry expression of disapproval) manner. CNA 2 stated she reported the incident to licensed vocational nurse (LVN) 1 on duty, who then reported the incident to the Administrator. CNA 2 stated LVN 1 did not actually see the incident.
A review of a written statement provided by LVN 1 regarding the incident between CNA 1 and Resident 1, dated 1/6/17, was conducted. This document indicated, "Around 7:30 P.M. (CNA 1's name) was passing some nourishment and (Resident 1's name) walk [walked] towards the nourishment cart. This nurse (LVN 1's name) was in the medcart (a cart that contains medication) 10 ft (feet) away heard the commotion that (Resident 1's name) said, 'Don't you dare put your hands on me again.' (CNA 1's name) said, 'That's why you don't put your hands on the nourishment.' (Resident 1's name) was very agitated and pointed her finger on (CNA 1) saying, 'Don't you dare put your hand on me again' repeatedly. Then this nurse called (CNA 1) and said, 'don't talk to the resident like that, you have to respect them.' (CNA 1's name) said, 'well, she's been acting up.' Then I said, 'you are making resident agitated talking back. In case that happen again, just leave and calm down you don't have to talk back. Then this nurse talked to (CNA 2's name) who witnessed what happened. She said, '(Resident 1's name) went to nourishment cart and put her hands to find her sandwich and (CNA 1's name) slap (Resident 1's name) hand.' That's then (Resident 1's name) start to be agitated as reported by the nurse above..."
A telephone interview with the Admin on 5/25/17 at 3 P.M. was conducted. The Admin stated the "tap" by CNA 1 was an unintentional response, not good, and not okay... it's inappropriate."
A review of the facility's policy and procedure titled Nursing Administration, Section: Resident Rights, Subject: Abuse Prevention, dated 11/28/16, was conducted. This policy indicated, " It is the policy of the facility that each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation... Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, resident representatives, families, friends, or other individuals..."
The facility failed to ensure that Resident 1 was free from abuse by CNA 1. This failure had the potential to compromise Resident 1's physical and mental well-being and potentially cause undue stress to a resident with a diagnosis of anxiety (a mental health disorder characterized by worry or fear that interferes with daily functioning). In addition, the facility allowed CNA 1 to return to the facility prior to conducting a thorough investigation by interviewing other residents or staff to make sure there was not a pattern of behavior or other incidents by CNA 1, which put Resident 1 and other residents at risk for physical or mental harm. This violated state law and had the potential to put Resident 1's health, safety, and security at risk.
The above violations jointly, separately, or in any combination had a direct or immediate relationship to health, safety, or security of residents. |
| 010000572 |
VICTORIA DRIVE HOUSE |
110009251 |
B |
11-Oct-12 |
KEUH11 |
10520 |
T22 DIV5 CH8.5 ART3-76875(a)(2) Health Support Services-Nursing Services (a) Facilities shall provide registered nursing services in accordance with the needs of the clients for the purpose of: (2) Development and implementation of a written plan for each client to provide for nursing services as a part of the individual service plan, consistent with diagnostic, therapeutic and medication regimens. The facility failed to revise and ensure that staff implemented a care plan to ensure the safety of a client (Client 1), who was a fall risk, when staff failed to supervise Client 1, who fell. This failure resulted in Client 1's fall, and a broken hip and hospitalization as a result of the fall. The facility is a 6 bed Intermediate Care Facility for people with varying degrees of developmental disabilities. The clients are dependent on the facility for basic safety. On 11/7/2011, review of the incident report faxed to the department on 10/26/11, dated 10/24/2011, indicated on 10/22/11 that staff left Client 1, alone to begin getting dressed. A few minutes later at 7 a.m., staff heard Client 1 fall and went to his room to find Client 1 on the floor next to his bed. Client 1's walker was knocked over. The report indicated that Client 1 had started to get dressed but had not finished and that staff concluded that Client 1 stood up and lost his balance and fell over forwards knocking his walker over as he fell. Client 1 was taken to the Emergency room and X-rays revealed that he had a broken hip for which he had a surgical repair. The report indicated that Client 1 was transferred to a skilled nursing facility for physical therapy after the surgery. Review of the incident report indicated that Client 1 had a care plan in place prior to this fall and that the care plan was for safe transferring and walking. The Incident report indicated that an action taken to protect the client after this fall was that the QMRP (Qualified Mental Retardation Professional) and the House Manager reviewed Client 1's care plan and supervision plan with staff. The plans reviewed, indicated that staff were to stay with Client 1 in his room when he is dressing/undressing. Staff was to be immediately available to support Client 1 if he attempted to transfer or walk independently. During an interview on 11/8/2011 at 7:45 a.m., DCS (Direct Care Staff) A stated that the event happened on a Saturday morning and the night shift overlaps with the day shift to help get the clients ready in the morning. Someone comes in early on weekends at 7 a.m. or 8 a.m.. DCS A stated that DCS B was working the night shift. DCS A stated that with Client 1, staff has to be there when he walked as he can trip; he does not bend his legs but drags them. They use a safety gait belt and tell him to lift his feet when he walks. During an interview on 11/8/2011 at 8:05 a.m., DCS C stated that she was coming to work on 10/22/11 and a driver was taking Client 1 to the Emergency room. DCS C stated that DCS B and DCS D were working. DCS B was working 10 p.m. to 8 a.m., and DCS D was working 7 a.m. to 3 p.m. DCS C stated that Client 1 needed help in the shower, going to the bathroom, help with changing clothes and walking. He used a walker normally. DCS C stated that Client 1 sat on a chair to put on his pants and shirt. He "wobbles" when he was without his walker. He thinks he is going to fall and "wobbles". During an interview on 11/8/2011 at 8:25 a.m., DCS C stated that it was common sense to watch Client 1 as he cannot walk and the manager told her Client 1 needed to be supervised and needed to be watched. During an interview on 11/8/2011 at 2 p.m., DCS D stated she was scheduled to come to work, the Saturday that Client 1 fell, at 8 a.m., and night shift staff (DCS B) stated that Client 1 had fallen around an hour before, called the QMRP (Qualified Mental Retardation Professional) and got Client 1 dressed. DCS D stated that she usually came to work at 7 a.m., but she was scheduled later because of overtime and was working a double shift that day. DCS D stated that they were a little short staffed on that morning and DCS B also had to pass medication. DCS D stated that sometimes Client 1 will get his walker and try to do things himself. DCS D stated that he was not steady on his feet and needed "a lot of prompting" because he "shuffles" and tends to forget what you tell him. DCS D stated that Client 1 needed constant supervision because he forgot what you told him and is confused.During an interview on 11/8/2011 at 2:40 p.m., DCS B stated that he had been at the facility a year and worked the night shift. DCS B stated that the Saturday morning of 10/22/11, he woke Client 1 to get him dressed and laid out his cloths for him. DCS B stated that Client 1 usually sat on the edge of the bed and stood up with his walker. DCS B stated that he was never informed that he had to be there when Client 1 was dressed, but had to be there when he was in the bathroom, as he fell once before at the house. "It wasn't clear to me" that I had to be there when he dressed. DCS B stated that morning, staff came at 8 a.m., instead of 7 a.m. DCS B stated that he left Client 1 sitting on the side of his bed and he went to do the medication pass. Shortly after starting the medication pass, he heard Client 1 fall. DCS B stated he found Client 1 on the floor next to his bed with his walker tipped over. DCS B stated that he helped him stand up and sat him on the edge of the bed. DCS B stated that Client 1 could not walk and complained of pain in his stomach area. DCS B called the QMRP and Client 1 was taken to urgent care or emergency care about 8 a.m. DCS B stated that this was the first problem with him dressing himself. DCS B stated that he knew Client 1 was a fall risk, but that he did not have instruction that he had to be there when he dressed, just when he was walking or in the bathroom. On 11/8/2011 at 3:10 p.m., review of Client 1's "Physician's Orders" signed 9/19/2011, indicated that Client 1 had a diagnosis of mild mental illness, Autism (developmental disorder), Schizophrenia (mental disorder), epilepsy/Seizure disorder, and had neck spine fusion surgery on 10/15/10. Client 1's "Initial 30 Day Individual Service Plan", dated 5/16/11-6/9/11, indicated that Client 1 was independent in dressing and undressing, but needed physical help to help lace his shoes. Under "Sensori -Motor Skills" the plan indicated that he could stand alone, but used a walker and gait belt with staff holding the gait belt. The plan indicated under "extremities" that Client 1 had unsteady ambulation, needed a gait belt, stand by or contact assist and needed cuing to pick up feet to avoid tripping, stay close to walker and needed reminders for hand placement during transfers, was unsteady with turns, and uneven surfaces and during transfers. Under "Review of Recommendations and Discussion" staff were to maintain safety measures per care plan to prevent falls and injury and the Registered Nurse was to monitor. On 11/8/2011, review of Care Plan, reviewed by the facility on 8/21/2011, indicated that the "Condition" for the care plan was for injury due to unsteady gait and falls. The care plan indicated that staff was to utilize all adaptive equipment and use a postural support plan as recommended by OT (Occupational therapy), PT (Physical Therapy), and /or MD (Medical Doctor). Observe that equipment is free of obstacles when performing activities of daily living and other activities. Accompany client when ambulating outdoors or on uneven surfaces and monitor bathroom transfers as possible. The care plan was not specific for instructions to staff to provide supervision while the client dressed, or instructions to ensure the client dressed himself safely. Review of Physical Therapy "Exercises" for Client 1, dated 4/18/11, indicated that staff had instructions for client for sit to stand exercises which included keeping knees apart and also indicated that client needed standby assistance if there was no walker and staff were to cue Client 1 to stay close to his walker and pick up his feet while walking.During an interview on 11/9/11 at 3 p.m., The Registered Nurse stated that usually Client 1 got dressed while in a chair and wondered about him sitting on the side of the bed. The Registered Nurse stated that Client 1 was a fall risk and needed supervised transfers. Client 1 needed stand by assistance when he used the walker and stated that information or instructions could have been communicated to staff more "universally" than it was. Information and instruction such as the chair worked better for him to get dressed and to also do frequent checks on him. The Registered Nurse stated that staff perceived the information in the care plan differently, it would have been better if all staff did the same thing. On 11/9/11 review of the Acute Care Hospital consultant physician's History and Physical, dated 10/22/11, indicated that Client 1 had surgery the previous year for spinal stenosis. The notes indicated that before that spinal surgery, the patient had been bedridden and that day (10/22/11) Client 1 had fallen over his walker and was unable to walk. The consultant's note indicated that Client 1 was diagnosed with a left hip fracture in the emergency room. Physician Emergency Room Progress notes, dated 10/22/11, indicated Client 1 presented with Left Hip Pain and was unable to bear weight after an unwitnessed fall at the care home, used a walker and also noted that there was a left hand injury from "few days ago". The physician emergency room progress notes indicated that physical exam revealed left hip pain with range of motion and left hand swelling/ecchymosis at the thumb and 2nd metacarpal (bone in the hand). Assessment was "Closed FX (Fracture) Femur" and "Closed FX Hand, Metacarpal Bone". The physician "Operative Note" dated 10/22/11 indicated that Client 1 had a pre and post diagnosis of a fracture of the "Left intertrochanteric area" (Hip) and the surgery performed was an "Open reduction internal fixation" with a "IMHS" system (metal implants consisting of screws and metal components for stabilization of the left hip fracture).The failure to provide staff to supervise Client 1 and to ensure staff followed the same plan of care, resulted in serious harm, when Client 1 sustained a broken hip, requiring surgical intervention as well as other injuries. This failure had a direct relationship to the health, safety, or security of patients. |
| 110000467 |
VACAVILLE CONVALESCENT AND REHABILITATION CENTER |
110009561 |
B |
22-Oct-12 |
581V11 |
1636 |
1418.21(b) Health & Safety Code 1418 (b) Violation of this section shall constitute a class B violation, as defined in subdivision (e) of Section 1424 and, notwithstanding Section 1290, shall not constitute a crime. Fines from a violation of this section shall be deposited into the State Health Facilities Citation Penalties Account, created pursuant to Section 1417.2. 1418.21 (a)(1)(B) Health & Safety Code 1418 (a) A skilled nursing facility that has been certified for purposes of Medicare or Medicaid shall post the overall facility rating information determined by the federal Centers for Medicare and Medicaid Services (CMS) in accordance with the following requirements: (1) The information shall be posted in at least the following locations, in the facility: (B) An area used for employee breaks. The facility violated the regulation when the facility failed to post the facility's overall rating in an employee's break room used by the facility staff. This failure resulted in the potential for staff not being informed of the facility's overall rating.During a tour of the employee's break room with the facility Management Staff A on 10/11/12 at 3:30 p.m., there was no posting of the facility's overall rating observed. Management Staff A stated that he did not know the ratings were to be posted in the break room. Therefore, the facility violated the regulation when the facility's overall rating was not posted in an employee break room. This failure resulted in the potential staff not being informed of the facility's overall rating. This failure had a direct relationship to health, safety, or security of patients. |
| 120000355 |
Valley Convalescent Hospital |
120010405 |
B |
28-Jan-14 |
Q4CY11 |
6069 |
F223-42CFR 483.13(b) Abuse The Resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. On 6/13/13, at 8:45 AM, an unannounced visit was made to the facility to investigate an entity reported resident to resident altercation. Based on observation, interview, and record review, the facility failed to protect one resident (Resident 2) when another resident (Resident 1) had his arms around Resident 2's neck attempting to choke her and threatening to kill her.On 6/13/13, Resident 2's clinical record was reviewed. Resident 2, a female resident, was admitted with diagnoses including generalized weakness and severe cognitive impairment. A Nurse's note, dated 6/11/13, at 5 PM, indicated Resident 2 was in the dining room already yelling out uncontrollably. She made some verbal remarks to a male resident, Resident 1. Resident 1 reached over, grabbed her shoulders from behind, and placed his arms around Resident 2's neck in a choke hold. Resident 1 and 2 were both separated by facility staff immediately. Resident 2 was in the Director of Nursing's (DON) office feeling in shock and crying. Resident 2 stated she feared for her life in the facility. Resident 2 was transferred to an emergency department for evaluation. The Emergency Room report, dated 6/11/13, at 8:14 PM, read, "Female presents after being choked. Patient states she has pain all over her neck and chest that is 10 out of 10 (a pain scale, 10 means the most intense pain)..." During a concurrent observation and interview with Resident 1, on 6/11/13, at 8:45 AM, he stated, Resident 1 stated while he was in the dining room, Resident 2 made a comment about his mother. He grabbed her shirt and pulled her backwards towards him. Then he put his arms around her neck and began choking her. Resident 2 stated, "If any one disrespects me or my mother I will kill them...I was trying to kill her." During a review of the clinical record for Resident 1 on 6/13/13, the admission record indicated he had diagnoses of mental illness, mild cognitive impairment, and had a loss of contact with reality. A mood and behavior care plan, dated 5/6/13, indicated Resident 1 was easily angered and irritated. He had sudden angry outburst manifested by verbal and physical agitation. He was assessed to be a danger to self and others, at risk of hurting self and others. He also had a history of assaulting others such as striking out at facility staff and other residents. The approach the facility planned to deal with his sudden anger outburst was to keep him away from others when he became angry or agitated and visually check his whereabouts for his safety and the safety of others. Resident 1's clinical record indicated he had had several altercations with other residents in the facility. On 1/19/13, he kicked a resident after a verbal altercation and hit a staff. On 2/16/13, he slapped a resident who was using the shared bathroom. On 3/3/13, Resident 1 verbalized he was going to stab a resident who he believed stealing his funds. On 3/28/13 and 4/27/13, he was kicking and punching the windows, doors, and walls. He threw everything that was in his way. In both instances, the facility had to call law enforcement to handle the situation. During an interview with the DON on 6/13/13, at 11:10 AM, she stated Resident 1 was in the dining room and Resident 2 made a verbal remark about Resident 1's mother. Resident 1 grabbed Resident 2 from behind, pulled her down by her shoulder and placed his arm around her neck and began to choke her. During a subsequent interview at 11:25 AM, Certified Nurse Assistant (CNA 1) stated she heard yelling and screaming coming from the dining room. She ran to the dining room and witnessed Resident 1 had Resident 2 on his lap with his arms around her neck in a choke hold. CNA 1 stated it took three staff to separate them. She stated Resident 2 was yelling and screaming saying: "He's going to kill me, I can't breathe." During an interview with CNA 2, on 6/13/13, at 10:25 AM, she stated Resident 1 was demanding, hit the walls when angry, and tried to break things. CNA 2 stated if another resident was in his way he would push them out of the way. The resident had attacked other residents before and if he verbalized that he was going to hurt someone he meant it. CNA 2 stated, "I 'm afraid of him." During an interview with License Vocational Nurse (LVN 1), on 6/11/13, at 10:30 AM, she stated Resident 1 would get very anxious; his face would turn red, and became physically aggressive. She said, "He is strong and fast." During an interview with CNA 3, on 6/11/13, at 10:35 AM, she stated Resident 1 had been yelling at the nurses and other residents often. Resident 1 would order other residents to "shut up." CNA 3 stated, about a month ago, Resident 1 was upset with the nurses and he went into the nurses' station and started throwing everything such the phones and papers at staff. During an interview with LVN 2, on 6/13/13, at 10:41 AM, she stated Resident 1 had angry outburst, if someone or something blocked his way; he would yell, "Move" and staff had to run or pushed another resident out of his way before he threw the object at them. LVN 2 stated if he was angry or mad he became physically and verbally abusive. LVN 2 said Resident 1 once told her he could not control his aggressive behavior. "He's not safe here at this facility. It's not safe for the other residents." On 6/13/13, Resident 2's "BEHAVIORAL SYMPTOMS CARE PLAN" was reviewed. The approach to be taken when Resident 2 became agitated was to "Keep resident away from physically aggressive resident." Resident 1 could be an extremely aggressive to other residents. The facility staff did not remove Resident 2 from the dining room when she dined at the same table with Resident 1.The failure to remove Resident 2 from the dining room as directed on the care plan caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety, or other emotional trauma to patients. |
| 120000355 |
Valley Convalescent Hospital |
120010409 |
B |
28-Jan-14 |
ZC7M11 |
4830 |
F323-42 CFR 483.25 (h) AccidentsThe facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents On 6/25/13, at 4:25 PM, an unannounced visit was made to the facility to investigate an entity report incident involving a resident (Resident 1) attempting to kill him by cutting his left side of neck.Based on interview, and record review, the facility staff failed to monitor Resident 1 on one-to-one basis and left him unsupervised for a period of time that had resulted in Resident 1 attempting to kill himself with a knife. Findings: During a review of the clinical record for Resident 1 on 6/25/13, the admission assessment his cognition was mildly impaired and had history of behavioral problems such as sudden outburst of verbal aggressiveness such as name calling; kicking or punching walls; making threats to other residents; and physically attempting to chock a female resident. Resident 1's mood and behavior care plan, revised on 5/6/13, listed the problems for the resident included: easily angered behavior, easily irritated, sudden angry outburst, verbal and physical aggression. Resident 1 was also at risk of harm himself as well we other residents. The facility staff wrote on the plan of care for "Mood and Behavior" that Resident 1 had a history of "wanting to kill self, using sharp objects and hitting self." One of the approaches the facility staff planned to manage his tempting to harm self and others was to "Keep resident's (Resident 1) environment safe and free from objects he may use to hurt self or others."During further review of the resident's clinical records, another care plan, dated 6/14/13, after Resident 1 attempted to kill a female resident by a shock hold, the interdisciplinary team decided to place him on one-to-one monitoring. On 6/22/13, at 6:15 PM, a charge nurse documented: "Charge nurse was informed by CNA (Certified Nursing Assistant) that resident is bleeding that he cut himself in the neck area. CN (Charge Nurse) went to resident's room and found resident lying in bed bleeding in the L (left) neck area...approx. (approximate) 2 1/2 inches superficial laceration on L lateral to medial area w/ (with) moderate bleeding..." Resident 1's emergency room report, dated 6/22/13, at 7:35 PM, read; "...a 34 year old male who presents with: self-inflicted stab/slash wounds to the left neck...after an argument with his girlfriend. He used a razor blade to cut himself in an attempt to end his life." During an interview with the Director of Nursing (DON), on 6/25/13, at 4:30 PM, she stated, prior to the incident, Resident 1 had been on one-to-one monitoring since 6/14/13 for his aggressive behavior toward another resident. The DON stated on the day of the incident, Resident 1 ask Certified Nurse Assistant (CNA 1) for a sandwich. CNA 1 asked CNA 2 to watch Resident 1 while she went to the kitchen. CNA 2 stayed in the hallway instead and left Resident 1 in his room alone. The DON stated Resident 1 was not being monitored during that time.During an interview with CNA 1, on 6/26/13, at 8:50 AM, she stated Resident 1 told her he wanted to go to bed but he was hungry and wanted a sandwich. She asked CNA 2 who was in the hallway monitoring another resident to watch Resident 1 while she went to the kitchen. CNA 1 stated when she came back from the kitchen; CNA 2 was in the hallway. CNA 1 stated she went into the room to give Resident 1 his sandwich and saw blood dripping down from the side of Resident 1 neck. During an interview with CNA 2, on 6/26/13, at 9:10 AM, she stated she never knew she was supposed to watch Resident 1. She stated she was assigned to watch another resident who was in the hallway at the time.During the interview with the DON on 6/25/13, at 4:30 PM, regarding Resident 1's suicidal attempt, she stated Resident 1 had a history of injuring himself but was cleared by the facility's psychiatrist. His one-to-one monitoring was to ensure he would not harm others.On 6/25/13, during further review of Resident 1's "PHYSICIAN'S PROGRESS NOTES," dated 6/18/13, indicated Resident 1 was evaluated by a psychiatrist. The psychiatrist documented that the resident was "not suicidal."The facility policy and procedure titled "Safety and Supervision of Residents" undated, read; "Resident safety and supervision and assistance to prevent accidents are facility wide priorities. Implementing interventions...ensuring interventions are implemented..." The facility failed to ensure consistent and continuous monitoring of Resident 1 and left him unsupervised for a period of time had given the resident an opportunity to harm himself. Such failure had a direct relationship to the health, safety, or security of patients. |
| 120000355 |
Valley Convalescent Hospital |
120013119 |
AA |
7-Jul-17 |
ENR611 |
10210 |
F323 ?483.25(d) Accidents
The facility must ensure that -
(1) The resident environment remains as free from accident hazards as is possible; and
(2)Each resident receives adequate supervision and assistance devices to prevent accidents.
On 2/27/17 at 1:53 PM, an unannounced visit was conducted at the facility to investigate an entity reported incident regarding Resident 1 falling from his bed and sustaining cervical spine fracture.
Resident 1 was an 80-year-old male, admitted to the facility on XXXXXXX 16, with diagnoses of dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning), diabetes mellitus (a disease in which the body's blood sugars were elevated for prolonged period), right below-knee amputation, contracture, and high blood pressure. Resident 1's cognition status was assessed by the facility staff on 2/14/17. This assessment indicated Resident 1 was cognitively intact.
Resident 1 fell out of bed after a Certified Nursing Attendant (CNA 1) repositioned him on 2/21/17. CNA 1 heard the noise and found the resident on the floor. Resident 1 was transferred to an acute hospital emergency department for evaluation. After being evaluated by physicians, Resident 1 was diagnosed with an unstable C2 fracture (break of the second cervical vertebrae- the tubular ring-like bone just below the skull which serves to protect the spinal cord). A neurological surgeon recommended conservative treatment. Resident 1 and his wife requested hospice evaluation. He was transferred back to the facility on XXXXXXX 17 and died the following day. Hospital medical records indicate the cause of death was "s/p (status post) C2 fx (fracture), Hx (history) CVA (Cardiovascular accident), Hx of Alzheimer (Dementia)."
The Department determined that the facility failed to ensure a resident's (Resident 1) bed side-rail was up after a nursing staff had re-positioned him. This resulted in Resident 1 falling, sustaining a cervical fracture at the second vertebrae (C2) fracture, being unable to consume nutrition orally, and being placed into hospice care. Resident 1 died eight days after the fall incident.
The fall care plan for Resident 1, dated 11/11/16, was reviewed. Resident 1 was at risk for falls due to incontinence (lack of bladder and/or bowel control), an amputated leg, dementia, and history of falls. The "SCREENING GUIDE FOR THE USE OF RESTRAINTS," dated 11/11/16, indicated Resident 1 had poor safety awareness and needed one side rail up. Another care plan titled "ADLS (activities of daily living) CARE PLAN," initiated on 11/11/16; indicated Resident 1 required one side rail up for bed mobility. In addition, Resident 1's physician prescribed to have "SIDERAIL UP X1 FOR MOBILITY" on 11/8/16. The Nutritional Progress Note dated 2/8/17, indicated Resident 1 was on a mechanical soft diet (a diet containing ground or pureed foods and was consuming approximately 55% of his meals.
The Interdisciplinary Team Review for Resident 1 dated 2/14/17, indicated Resident 1 was alert and oriented with periods of forgetfulness with a Brief Interview for Mental Status (BIMS-a brief screening interview that aids in detecting cognitive [conscious intellectual activity as in thinking, reasoning, or remembering] impairment) of 15 out of 15 (score of 13-15 means cognitively intact). This review also indicated Resident 1 required extensive assistance with his ADLs and one person assist in bed mobility.
The "Licensed Nurse Notes" for Resident 1 dated 2/21/17, at 9 PM, indicated, "I [Licensed Nurse 1- LN 1] was called to room by CNA [Certified Nursing Assistant 1] and found resident [Resident 1] on the floor. Bleeding noted above right eyebrow and below the eye. I (LN 1) asked resident (Resident 1) what happened. He (Resident 1) stated, 'I fell out of bed.' He (Resident 1) complained of head and neck pain."
The post fall investigation document for Resident 1 dated 2/21/17, at 9 PM, indicated under mechanical devices that no side rails were in place at the time of Resident 1's fall. This same document indicated side rails was the contributing factor for Resident 1's fall and under action plan all side rails in the facility would be checked for functionality.
During a review of the hospital record for Resident 1, the "Emergency Room Report" for Resident 1, dated 2/21/17, indicated a CT [computed tomography (CT) scan uses X-rays to make detailed pictures of parts of your body and the structures inside your body] of the cervical spine (neck vertebra) was performed and was read by a radiology physician as a cervical spine fracture at the second vertebrae (C2) with a 4 millimeter separation (space). It was an unstable fracture and unlikely to close or heal.
The Neurosurgeon's consultation (MD 2) for Resident 1 dated 2/22/17, indicated "In view of patient's (Resident 1) advanced age and the presence of other medical comorbidities (the simultaneous presence of two or more chronic diseases or conditions in a patient), we recommend he should be managed conservatively. The patient (Resident 1) is too old for halo cervical immobilization (A device used to manage cervical spine injuries to minimize neurological damage, requiring long-term immobilization)."
An undated written statement by the Maintenance Supervisor (MS) indicated "On 2/22/17 I (MS name) heard about a resident falling out of bed so around 8:00 am I went to the room where the incident took place and checked bed 4-2 to see if it was in good standings. After checking it out head limit, foot limit (the space between the inside surface of the head board or foot board and the end of the mattress) and rails were in good operable state."
The Hospice Admission Record for Resident 1 dated 2/28/17, indicated "Pt (Patient-Resident 1) noted to have rattling cough and mild SOB (shortness of breath)....Pt becoming increasing confused and agitated....Family reported that pt. has been asking for food and would like puree diet to be offered. They understand that pt may aspirate and are willing to take that chance for his comfort/gratification. Pt asking for milk shake and advised staff that it is okay to give milk shake per request."
The Hospice "History and Progression of the Terminal Illness" document for Resident 1, 3/1/17, 5:15 PM, indicated "He (Resident 1) underwent a swallow evaluation and is NPO (take nothing by mouth) at the time of the visit...Diagnostics: failed swallow evaluation."
The facility "Discharge Summery", undated, for Resident 1 and signed by the Physician, indicated Resident 1 was readmitted to the facility on XXXXXXX 17 and died on XXXXXXX 17, with a cause of death as: status post C2 fracture, a history of CVA, and history of Alzheimer's disease. Under "Summary of Care", this document indicated "Pt admitted to hospice s/p (status post) fall with C2 fx (fracture)-not surgical. C-collar (cervical collar- a medical device used to support a person's neck) for tx (treatment). Unable to swallow effectively. Pt expired."
During a concurrent observation of Resident 1's room and interview with Resident 2 (Resident 1's roommate) on 2/27/17, at 4 PM, Resident 2 stated he saw Resident 1 roll out of bed. Resident 2 stated, "I was watching TV when I heard him [Resident 1] yell, 'I'm falling, I'm falling'. All I can say is when he [Resident 1] fell, the side rails were down. I saw it clearly." It was observed that Resident 2 was approximately three feet away from Resident 1's bed. Resident 1's bed was very close to the far wall by the window. Resident 1's bed had a pressure relieving air mattress (Pressure relief air mattresses help individuals prevent the formation of bedsores) and a three-quarter size side rail (a bed side rail that is approximately three quarters the length of the bed). The far side of the bed was within a few inches from the wall. The bed side rail release was located on the outside bottom edge of the side rail towards the foot of the bed.
During a review of the clinical record for Resident 2, the "MDS (Minimum Data Set-Comprehensive Assessment Tool)", dated 2/6/17, indicated under Cognitive Patterns, Resident 2 had a Brief Interview for Mental Status score of 15.
During an interview with CNA 1, on 3/1/17, at 12:20 PM, she stated Resident 1 was positioned facing the door (his back to the window and far wall) with a wedge (a foam devise used to position residents on their sides) behind his back before the fall incident. CNA 1 stated she repositioned Resident 1 by herself and then went to the next room to answer a call light. CNA 1 stated she heard a loud falling sound and went to check Resident 1, and then she stated she found Resident 1 on the floor. CNA 1 stated she was sure she put the side rail up on the side Resident 1 was facing before she left the room. CNA 1 stated, "I don't know how he fell."
During a concurrent interview with LN 2 and review of Resident 1's clinical record on 3/2/17, at 2:54 PM, LN 2 verified the findings during the review of Resident 1's clinical record listed above.
During an interview with LN 1, on 3/2/17, at 2:57 PM, she stated at the beginning of her shift, Resident 1's side rail was up. LN 1 stated Resident 1 was able to help with repositioning in bed by grabbing onto the side rail. LN 1 stated when she responded to the call, Resident 1 was on the floor and his side rails were down at the time of the fall. LN 1 stated, "He [Resident 1] said he fell out of bed."
In violation of the Code of Federal Regulations ?483.25(d), the facility failed to ensure that the resident environment remains as free from accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents, including but not limited to failure to ensure Resident 1's bed side-rail was in the up position.
This violation presented either an imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result, and was a direct proximate cause of death of the resident. |
| 150001231 |
VETERANS HOME OF CALIFORNIA - YOUNTVILLE |
150010717 |
B |
03-Jul-14 |
9MW611 |
4852 |
T22 DIV 5 CH 3 ART 3 72345(d) Dietetic-Sanitation (d) Ice which is used in connection with food or drink shall be from a sanitary source and shall be handled and dispensed in a sanitary manner.The facility failed to ensure that the ice patients consumed was from a sanitary source when the facility failed to ensure: a necessary air gap to provide adequate backflow prevention between the floor drain and the ice machine pipes, the maintenance of the interior of the ice chutes in a clean manner and the maintenance of clean floor drains beneath the ice machines. These failures had the potential to place patients at risk for food borne related illness (es).On 3/12/14, at 11:15 a.m. observations of the ice machine in the Holderman Building kitchen revealed no air gap between the drainage pipe and floor drain.During a concurrent interview the Plant Operations Director stated that he was aware of the air gap procedure and that when the ice machine in the kitchen and other ice machines in the facility had been originally installed, the air gap was included.The 2013 Federal Food code section 5-202.13 titled "Backflow Prevention, Air Gap", indicated the following: "An air gap between the water supply inlet and the flood level rim of the plumbing fixture, equipment, or non-food equipment shall be at least twice the diameter of the water supply inlet and may not be less than 25mm (millimeters) 1 inch."On 3/12/14, at 10:00 a.m., observation of ice machines in the nourishment rooms of the facility's 14 licensed care wards revealed that 8 out of 13 ice machines did not have the necessary air gap backflow prevention. (Total sample is out of 13, because two wards in the Eisenhower Annex II share one ice machine.) On 3/12/14, at 11:15 a.m., an observation of the Holderman kitchen ice machine revealed visible white debris buildup on the inside surfaces of ice chute. Subsequent observation of ice machines in the licensed care wards in Holderman, Eisenhower and Memory Care revealed 13 out of 13 had visible white debris buildup on the inside surfaces of the ice chute.In an interview on 3/12/14, at 11:10 a.m., the plan operations director also stated that the plan operations staff was responsible for the cleaning and sanitation of the interior of the ice machines, and that the sanitation and housekeeping staff was responsible for the exterior cleaning and sanitizing of the ice machines. In subsequent interview the Director of Sanitation and Housekeeping stated that his staff was responsible for the exterior cleaning of the ice machines, including the lower external ice chute where ice was dispensed from the machine. He stated that this cleaning was completed on a daily basis, and that cleaning staff have green, abrasive pads for removing any hardened mineral deposits.The facility's policy titled "Cleaning Ice Machines on Resident Wards" indicated the following: "Environmental Services has the responsibility to clean outside of ice machines and sink area including under grate area with disinfectant solution daily. ...Remove water deposits/scales from under grates of ice machine; ...plant operations will clean inside of ice machines during routine maintenance." The 2013 Federal Food Code, section 4-602.11 (4) titled "Equipment Food Contact Surfaces and Utensils" indicated: "In equipment such as ice bins and beverage dispensing nozzles and enclosed components of equipment such as ice makers..... (a) At a frequency specified by the manufacturer, or, (b) absent manufacturer specifications, at a frequency necessary to preclude accumulation of soil or mold." On 3/12/14, at 10:00 a.m. an observation of the floor drains on Holderman wards 1C, 2C, and 2D revealed significant debris accumulated in the drains.In a concurrent interview, supervising RN (Registered Nurse) on Ward 2C stated that the sanitation department staff was responsible for the cleaning of the floor drains under the ice machines in the nourishment rooms. The facility's policy for Environmental and General Services, titled "Cleaning, Floor Drains", indicated: "All floor drains are to be cleaned daily with disinfectant solution." In an interview on 3/13/14 at 4:30 p.m., the Director of Sanitation and Housekeeping stated he had seen the floor drains on wards 1C, 2C, and 2D, and that they needed to be cleaned. In summary, the facility failed to ensure that the ice consumed by patients was from a sanitary source due to the lack of air gaps to provide adequate backflow prevention between floor drains and ice machine pipes, the maintenance of the interior of the ice chutes in a clean manner and the maintenance of clean floor drains beneath the ice machines. These failures had the potential to place patients at risk for food borne related illness (es).These failures had a direct relationship to the health, safety or security of patients. |
| 630014895 |
Veterans Home of California - Redding |
150011948 |
B |
02-Jun-16 |
DEWT11 |
5047 |
REGULATION VIOLATION F 411 483.55 Dental Services The facility must assist residents in obtaining routine and 24 hour emergency dental care. Findings: The facility failed to ensure a contracted dentist provided dental services in accordance with professional standards of quality. During a dental examination, staff witnessed Dentist A using, what appeared to be, a rusty and dirty paring knife to dislodge Resident 1's partial denture (a removable partial denture or bridge usually consisting of replacement teeth attached to a pink or gum-colored plastic base, which is sometimes connected by metal framework that holds the denture in place in the mouth). This failure resulted in Resident 1 sustaining two lip lacerations, a skin-tear to his left hand, pain, visible agitation, and put Resident 1 at risk for infection. Resident 1 was a XXXXXXX year old individual admitted on XXXXXXX, with diagnoses including, but not limited to, dementia with behavioral disturbance. On 12/21/15, Interdisciplinary Progress Notes (IDNs) dated 9/24/15 at 7 p.m., were reviewed. Documentation indicated Resident 1 sustained a small superficial scratch to the left lateral inner upper lip, a cut in the middle inner upper lip, and a small skin tear to the back of his left hand. Further documentation indicated Dentist A saw Resident 1 on 9/24/15. Resident 1 was asked to remove his dentures for Dentist A. After Dentist A cleaned and applied a gel like substance to the dentures, they were placed back in Resident 1's mouth. After approximately five minutes, Resident 1 was asked to remove the dentures. The top dentures were easily removed but the bottom denture would not come out. LVN A was asked to try to remove them and was unable to do so. Dentist A then continued to pull and tug on Resident 1's bottom (partial) dentures. Documentation indicated, the dentist stopped, went to her cart, and got a tool. The instrument was like a kitchen paring knife. The knife appeared rusted and very dirty. LVN A did not believe, for safety and sterile reasons, that a knife, of that nature, should be used. The dentist used the knife to try to pry up the metal clamps overlying the partial/ teeth and the dentist stated she needed to do so in order to remove the partial. LVN A stated, "I don't think you should be using a knife" and LVN A mentioned that she could possibly cut the resident. The Dental Assistant offered Dentist A another instrument but the dentist still insisted on using the "knife like" instrument. While trying to pry up the metal clamps LVN A observed the "paring" knife slip and believed the dentist had cut the resident's lip, as a small amount of visible blood appeared. The resident became very upset and agitated. LVN A asked the Dental Assistant if she would try to remove the partial. She agreed but was unable to do so, and while trying, she said she thought something had broken off. The dental assistant looked into Resident 1's mouth, did a finger sweep of the mouth, and had him spit into a washcloth when LVN A again noticed blood. LVN A asked the resident to "swish and spit" which he did 3-4 times and each time spit up bright red blood. LVN A also noted that Resident 1's left hand was bleeding, as he had been crossing his hands and dug his fingernails into his own hand during the abnormal denture removal process performed by Dentist A. Physician's "Interdisciplinary Progress Notes," dated 9/25/15 at 11 a.m., indicated, "As bizarre as it sounds, pt. (patient) [Resident 1] apparently had sustained an upper lip laceration and dislodgement of "tooth" s/p (status /post) use of unorthodox dental implement yesterday." Review of "Interdisciplinary Progress Notes," dated 9/25/15 at 1:55 p.m., indicated new physician's orders were received for a dental examination to be "performed today" [9/25/15]. The staff RN accompanied Resident 1 to the examination. Documentation indicated the resident expressed obvious discomfort as evidenced by touching his mouth, facial grimacing and repeatedly pointing his finger to the area of the missing tooth, stating, "She went Bam Bam!" LVN A was interviewed on 12/21/15 at 3PM and stated the tool looked like a paring knife, rusted and dirty, "it looked like oil." The dentist was "flicking up the knife" trying to pry off the metal wire. The resident was cut twice and he spit up blood. The dentist said that he was not cut and the bleeding was from dry lips. LVN A stated, "The Dental Assistant was in shock like I was" and Resident 1 dug his nail into his own hand. Therefore, the facility failed to ensure dental services were provided in accordance with professional standards of quality. During Resident 1's dental examination, a dentist (Dentist A) used a dirty and rusty paring type knife in Resident 1's mouth to pry out a lower denture. This failure resulted in cuts to the resident's mouth, pain, discomfort, agitation, dislodgment of a tooth, and the possibility of infection. This failure had a direct or immediate relationship to the health, safety, or security of patients. |
| 150001231 |
VETERANS HOME OF CALIFORNIA - YOUNTVILLE |
150012309 |
B |
11-Jul-16 |
5UHY11 |
5246 |
F-223 ?483.13(b) Abuse The resident has the right to be free from verbal, sexual physical, and mental abuse, corporal punishment and involuntary seclusion. F-226 ?483.13(c) Staff Treatment of Residents The facility must develop and implement written policies and procedures that prohibit mistreatment, neglect and abuse of residents and misappropriation of resident property. The facility violated the above regulations when office technician, Staff A, was verbally abusive and accusatory to Resident 1 and loudly made untrue and upsetting comments about the resident to others the resident overheard, as did potentially anyone nearby. Review of the facility reporting document indicated that on 1/23/15 Resident 1 reported to the Supervising Registered Nurse Staff B that he had been verbally abused by Staff A. The resident described the experience to Staff B as "disrespectful" and "greatly upsetting." The resident told Staff B that Staff A accused him of being an alcoholic and he then heard her gossip about him to other staff. Resident 1 stated that the behavior was "malicious" and "crossed the line." The document showed that on 1/27/15 at 11:20 a.m., during an interview with facility staff, Registered Nurse Staff C reported, on the day of the incident she heard arguing and then witnessed Staff A in the nursing station say: "That (Resident 1's name), he was drunk and throwing up all night. (Resident 1) then arrived in his wheelchair and stated to Staff A "...You are saying I am an alcoholic."' Staff A then stated "Yesterday you were drunk and threw up all over. You get out of here and go, (sic) I don't want to talk to you at all." Concurrently Staff C "overheard Staff A speaking loudly to her coworkers about Resident 1. Staff C stated Resident 1 told her that he is not an alcoholic and "I was just having fun with my friends." Staff E stated Resident 1 told her he lets things go most of the time, but this incident affected his reputation. Staff E stated that Resident 1 was upset for the rest of the day. Facility document review indicated during a facility interview on 1/27/15, Staff C and D who witnessed the interaction were asked by the facility the reason they failed to report the allegation of abuse immediately. In her statement to the facility on 1/27/15 at 10:45 a.m., Staff D stated she was "scared of (Staff A)," as "she can come down hard on people" and "is very unprofessional." During an interview for the facility investigation on 1/27/15 at 11:20 a.m., Staff C stated she did not report the allegation of abuse, because she avoids Staff A whom she had witnessed to be very unprofessional with people, intervened too much and showed no respect. Review of the facility policy titled: "Elder Abuse Reporting" 4197 v. 3 indicated the following: "All veterans Homes of California employees are, by law, 'mandated reporters' required to report any known or suspected incidents of elder abuse." During an interview with Staff C on 4/4/16 at 1:30 p.m., Staff C verified her statement provided during the initial facility investigation on 1/27/15. When asked again the reason she failed to report the allegation of abuse, Staff C stated the behavior of Staff A had been a problem for a long time. Staff A had been reported for inappropriate behavior many times but nothing had been done about it. Review of an Interdisciplinary Note (IDN) dated 1/23/15 at 4:20 p.m., showed Resident 1 indicated he was verbally abused by a staff, that staff spoke to him disrespectfully. Resident 1, interviewed on 2/1/16 at 11:30 a.m., stated "the girl was absolutely disrespectful. I recall the lady, date and incident very well. She accused me of being an alcoholic, in front of other patients, staff and visitors. I was very angry." On 2/1/16 the personnel file of Staff A was reviewed and indicated past counseling for similar incidents. Staff A's evaluation dated 1/17/14, indicated the standard under the section assessing relationships was not met. The comments indicated that the staff was often accusatory, and argumentative when interacting with coworkers...and could be a hindrance to teamwork. "It is imperative that you treat others with dignity and respect." During an interview on 2/1/16 at 1:30 p.m. Staff A stated she did lean over the counter and stated to Resident 1 "you need to stop drinking." Staff A stated she heard that the resident had been drinking and threw up the night before. Staff A stated "he was following me down the hall yelling don't insinuate I'm an alcoholic." Review of facility policy titled: "Elder Abuse, Reporting (All Homes) #4197 version 3, revised 10/30/14 indicated under subsection Definitions, "Abuse of an Elder or Dependent Adult- Can be any of the following: physical abuse, neglect, financial abuse, abandonment, isolation, abduction, or other treatment with resulting physical harm or pain or mental suffering; or the deprivation by a care custodian of goods or services that are necessary to avoid physical harm or mental suffering." In summary, the facility failed to protect Resident 1 from verbal abuse by Staff A, and staff witnessing the abuse failed to report promptly. These failures had a direct or immediate relationship to resident health, safety and security. |
| 630014894 |
Veterans Home of California - Fresno |
150013021 |
B |
26-Jul-17 |
KUHJ11 |
6659 |
T22- DIV5 CH3 ART4 72527 (a)(10) Patient Rights
(a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request:
(10) To be free from mental and physical abuse.
Based on staff interviews and administrative document review, the facility failed to prevent mental and physical abuse to six of six Residents: (Resident 1, Resident 2, Resident 3, Resident 4, Resident 5, Resident 6) when CNA 1 was witnessed by multiple staff members to verbally and physically abuse Residents.
On 2/4/2017, at 7:05 AM, during an interview, Certified Nursing Assistant (CNA 4) stated, on 11/4/2017, she had reported four allegations of abuse to Supervising Registered Nurse (SRN 2). CNA 4 stated she witnessed CNA 1 act like she was going to spit on Resident 1, stating "I can do that too. Don't hit me, I have military background." CNA 4 witnessed CNA 1 bend Resident 3's hand and the Licensed Vocational Nurse (LVN 1) witnessed the event as well. CNA 4 witnessed CNA 1 tell Resident 5, "Get the f... out of my way." CNA 4 stated during shift report, and upon learning they will need to do "Alert Charting" (assessment and documentation of injuries of unknown origin), CNA 1 stated to "You better not say anything, because you know we do stuff like that."
On 2/5/2017, at 1:20 AM, during an interview, CNA 2 stated that on 11/4/2017 she verbally reported the allegations of abuse to SRN 3 and the Registered Nurse (RN 1). CNA 2 stated SRN 3 requested that she email SRN1, SRN 2 and SRN 3 and include a detailed account of the suspected abuse allegations. One allegation indicated that CNA 1 used mouthwash to clean the perineal area "so that Resident 1 could feel the burn when CNA 1 cleaned him." The second allegation indicated that CNA 1 stated "Good, now he can feel pain." When she had witnessed Resident 2 fall.
On 2/5/2017, at 1:35 AM, during an interview, Supervising Registered Nurse (SRN 3) stated that on 11/4/2017 he was notified, by CNA 4 (by email) and by SRN 2 (verbally) of two suspected abuse allegations committed by CNA 1 on Resident 1 and Resident 2. The first allegation indicated that CNA 1 used mouthwash to clean the perineal area of Resident 1, "so that he [Resident 1] can feel the burn when I (CNA 1) clean him." The second allegation indicated that CNA 1 stated, "Good, now he can feel pain." After she had witnessed Resident 2 fall. SRN 3 stated he would consider both allegations as abuse, and as a mandated reporter he should have reported them within 24 hours.
On 2/5/2017, at 10:45 AM, during an interview, SRN 1 stated that on 11/4/2017 he was notified, by CNA 2 (by email), and by SRN 2 (verbally) of two suspected abuse allegations committed by CNA 1 on Resident 1 and Resident 2. The first allegation indicated that CNA 1 used mouthwash to clean the perineal area of Resident 1 "So that he could feel the burn when she cleaned him." The second allegation indicated that CNA 1 stated "Good, now he can feel pain." After she had witnessed Resident 2 fall. SRN 1 stated he considers both allegations as abuse and as a mandated reporter he should have reported them within 24 hours.
On 2/6/2017, at 8:00 PM, during an interview, CNA 5 stated that on 11/4/2016 she reported an allegation of abuse that occurred on 8/28/2016 to SRN 2. CNA 5 stated CNA 1 bent the pinky fingers of Resident 3 "far and back" to get him to release his grip on her (CNA 5). CNA 5 stated upon Resident 3 releasing his grip he held his hands to his chest and moaned. CNA 5 stated she considers these allegations as abuse.
On 2/6/2017, at 11:00 PM, during an interview, CNA 3 stated she witnessed CNA 1 using mouthwash on wipes to remove and clean a bowel movement from Resident 4.
On 2/7/2017, at 10:00 AM, during an interview, the Medical Director (MD 1) stated mouthwash shouldn't be used for perineal care and has never been ordered by him for that purpose. MD 1 stated if the mouthwash was used for perineal care in association with statements reflecting intentions to inflict harm, then it would be considered abuse.
On 2/7/2017, at 10:00 AM, during an interview, the Director of Nurses (DON) stated that if the mouthwash was used for perineal care in association with statements reflecting intentions to inflict harm, then it would be considered abuse.
On 2/7/2017, at 7:30 PM, during an interview, CNA 6 stated that on 11/4/2016 she reported two allegations of abuse to SRN 2. CNA 6 stated she witnessed CNA 1 using mouthwash on wipes to clean the perineal area of Resident 4. CNA 6 stated when she asked why she (CNA 1) was using mouthwash, CNA 1 responded, "So he will learn." CNA 6 stated that CNA 1 stated to her "Don't let them hurt you. You get them first. Pull their finger first, and back, and hurt them." CNA 6 stated she considered both allegations as abuse.
On 2/8/2017, at 10:10 AM, during an interview, SRN 2 stated that on 11/4/2017 she was notified, by CNA 4 by email of two suspected abuse allegations committed by CNA 1 on Resident 1 and Resident 2. The first allegation indicated that CNA 1 used mouthwash to clean the perineal area of Resident 1, "So that he can feel the burn when I clean him.", and the second allegation indicated that CNA 1 stated, "Good, now he can feel pain.", after Resident 2 suffered a fall. SRN 2 stated she interviewed CNA 2, CNA 3, CNA 5, and CNA 6 on 11/4/2017 regarding their knowledge of suspected abuse committed by CNA 1. SRN 2 stated the allegations should be considered suspected abuse, and should have been reported within 24 hours.
On 2/17/2017, at 2:00 PM, during an interview, CNA 7 stated that on, date unknown to CNA 7, CNA 1 appeared to have done something to get Resident 6 to release his firm grip on her, because she noticed Resident 6 react and release his grip. When asked, CNA 1 stated "You have to pull hair.", and then she positioned herself to the side and rear of Resident 6, raised her hand up close to the Resident's hair on the back lower area of Resident 6's head, and pretended to pull it. CNA 7 stated she considered the behavior abuse and reported the incident to the Charge Nurse, an LVN but CNA 7 could not remember which one.
The above violation had a direct or immediate relationship to the Resident's health, safety, or security and therefore constitutes a Class "B" Citation. |
| 630014894 |
Veterans Home of California - Fresno |
150013022 |
B |
26-Jul-17 |
KUHJ11 |
7377 |
HSC 1418.91 (a)(b)(c)(d)
(a) A long-term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the department immediately, or within 24 hours.
(b) A failure to comply with the requirements of this section shall be a class "B" violation.
(c) For purposes of this section, "abuse" shall mean any of the conduct described in subdivisions (a) and (b) of Section 15610.07 of the Welfare and Institutions Code.
(d) This section shall not change any reporting requirements under Section 15630 of the Welfare and Institutions Code, or as otherwise specified in the Elder Abuse and Dependent Adult Civil Protection Act, Chapter 11 (commencing with Section 15600) of Part 3 of Division 9 of the Welfare and Institutions Code.
Based on staff interviews and administrative Document review, the facility failed to report allegations of abuse to the California Department of Public Health (CDPH) within the required period of time (24 hours) for six of six Residents (Resident 1, Resident 2, Resident 3, Resident 4, Resident 5, Resident 6) when it was reported by multiple staff members that Certified Nurse Assistant (CNA 1) was verbally and physically abusing Residents.
On 2/4/2017, at 7:05 AM, during an interview, CNA 4 stated, on 11/4/2017 she had reported four allegations of abuse to Supervising Registered Nurse (SRN 2). She witnessed CNA 1 act like she was going to spit on Resident 1 as she stated "I can do that too. Don't hit me, I have military background ," CNA 4 witnessed CNA 1 bend Resident 3's hand and the Licensed Vocational Nurse (LVN 1) witnessed the event as well, CNA 4 witnessed CNA 1 tell Resident 5, "Get the f... out of my way." CNA 4 further stated, during shift report and upon learning they will need to do "Alert Charting" (assessment and documentation of injuries of unknown origin), CNA 1 stated to her (CNA 4) "You better not say anything, because you know we do stuff like that.", referring to the bruising of the hand and fingers of Resident 1 due to the bending of his hand the day before.
On 2/5/2017, at 1:20 AM, during an interview, CNA 2 stated that on 11/3/2017 she was informed by an unidentified CNA of a suspected abuse allegation committed by CNA 1. On 11/4/2017 CAN 2 verbally reported the allegation to SRN 3 and the Registered Nurse (RN 1). CNA 2 stated SRN 3 requested that CNA 2 email SRN1, SRN 2 and SRN 3 and include a detailed account of the suspected abuse allegations. One allegation indicated that CNA 1 had used mouthwash to clean the perineal area "So that he (Resident 1) could feel the burn when she (CNA 1) cleaned him." The second allegation indicated that CNA 1 stated "Good, now he can feel pain after she had witnessed Resident 2 fall."
On 2/5/2017, at 1:35 AM, during an interview, Supervising Registered Nurse (SRN 3) stated that on 11/4/2017 he was notified, by CNA 4 (by email) and by SRN 2 (verbally) of two suspected abuse allegations committed by CNA 1 on Resident 1 and Resident 2. The first allegation indicated that CNA 1 used mouthwash to the clean the perineal area of Resident 1, "So that he can feel the burn when I (CNA 1) clean him (Resident 1)." The second allegation indicated that CNA 1 stated, "Good, now he can feel pain.", after CNA 1 had witnessed Resident 2 suffer a fall. SRN 3 stated he would consider both allegations as abuse, and as a mandated reporter he should have reported them within 24 hours. SRN 1 stated he did not generate a report to CDPH.
On 2/5/2017, at 10:45 AM, during an interview, SRN 1 stated that on 11/4/2017 he was notified, by CNA 2 (by email), and by SRN 2 (verbally) of two suspected abuse allegations committed by CNA 1 on Resident 1 and Resident 2. The first allegation indicated that CNA 1 used mouthwash to clean the perineal area of Resident 1 "So that he could feel the burn when she cleaned him." The second allegation indicated that CNA 1 stated "Good, now he can feel pain." After she had witnessed Resident 2 suffer a fall. SRN 1 stated he considers both allegations as abuse and as a mandated reporter he should have reported them within 24 hours. SRN 1 stated he did not generate a report to CDPH.
On 2/6/2017, at 8:00 PM, during an interview, CNA 5 stated that on 11/4/2016 she reported an allegation of abuse that occurred on 8/28/2016 to SRN 2. CNA 5 stated CNA 1 bent the pinky fingers of Resident 3 "far and back" to get him to release his grip on her (CNA 5). CNA 5 stated upon Resident 3 releasing his grip he held his hands to his chest and moaned. CNA 5 stated she considers these allegations as abuse.
On 2/6/2017, at 11:00 PM, during an interview, CNA 3 stated she witnessed CNA 1 using mouthwash on wipes to remove and clean a bowel movement from Resident 4.
On 2/7/2017, at 10:00 AM, during an interview, the Medical Director (MD 1) stated mouthwash shouldn't be used for perineal care and has never been ordered by him for that purpose. MD 1 stated that if the mouthwash was used for perineal care in association with statements reflecting intentions to inflict harm, then it would be considered abuse.
On 2/7/2017, at 10:00 AM, during an interview, Director of Nurses (DON 1)1 stated that if the mouthwash was used for perineal care in association with statements reflecting intentions to inflict harm, then it would be considered abuse.
On 2/7/2017, at 7:30 PM, during an interview, CNA 6 stated that on 11/4/2016 she reported two allegations of abuse to SRN 2. CNA 6 stated she witnessed CNA 1 using mouthwash on wipes to clean the perineal area of Resident 4. CNA 6 stated when she asked why she (CNA 1) was using mouthwash, CNA 1 responded, "So he will learn." CNA 6 stated that CNA 1 stated to her "Don't let them hurt you. You get them first. Pull their finger first, and back, and hurt them." CNA 6 stated she considered both allegations as abuse.
On 2/8/2017, at 10:10 AM, during an interview, SRN 2 stated that on 11/4/2017 she was notified, by CNA 4 (by email) of two suspected abuse allegations committed by CNA 1 on Resident 1 and Resident 2. The first allegation indicated that CNA 1 used mouthwash to clean the perineal area of Resident 1, "So that he can feel the burn when I clean him.", and the second allegation indicated that CNA 1 stated, "Good, now he can feel pain.", after she had witnessed Resident 2 suffer a fall. SRN 2 stated she interviewed CNA 2, CNA 3, CNA 5, and CNA 6 on 11/4/2017 regarding their knowledge of suspected abuse committed by CNA 1. SRN 2 stated the allegations should be considered suspected abuse, and should have been reported within 24 hours.
On 2/17/2017, at 2:00 PM, during an interview, CNA 7 stated that on, date unknown to CNA 7, CNA 1 appeared to have done something to get Resident 6 to release his firm grip on her, because she noticed Resident 6 react and release his grip. When asked, CNA 1 stated "You have to pull hair.", and then she positioned herself to the side and rear of Resident 6, raised her hand up close to the Resident's hair on the back lower area of Resident 6's head, and pretended to pull it. CNA 7 stated she considered the behavior as abuse.
The above violation had a direct or immediate relationship to the Resident's health, safety, or security and therefore constitutes a Class "B" Citation. |
| 630014895 |
Veterans Home of California - Redding |
150013124 |
B |
22-Jun-17 |
GPR711 |
6399 |
CFR T42 ?483.25(h) Accidents
The facility must ensure that
(1) The resident environment remains as free from accident hazards as is possible; and
(2) Each resident receives adequate supervision and assistance devices to prevent accidents.
(3) (n) - Bed Rails. The facility must attempt to use appropriate alternatives prior to installing a side or bed rail. If a bed or side rail is used, the facility must ensure correct installation, use, and maintenance of bedrails, including but not limited to the following elements.
The facility failed to ensure Resident 1 remained free of accidents due to lack of adequate supervision. The resident fell out of his wheelchair breaking his arm. The resident's plan of care failed to identify use of the wheelchair and associated risk for the resident. This failure resulted in actual harm to Resident 1 who sustained a fractured right arm.
Findings:
The facility reported incident indicated that on 6/29/16 at 11:05 a.m., Resident 1, while being pushed in his wheelchair, by a volunteer, fell out of the wheelchair and sustained a broken arm.
The facility incident report indicated while Resident 1 was being pushed over yellow safety bumps on a sidewalk ramp, "the wheelchair stumbled," and the jarring caused the resident to fall out of the wheelchair. The volunteer was reported to have stated, "I panicked and started yelling for help." Two passersby picked up the resident and transferred him back to the wheelchair. The volunteer stated she heard a "pop during the lift." The volunteer had separated from the group and brought the resident to a distant restaurant across the mall parking lot at the resident's request. After the fall the volunteer pushed the resident back across the mall parking lot to the mall where the remainder of the group was gathered. The resident was asked if he wanted to go to the hospital or return to the facility. The resident stated he preferred to return to the facility. After an assessment by the nurse practitioner at the facility, the resident was transferred to a community hospital where he was diagnosed and treated for a right arm fracture.
The record indicated that Resident 1 was wheelchair bound due to severe Parkinson's disease. The Minimum Data Set (MDS) quarterly assessment dated 6/3/16 indicated Resident 1 had limitation of both upper extremities, was not able to walk and required extensive assistance by another person to weight bear, transfer and move about in a wheelchair. A wheelchair was identified as the assistive device used.
During an interview, on 1/30/17 at 1:30 p.m., the Administrator and Director of Nursing (DON) stated that the resident did not have footrests in place on this outing. The resident was not wearing a safety belt during the outing although the Administrator and DON stated there had not been a reason to assess the need for one.
During an interview, on 1/30/17 at 3 p.m., the Recreation Therapist (R.T.) stated that nursing staff only accompany residents during an outing if residents would be eating. The R.T. stated that the volunteer did not notify her that she and Resident 1 were leaving the mall, which she should have done. The RT stated the volunteer should not have left the mall alone with Resident 1. Regarding the resident's fall out of the wheelchair, the R.T. stated that the resident would jump when startled. She could imagine him being jostled out of the wheelchair when going over those yellow bumps.
During an interview, on 2/7/17 at 3:15 p.m., the volunteer accompanying Resident 1 stated she verbally prepared the resident before going over the bumps. The volunteer stated the resident tended to lean forward in the wheelchair and with the bumping he fell to the ground. She stated she yelled for help. The resident was very uncomfortable as it was a hot day and the resident was on the pavement. Two passersby lifted the resident back into the wheelchair. The volunteer stated she heard a pop when the resident was transferred back to the wheelchair. The volunteer stated the passerby wanted to call 9-1-1 however she told them she need to take the resident back to the mall. The volunteer then pushed the resident back across the parking lot to the mall. The resident reported to the Recreation Therapist he thought he broke his arm. The Recreation Therapist contacted the facility. The resident did not have footrests on the wheelchair for the outing. Regarding the lack of footrests, the volunteer stated that she could not put footrests on the wheelchair, only nursing.
The resident's plan of care updated 6/25/16 for "Activities of Daily Living," and for the problem of "Potential for Fall and/or injury," failed to identify the resident's use of a wheelchair. The care plan did not indicate the resident had the tendency to lean forward when in the wheelchair.
Review of facility policy titled: "Therapeutic Activities, Community Outing (SNF)" under the section "staffing" 6. "Nursing staff will provide assistance with Resident transfers, toileting, and provide escort services as indicated to ensure the care and safety of the attending Residents."
Review of wheelchair procedures from the facility's "Volunteer Services Handbook" revised May 2016, indicated the following section: "IMPORTANT! THIS IS A "NO LIFTING" FACILITY. If a resident falls do not help them up ask them to lie still and go to the nearest staff and ask them to page the nurse. If you are with another volunteer or if someone is walking by ask them to go to security for you and stay with the resident. Medical personnel must evaluate each fall. The handbook under the section wheelchair procedures also indicated, "After a resident is seated, put foot pedals down..." Another document titled: "...Volunteer Services - Wheelchair Assist" indicated to make sure the resident's feet were on the footrests to prevent dragging and possible injury.
The facility's failure had a direct relationship to the health, safety, or security of patients. The facility failed to ensure Resident 1 remained free of accidents due to lack of adequate supervision. The resident fell out of his wheelchair breaking his arm. The resident's plan of care failed to identify use of the wheelchair and associated risk for the resident. This failure resulted in actual harm to Resident 1 who sustained a fractured right arm. |
| 170001867 |
VETERANS HOME OF CALIFORNIA - BARSTOW |
170008822 |
A |
19-Jul-12 |
None |
4473 |
T22 DIV5 CH5 ART4 - 73313(a) Nursing Services - Drug Administration Nursing service shall include but not be limited to the following, with respect to the administration of drugs: (a) Medications and treatments shall be administered as prescribed and shall be recorded in patient's health records. T22 DIV5 CH5 ART4 - 73351 Pharmaceutical Service - Policy and Procedure There shall be written policies and procedures for safe and effective distribution, control, use and disposition of drugs developed by the patient care policy committee. The committee shall monitor implementation of the policies and procedures and make recommendations for improvement. The following findings reflect an investigation of Entity Reported Incident # CA00273088. The Department determined the facility failed to: 1. Ensure that Resident A was free of significant medication errors. 2. Implement established policy and procedures to provide safe care. Clinical record review indicated that Resident A was a 75 year old male admitted to the facility on 8/7/07. His diagnoses included: hypertension (high blood pressure), diabetes mellitus with renal manifestation (diabetes with kidney complications) and congestive heart failure (heart does not pump properly). On 9/27/11, a review of the facility investigation report dated 6/23/11, indicated that on 6/14/11 Staff 1(7am-7pm shift) administered Insulin Human 70/30 (a medication used to control high blood sugar in patients with diabetes mellitus), 100 units subcutaneously (under the skin) to Resident A at approximately 5 pm. Resident A reported to Staff 2 (7pm-7am shift) that he was given 100 units of insulin by Staff 1. Staff 2 advised Staff 3 (7pm-7am shift) of Resident A's allegation. Review of the nursing progress notes indicated that from 6/14/11 at 8 p.m. to 6/15/11 at 6:30 a.m., Resident A's blood sugar was checked 10 times. The lowest blood sugar level obtained was 36 mg/dl (milligrams per deciliter), taken seven hours after the incorrect dose was administered.At 8 pm: the vital signs were B/P(blood pressure)=170/76, P(pulse)=70, R(respiration)=18, T(temperature)=97.5, BSL(blood sugar level)=53mg/dl. Resident A was administered with Glucagon 1mg (milligram), IM (intramuscular) to left deltoid. "Resident remains alert and oriented x3." At 9 pm: BSL=44mg/dl, Resident A "remains awake and alert" At 10 pm: BSL=92 At 12 MN: BSL=36mg/dl, Glucagon IM and Glucagon gel given. "Resident A remains oriented x3" Normal blood glucose level is approximately 70 to 107 mg/dl (milligrams per deciliter).Resident A received a total of three doses of Glucagon 1mg IM (intramuscular), three tubes of glucose gel and glucose added juice. Glucagon is used to treat insulin coma or insulin reaction resulting from severely low blood sugar.Review of the physician's order dated 2/17/11 indicated "Insulin Human 70/30 U - 100 (Novolin 70/30) 100 u/ml (units per milliliter) ...disp 10ml vial o.oo6 vials (6 u) subcutaneous (under the skin) every evening at 1700."Review of the facility policy titled "Insulin Administration (dated 6/2010) Steps in Procedure, 16. Insulin may be injected... FACILITY POLICY STATES THAT TWO NURSES WILL CHECK THE DOSE OF INSULIN, TO VERIFY THAT THE CORRECT DOSE HAS BEEN DRAWN UP."Additionally, review of the May and June 2011 Medication Administration Records (MARs) indicated that from 5/1/11 to 6/16/11, during the times when insulin was administered, the spaces or lines to indicate that insulin dose was verified by another licensed nursing staff were left blank. A total of 43 doses of Insulin were given without documentation that two nurses will check the dose of insulin, to verify that the correct dose has been drawn up.On 9/27/11 at 2: 00 p.m., during an interview, the administration staff stated that the facility policy and procedure related to Insulin Administration was not implemented.The facility failed to follow its Insulin Administration policy which resulted in a significant medication error when Resident A received an almost 17-fold overdose of Insulin, (he received 100 units of insulin when order was to administer 6 units of insulin) sustained negative effects of the high dose of insulin administered (hypoglycemia). Resident A's blood sugar level dropped to 36 mg/dl. at its lowest, 7 hours after it was administered. This presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result. |
| 170001870 |
VETERANS HOME OF CALIFORNIA - CHULA VISTA |
170009974 |
B |
28-Jun-13 |
Y41J11 |
6290 |
483.25(h) FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICESThe facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents.Based on observation, interview, and record review, the facility failed to: 1. Provide Resident 1, who had multiple incidents of falls with proper supervision. 2. Revise Resident 1's care plan to include necessary interventions to address Resident 1's high risk for falls. These failures resulted in Resident 1 sustaining a fall on 4/11/13, in which she suffered a laceration to the left eyebrow and a broken left wrist.Resident 1's clinical record was reviewed on 4/25/13. The review indicated that Resident 1 was admitted to the facility on 3/04/05, with diagnoses that included hemiplegia (paralysis on one side of the body), abnormal posture, and osteoarthritis (degenerative joint disease). The quarterly Minimum Data Set (MDS) assessment dated 3/20/13, indicated that Resident 1 rarely or never understood communications with others, had problems with short and long term memory and had some impairment in her daily decision- making. Resident 1 required limited assistance and one person to assist her physically in toileting; however, she required extensive assistance during transfers. Her balance was unsteady, but she was able to stabilize herself with staff's assistance.The Mini Mental Status Examination dated 9/24/12, which was conducted by a Licensed Clinical Social Worker (LCSW), provided a result of 7/30, which was indicative of a severe cognitive impairment. The neurology consultation conducted on 2/21/13, confirmed that she had severe dementia (cognitive impairment). Her Fall Risk Assessment dated 3/25/13, had a score of 20, which indicates a high risk for falls.Review of Resident 1's "Special Review for Fall" indicated that Resident 1 had fell to the floor three times (12/6/12, 1/16/13, and 3/25/13) prior to her 4/11/13 fall. The form contained documentation that Resident 1 would attempt to transfer herself to a toilet or bed, but would miss the toilet or bed and fall on the floor.Resident 1's x-ray results dated 4/22/13, confirmed that Resident 1 had left radial and ulnar fractures (left wrist fractures). A cast was applied to her left hand to immobilize the left wrist as part of the treatment.Resident 1's care plan identified that she was at risk for falls related to dementia, balance gait disturbance, and lack of safety awareness. The care plan did not include interventions identifying what type of monitoring and supervision would be implemented given her prior history of three falls.The Supervising Registered Nurse of Unit 1100 (SRN) stated during an interview on 4/29/13 at 1:43 p.m., that Resident 1 fell on 4/11/13 at around 4:45 p.m. SRN stated that Certified Nursing Assistant 1 (CNA 1) heard a bed sensor alarm go off. CNA 1 responded and assisted the resident to the bathroom. While the resident was on the toilet, CNA 1 left the resident to turn the alarm off. CNA 1 then heard a loud sound and saw Resident 1 face down with blood on the floor. SRN stated that Resident 1 was diagnosed with dementia and had incidents of falls in the past. SRN stated that Resident 1 would get up on her own most of the time without calling for assistance. SRN stated that CNA 1 should have not left Resident 1 alone while Resident 1 was on the toilet. Resident 1 was observed on 4/30/13 at 2 p.m., on Unit 1100 pod (group area) sitting in a wheelchair with staff next to her and a tab alarm connected to her shirt. Resident 1's left arm was observed to be in a white cast immobilizing her fractured left wrist. Room 1403-1(Resident 1's bedroom) was visited on 4/30/13 at 2:10 p.m., The bathroom was located inside the room; however, there were no line of vision between the resident's bed and the toilet, due to the wall separating the room and resident's bed.Certified Nursing Assistant 2 (CNA 2) stated during an interview on 4/30/13 at 3:10 p.m., that Resident 1 was confused and should have been supervised at the toilet and not left alone. CNA 2 stated that Resident 1had the tendency to get up without asking for assistance. Certified Nursing Assistant 3 (CNA 3) stated during an interview on 4/30/13 at 3:15 p.m., that Resident 1 was confused at times. CNA 3 stated that she always stayed with the resident until she had finished using the toilet, because of her past experience with Resident 1 getting up from the toilet on her own.Certified Nursing Assistant 4 (CNA 4) stated during an interview on 4/30/13 at 3:25 p.m., that she always stayed with Resident 1 until she had finished using the toilet because Resident 1 would stand up without alerting the staff. CNA 4 stated that the CNAs who worked with the resident should have known that Resident 1 would get up from the toilet. Licensed Vocational Nurse (LVN) stated during an interview on 4/30/13 at 3:35 p.m., that Resident 1 had dementia and had a tendency to get up on her own without staff assistance. LVN stated that when toileting Resident 1, staff had to have Resident 1 within their line of vision at all times. CNA 1, who provided assistance to Resident 1 when the incident occurred, stated during an interview on 5/17/13 at 4:25 p.m., that she heard the bed sensor activated in room 1403-1. She responded and saw the resident standing by her bed, wanting to go to the bathroom. She assisted the resident to the toilet. While the resident was on the toilet, she left to turn the alarm off and fix the resident's bed. She then heard a loud sound; she responded and found Resident 1 on the floor, face down. She noticed blood on the floor and decided to leave the resident to call for help. When asked if she should have left Resident 1 by herself on the toilet, CNA 1 replied, "No.", she stated that she left to turn off the alarm and fix Resident 1's bed.The facility failed to protect Resident 1 when the facility failed to: 1. Provide Resident 1, who had multiple incidents of falls with proper supervision. 2. Revise Resident 1's care plan to include necessary interventions to address Resident 1's high risk for falls. These violations had direct or immediate relationship to the health, safety, or security of patients. |
| 170001870 |
VETERANS HOME OF CALIFORNIA - CHULA VISTA |
170009991 |
B |
15-Jul-13 |
EF9911 |
32534 |
The citation narrative for this penalty will not fully display due to narrative length limitations. Please send a request toÿCHCQdata@cdph.ca.govÿto obtain a full copy of this citation narrative.ÿ
F493 483.75 ( d) Governing Body
The facility must have a governing body, or designated persons functioning as a governing body, that is legally responsible for establishing and implementing policies regarding the management and operation of the facility; and the governing body appoints the administrator who is licensed by the State where licensing is required; and responsible for the management of the facility
F500 483.75 (h) Use of Outside Resources
If the facility does not employ a qualified professional person to furnish a specific service to be provided by the facility, the facility must have that service furnished to residents by a person or agency outside the facility under an arrangement described in section 1861(w) of the Act or an agreement described in paragraph (h)(2) of this section.
Arrangements as described in section 1861(w) of the Act or agreements pertaining to services furnished by outside resources must specify in writing that the facility assumes responsibility for obtaining services that meet professional standards and principles that apply to professionals providing services in such a facility; and the timeliness of the services.
Based on observation, interview, and record review, the Governing Body failed to ensure that the facility established and implemented policies regarding the management of the facility; and failed to ensure the contracted providers providing dental services and biomedical equipment maintenance in the Skilled Nursing Facility (SNF) conformed and implemented signed agreements that meet professional standards in providing services by failing to:
1. Ensure that the dental autoclave machine used to sterilize dental instruments was properly maintained.
2. Ensure that there was a proper reporting process of the sterilization tests results.
3. Ensure that all sterilization tests results provided by a provider were reviewed to ensure that all dental instruments were free from cross contamination and safe for residents and other patients' use.
4. Ensure that a policy and procedure on infection control was established in the dental clinic.
5. Ensure that proper infection control practices were implemented in the dental clinic to ensure the health and safety of the residents and other patients.
6. Ensure to submit a complete report to the Contract Manager of the services provided, including necessary repairs.
7. Ensure that contractor made every attempt to complete repairs the same working day.
8. Ensure that contractor responded to requests for emergency repair within eight (8) hours of telephone notification by the Contract Manager.
9. Ensure that contractor provide loan equipment, repair(s) lasting more than five working days.
On 5/2/13 at 9:45 a.m., an unannounced visit was made to the facility to investigate an entity reported incident of a failed sterilization of a dental autoclave machine (used for the sterilization of dental instruments) in the Ambulatory Care Clinic (ACC), an out patient clinic, which is located inside the Skilled Nursing Facility (SNF) building, owned and operated by the facility.
On 5/2/13 at 10 a.m., an interview with the Standard Compliance Coordinator (SCC) was conducted. The SCC was employed by the facility as a full time employee of the SNF. According to the SCC, on 4/29/13 before lunch time, the dental clinic received a notification that one of the sterilization tests failed. The dental clinic immediately stopped all appointments on 4/29/13. She also stated that it was later found out that there was more than one test that failed.
On 5/2/13 at 10:15 a.m., an interview with the Administrator was conducted. The Administrator was employed as a full time employee of the SNF. He stated that the Chief Medical Officer was in charge of the dental clinic and that he (Administrator) had never been involved in the oversight. He also stated that it was unknown to them that the sterilization tests of the dental instruments failed numerous times and that there was almost no involvement or monitoring of the Infection Control Nurse (ICN) in the dental clinic.
On 5/2/13 at 10:45 a.m., an interview with the Chief Medical Officer (CMO) was conducted. The CMO also known as the Medical Director, was employed as a full time employee by the facility and had oversight of the SNF and clinics. He stated that he was in charge of the dental clinic. He also stated that a contracted Dentist and a Dental Assistant came in to provide services in the dental clinic.According to him, there were two failed sterilization tests in February and three failed sterilization tests in March 2013 reported by a provider (Sterilizer Monitoring System). The Health Safety Officer's (HSO) phone received messages for failed results; however, when the HSO left in June of 2011, her phone number was not deactivated and it continued to receive messages. The new HSO hired in 2012 did not receive any failed test results because the phone number previously designated to receive reports was not transferred to him (HSO), according to the CMO.
The CMO further stated that when the February 2013 failed sterilization test results was received by the Office Technician (OT), she did not notify the clinic Supervising Registered Nurse (SRN). The SRN had the responsibility to read the sterilization test results. The Dentist was not informed of the failed results until 4/26/13. He also added that 54 Skilled Nursing Facility residents were seen from the periods of February thru April 2013 when the sterilization tests failed, in which the dental procedures where classified as "no blood, minimal blood, and moderate blood." The dental clinic's operation ceased on 4/29/13 and all appointments were cancelled. Blood borne disease tests (Human Immunodeficiency Virus, Hepatitis B and C) will be conducted for all patients who had been identified and affected, according to him.
On 5/2/13 at 11:36 a.m., an interview with the ICN was conducted. The ICN was employed as a full time employee of the SNF. She stated that she tracked the infection control practices in the SNF and dental clinic. According to her, there was a surveillance log in the dental clinic and that she worked with the SRN of the dental clinic, because sterilization of the dental instruments was part of her (ICN) tracking infection control practices. She indicated that when the HSO left in 2011, the dental clinic SRN told her that she'll (SRN) track the sterilization procedures and results, because it's addressed to her. She (ICN) also stated that the results were part of her tracking and that she depended on the SRN of the results. However, she stated that she did not receive any report whether normal or abnormal since 2000, because she was not part of the reporting process even though she was the ICN. She was not aware of the failed sterilization tests of the dental instruments in February, March, and April 2013. She stated that the dental clinic SRN did not report any results to her and that she assumed that there were no abnormal results because she relied on the SRN.
On 5/2/13 at 12:12 p.m., an observation was conducted inside the dental clinic. The clinic was located in the ACC, inside the building of the SNF. The dental clinic was observed without any patients. One dental autoclave machine was observed on top of a counter with a preventive maintenance sticker attached to it. The sticker indicated that the machine is due for maintenance in July 2013. There were multiple dental instruments wrapped in a plastic container observed in the upper and lower cabinet where the machine was located, and inside a brown box located on top of a counter across the autoclave machine. A log book was also observed on top of the counter that contained SMS sterilization test results from April 2011 thru April 2013.
On 5/2/13 at 12:15 p.m., a review of the SMS sterilization test results log was conducted. The review indicated that the "STATEMENT OF TEST RESULTS" was specifically addressed to the SRN of the clinic. It also indicated that a steam was used as a type of sterilizer when it was submitted to SMS for the spore testing (to determine presence of microorganism). The review further indicated the following:
a. For the month ending 2/28/13, two tests that were conducted in February (2/1/13 and 2/8/13) failed.
b. For the month ending 3/31/13, three tests that were conducted in March (3/1/13, 3/11/13, and 3/15/13) failed.
c. For the month ending 4/30/13, three tests that were conducted in April (4/11/13, 4/22/13, and 4/26/13). The test conducted in 4/11/13 passed the sterilization test. However, 4/22/13 and 4/26/13 tests failed.
Overall, seven sterilization tests failed between the periods of February 2013 thru April 2013, before it was discovered on 4/26/13.
On 5/2/13 at 12:17 p.m., a review of the dental clinic's appointment book was conducted. The review indicated that between the periods of February 1, 2013 thru April 26, 2013 there were a total of 112 patients seen in the dental clinic. 54 out of 122 patients were SNF (Skilled Nursing Facility) residents. There were 167 total procedures performed on patients (71 no blood, 70 minimal blood, and 26 moderate blood) and 61of 167 procedures were performed on SNF residents (13 no blood, 28 minimal blood, and 20 moderate blood). The clinic continued to provide dental services to patients as indicated in the appointment logs when the result of the sterilization tests indicated that it failed during that period.
On 5/2/13 at 12:19 p.m., an interview with the Office Technician (OT) was conducted. The OT was employed as a full time employee of the facility, who worked in the dental clinic and reported directly to the CMO. She stated that she receives the mail from the mailroom and opens it if it was addressed to the clinic. She indicated that the Sterilizer Monitoring System (SMS) sterilization test reports are specifically addressed to the dental clinic Supervising registered Nurse (SRN). According to her, she opened mails from SMS and just filed it. She was not told to show the results to anyone, because she was instructed by the SRN to just file it (SMS sterilization test results log). She had been receiving test reports via mail since 2011 when the Health Safety Officer (HSO) left. She also stated that when she saw the failed sterilization test result for March 2013, she showed it to the SRN and she was instructed to show it to the Dentist on 4/26/13. According to her, she taped the results on the autoclave machine and verbally alerted the Dentist on 4/26/13 of the failed sterilization tests.
On 5/2/13 at 2 p.m., a review of the Medical Director, Infection Control Nurse, Supervising Registered Nurse, and Office Technician's "Duty Statement" was conducted. The review indicated the following:
1. Chief Medical Officer, "ESSENTIAL FUNCTIONS...oversight to attain the medical care standards...Monitors the Infection Control Program and policies. Directs the work of the Infection Control Coordinator..."
2. Infection Control Specialist, "ESSENTIAL FUNCTIONS...develops, implements, and administers facility wide systems for the prevention and control of infection and diseases; assures compliance with regulations governing infection control...develop, implement, and monitor infectious control systems for hospital and domiciliary areas through observation consultation, and evaluation of statistical and medical reports..."
3. Supervising Registered Nurse, "...in charge of the Ambulatory Care Clinic...will provide supervision and direction for the operation of the clinic ...ESSENTIAL FUNCTIONS...will develop and enforce policies that govern the day to day operation of the clinic..."
4. Office Technician, "...tracks and monitors reports from contracted services..."
On 5/2/13 at 3 p.m. a review of the Dentist's contract signed 5/31/11 was conducted. The review indicated that the she signed an agreement to provide dental services from 7/1/11 thru 7/30/14. The review also indicated, "SCOPE OF WORK...4. Contractor shall provide Dental Services in the Dental Clinic of the Ambulatory Care Clinic...6. Contractor shall provide bedside dental screening for Skilled Nursing Facility (SNF) residents...7. Services shall be in accordance with Medi Cal (Denti Cal) standards and requirements and shall include, but not limited to, the following responsibilities:...e) Provide all dental services as required by OBRA (Omnibus Budget Reconciliation Act) 483.5; California Code of Regulations, Title 22 for Skilled Nursing Facility (SNF)...i)...approve oral hygiene policies and practices for the care of residents..."
On 5/2/13 at 3:30 p.m., a review of the facility's "PURCHASE ORDER" dated 8/21/12 was conducted. The review indicated that SMS (Sterilizer Monitoring Systems) signed an agreement with the facility to provide a weekly spore testing of the facility's autoclave sterilizer monitoring system. The agreement was signed on 7/23/12. The purchase order did not include how test results will be reported and did not identify the person responsible for receiving the reports.
On 5/2/13 at 4:30 p.m., an Immediate Jeopardy was called to protect the health and safety of the residents. The Administrator was notified and informed of the following issues that led to the determination of Immediate Jeopardy:
a. Failure to properly sterilize the dental instruments for three consecutive months.
b. Failure to ensure that there was a proper reporting process of the failed sterilization tests results.
c. Failure to review sterilization tests provided by a provider to ensure that all dental instruments were free from cross contamination and safe for residents and other patients' use.
d. Failure to notify the responsible authority of the failed sterilization tests results.
e. Failure to ensure that proper infection control practices were implemented in the dental clinic.
f. Failure to ensure that a policy and procedure on infection control was established and implemented in the dental clinic.
g. Possible and potential exposure to bloodborne infectious diseases of patients seen in the dental clinic.
On 5/2/13 at 5:30 p.m., the facility presented an initial plan of correction. The plan of correction indicated the following:
1. The dental clinic ceased operations effective 4/29/13.
2. Affected residents and other patients will be identified and notified of possible risk due to failed sterilization test results.
3. The facility will asked for consents on blood screening test to all patients that were affected.
4. The use of the autoclave machine was discontinued.
On 5/2/13, the Immediate Jeopardy remained in effect, although the facility presented an initial plan of correction. The plan of correction submitted lacked the components needed to abate the Immediate Jeopardy.
On 5/4/13 at 11:13 a.m., an interview with the CMO was conducted. He indicated that the laboratory results for Human Immuno Virus, Hepatitis B and C (bloodborne infectious diseases due to exposures to blood and other body fluids) conducted on 5/2/13 for SNF residents who consented for the test were reviewed. He stated that two residents tested positive for HIV. Resident 1, a 79 year old male who was seen in the dental clinic on 3/22/13 for an oral exam showed a highly reactive result for HIV. He spoke to the resident and informed him of the HIV positive result. The resident was not surprised of the result, according to the CMO, stating, "He kind of knew that he's HIV positive." He also stated that based on his medical opinion, Resident 1 was not infected in the clinic and could have been HIV positive already when he was admitted in the facility on January 31, 2013. He further stated that the way the instruments were processed in the dental clinic using an ultrasonic emulsifier and autoclaving, and a blood less exam provided for Resident 1, he's doubtful that it was acquired in the clinic. A secondary confirmatory test (Western Blot) was conducted with pending results. A third test (Viral load) to measure the amount of virus particle in the blood was ordered on 5/4/13 with pending results.
Resident 2, an 87 year old male who was seen in the dental clinic twice at the end of January 2013 for a general oral exam and filling, showed a minimally reactive result for HIV. According to the CMO, Resident 2 had no identified risk factor and behavior. He believed that the laboratory test was a false positive result because the pieces of HIV measured particles were minimal. He also stated that based on his medical opinion, Resident 2 was not infected in the clinic, because of how the instruments were processed in the dental clinic. A secondary confirmatory test (Western Blot) was conducted with pending results. A third test (Viral load) to measure the amount of virus particle in the blood was also ordered on 5/4/13 with pending results.
On 5/6/13 at 9:12 a.m., an interview with SMS Business Manager was conducted. SMS was a company contracted by the facility to provide services in sterilizing dental equipments. According to her, they conducted weekly spore testing of the facility's autoclave sterilizer monitoring system. The facility's dental clinic will send the sterilization strips, SMS will incubate it for seven days to evaluate for any microorganism growth at 55 57 degree Celsius (131 135 degree Fahrenheit). Positive results for microorganism means failed sterilization test. The facility will be notified immediately via phone of the failed sterilization test results and hard copy was mailed as well. She stated that the test results were addressed to the SRN. She was unaware that the phone number provided by the facility to receive reports of failed result was changed and not being monitored, although it was still active. The facility did not contact SMS to give notification of the phone number change and the authorized person responsible to receive the report, especially failed sterilization tests.
On 5/6/13 at 11:42 a.m., an interview with the Dentist was provided. The Dentist was employed by the facility as a contracted provider, who reported directly to the CMO. She indicated that she had been a contracted provider since 2008, in charge of the dental clinic, and directly reports to the CMO. She was asked if she reviews or oversee the reports of the sterilization test results, she replied, "It's not my duty to oversee the reports of the sterilization result, because I just provide dental care. On the SMS document results, stated [name of SRN] on it. The dental assistant doesn't read the report either, that's not our duty." When she was asked if the failed test results will be reported to her via phone or mail, she stated, "I wouldn't know how the reports will come in, it's not my duty." The sterilization process was always done by the Registered Dental Assistant (RDA) on duty once or sometimes twice per week according to her. She explained how she categorized the procedures performed on patients:
1. Category I (no blood)oral exams, denture placements, and fittings. Instruments used were mouth mirror and explorer. No periodontal exams or digging of gums. Majority of the time, there were no blood involved.
2. Category II (minimal blood)fillings, cleaning, cementing. Instruments used were restorative instruments, packing instruments, and instrument made out of metal. Blood was always involved.
3. Category III (moderate bleeding)extractions and periodontal maintenance. Instruments used were forceps, scalers, etc. Blood was always involved.
The Dentist became aware of the failed sterilization test on 4/26/13 when the OT posted a paper note on the autoclave machine. She also stated that the staff in the dental clinic never reported any results to her. She didn't know that the sterilization tests failed in February thru April 2013 when she provided dental services; in which 100 plus patients were exposed to bloodborne pathogens (blood contamination). She also added, "I trusted the VA (Veterans Administration) that they're doing their job, looking at results and maintaining their equipment. Reading the result was not my duty." She indicated that she didn't have any policies and procedures for infection control and sterilization of dental instruments in the dental clinic of the ACC.
On 5/6/13 at 12:34 p.m., an interview with the RDA was conducted. The RDA was employed by the facility as a contracted worker, who reported directly to the contracted Dentist. He stated that he was responsible for autoclaving or sterilizing the dental instruments after use. According to him, the dirty dental instruments will be placed inside the ultrasonic bath machine for 10 to 15 minutes to be washed. Once washed and dried, the instruments will be individually packaged in a plastic container prior to placing it inside the autoclave machine. The packaged dental instrument will be placed inside the autoclave machine along with a sterilization test strip inside a plastic container. The plastic container had a pink dot outside the plastic, as an indicator that the dental instrument was sterilized. He stated, "The color of the dot is pink, when the machine is done, the color will change to a dark color indicating that it is done (sterilization process completed), but not necessarily indicating it passed or failed for bacteria testing." The sterilization test strip inside a plastic container will be removed, placed inside an envelope, and mailed to SMS by the RDA for testing.
The RDA mentioned that he conducted random checks when the autoclave machine was running. He didn't keep track of the machine's temperature and/or maintained any logs of the sterilization process of the autoclave machine. He was not aware of who's responsible for reading the results, whether passed or failed, and stated that he doesn't read the sterilization report when it comes back from SMS. When he was asked, "How did you know that the dental instruments were safe to use?" He stated, "Because I sterilized the instruments, that's my duty."He also stated that he never looked at the SMS results log book located in the dental clinic, stating, "It's not my duty to read it. The results are addressed to the homes. Nobody in the dental clinic had provided the results." He further explained that there were no steps, procedures, or manufacturer's recommendation on how to perform the autoclaving process in the dental clinic, stating, "I learned it (autoclaving) from school. The machine was pre programmed."
On 5/6/13 at 2:05 p.m., an interview with Resident 1 was conducted. According to him, the CMO spoke to him about his positive test result of HIV. He also stated, "I was surprised, I didn't expect to become positive." He stated that he gave wrong information to the HMO when he initially told him that he had an unprotected sex in November 2012. He further stated, "I had a funny feeling in October, in my mind that I had caught something. I asked the mobile doctor to draw blood for HIV and also told him to let me know. The doctor said, "If I don't call you, you're ok." Resident never heard from the doctor and was not aware of any results. He expressed his feelings of anxiety after learning the results from the CMO. He stated that he had lost interest in painting portraits.
On 5/6/13 at 2:50 pm., a review of the "Work Order Request" for the autoclave machine dated 4/5/13 was conducted. The review indicated that there was a work order generated due to a leaking problem of the autoclave machine. The work order did not indicate who made the request and/or any completion date when it was generated. There were no other documents found to indicate that the problem was resolved or completed.
On 5/6/13 at 3:40 p.m., an interview with the Stationary Engineer of Plant Operations was conducted. The Stationary Engineer of Plant Operations was employed as a full time employee of the facility who was responsible for operating, maintaining, inspecting and repairing mechanical, electrical, electronic, and manufacturing systems. He stated that [contracted company's name] was the contracted company responsible for maintaining the autoclave machine in the dental clinic. According to him, on 4/5/13 the autoclave was leaking. He was not certified to repair the autoclave machine, so he decided to call three vendors to get a bid for the repair on 4/8/13, although the facility already had a contract in place. On 4/18/13, [contracted company's name] repaired the gasket of the leaking autoclave machine. On the following day (4/19/13), the autoclave machine was noted to be leaking again. On 4/22/13, [contracted company's name] came back and checked the machine. The technician wanted to take the machine with him to be repaired, but he did not allow it, according to the Stationary Engineer.
The [contracted company's name] did not provide any documentation when they diagnosed and/or attempted to repair the autoclave machine on 4/18/13 and 4/22/13. The Stationary engineer stated, "I don't normally ask for documentation." When he was asked, "How did you know that they checked the machine?" He stated, "Most of the time, we just relied on them, when they tagged the machine, that it was inspected and it passed."
There were no documented evidence found that the autoclave machine was repaired when it was discovered leaking on 4/5/13. During the period of 4/5/13 thru 4/26/13, the dental clinic continued to provide dental services. There were 87 patients identified to have dental procedures done when the autoclave machine was not in a proper operating condition. The autoclaving of dental instruments continued (as evidenced by the date test received by SMS for 4/11/13, 4/22/13, and 4/26/13), knowing that the autoclave machine was not in proper operating condition.
On 5/6/13 at 4 p.m., a review of the "STANDARD AGREEMENT" signed on 5/21/12 between the facility and the contracted company responsible for maintaining the autoclave machine in the dental clinic was conducted. The review indicated that the contract was valid from 7/1/12 thru 6/30/15. The contracted provider agreed to provide an annual medical equipment certification and repair services. The review also indicated, "SCOPE OF WORK...7. Unscheduled Repair Service: Contractor shall provide unlimited visits for any repair services requested or necessary to keep the equipment fully operational...Contractor shall make every attempt to complete repairs the same working day...8. Emergency Repair Service:...Contractor shall respond to requests for emergency repair within eight (8) hours of telephone notification by the Contract Manager...9. Loan Equipment: For approved repair(s) lasting more than five working days, the State reserves the right to require the Contractor to provide loan equipment, as available...14. Documentation Requirements: After completion of service, the Contractor shall submit a complete report to the Contract Manager of the services provided, including necessary repairs. Reports shall include: a) Date of Service, b) Description of services provided, c) name and signature of service technician, d) Location of equipment, e) Equipment make, model, and serial number, f) Description of any noted deficiencies and suggestive corrective action, g) Total labor hours expended, h) Signature of State employee certifying indicated services were performed."
On 5/6/13 at 4:15 p.m., a review of the facility's Policy and Procedure (P&P) titled "Biomedical Equipment maintenance" with a revision date of 9/20/12 was conducted. The review indicated, "PROCEDURES: 1. CONTRACTOR QUALIFICATIONS AND RESPONSIBILITIESA. Medical equipment used in the facility must be inspected per the manufacturer's recommendation for safety, operational performance, and preventive maintenance....B...1. Contractor shall respond to requests for service within 48 hours or 8 hours if an emergency...5. When a piece of equipment is not functional and is required for the health and safety of the resident, a loaner will be obtained (if available) until item has been repaired...II. STAFF RESPONSIBILITIESA. Equipment failuresDefective equipment shall be removed from its designated area. 1. An equipment tag will be completed to include sanitation and repair."
On 5/7/13 at 9:50 a.m., a review of the facility's P&P titled "Infection Prevention and Control Surveillance" with a review date of 7/18/12 was conducted. The review indicated, "POLICY STATEMENT: It is the policy of the Home to have systems in place to conduct Infection Prevention and Control surveillance activities as an integral component of the Infection Prevention and Control Program...THE PROCESS OF SURVEILLANCE:...B. Process Surveillancereviews staff practices directly related to resident care in order to identify whether the practices comply with established Home prevention control procedures and policies...SCOPE OF SURVEILLANCE: A. infection Control surveillance shall be done in all areas of the Home... "
There were no P&P found regarding Infection Control practices in dental services and P&P on reporting of sterilization test and sterilization of dental instruments.
On 5/7/13 at 10:46 a.m., another interview with the CMO was conducted. The CMO provided an update of the laboratory results on the residents who gave consents to be tested for HIV, Hepatitis B and C. According to him, Resident 1's Polymerase Chain Reaction (PCR) came back negative and that there was no virus found in the blood. He stated that he was still waiting for the Western Blot result at this time. Resident 2's Western Blot test came back negative on 5/6/13. The initial result, he stated was a false positive. One resident's (Resident 3) test result for Hepatitis C collected on 5/2/13 came back positive. He further stated that a PCR test was still pending to confirm the initial finding. There were no other residents identified to have positive results on the laboratory tests ordered by the CMO. At 11:15 a.m., the CMO presented the Western Blot test for Resident 1. He stated that the test result was indeterminate and inconclusive for HIV.
On 5/7/13 at 11:30 a.m., a review of Resident 1's clinical record was conducted. The review indicated that he's a 79 year old male who was admitted in the facility on 1/31/13 with diagnoses that included cardiovascular accident, coronary arterial disease, depressive disorder, hyperlipidemia, and benign prostate hypertrophy. He scored 30 out of 30 on his Mini Mental State Examination conducted on 2/1/13, which indicated that he was alert and responsive. The Minimum Data Set assessment done on 2/20/13 indicated that he had no cognitive impairment and was able to make decisions for himself. There was no documented evidence found in the clinical record suggesting that Resident 1 had a history of HIV.
Resident 1's laboratory test for Hepatitis B and C collected on 5/2/13 indicated a negative result for the viruses. The HIV 1 and HIV 2 test collected on the same date indicated that he was reactive (HIV antibodies found in blood) to the virus. The Western Blot test collected on 5/2/13 indicated a result of "Indeterminate". The interpretation of the test result was, "INCONCLUSIVE for HIV I antibodies, possibly infected." On 5/4/13, a blood sample was collected to test Resident 1's blood for a Quantitative Real Time Polymerase Chain Reaction (technique to identify with high probability, disease causing viruses and/or bacteria). The result indicated, "Not Detected".
On 5/7/13 at 1:05 p.m., another interview with Resident 1 was conducted. According to the resident, the CMO told him that another test came back and he didn't have the any virus. He stated that he felt good about it, "It reduced my anxiety and I will be able to paint again."
On 5/7/13 at 1:20 p.m., another interview with the RDA was conducted to clarify the wait time for the result before using the dental equipment. He stated that they don ' t wait for the sterilization test results. He confirmed that he used the dental equipment he sterilized without waiting or knowing the sterilization test results. |
| 170001867 |
VETERANS HOME OF CALIFORNIA - BARSTOW |
170010545 |
B |
21-Apr-14 |
522D11 |
10616 |
F 333 - 483.25 (m) (2) Residents are free of any significant medication errors.The facility failed to protect Patient 1 from injury when Patient 1 received medications from a licensed nurse who failed to check Patient 1's identification prior to administering Patient 2's medications to Patient 1. The facility failed to ensure licensed nurses followed medication administration policy and procedures to prevent medication errors from occurring. Patient 1 required hospitalization for accidental drug overdose, hypotension (low blood pressure), bradycardia (heart rate under 60 beats per minute), dehydration (when you use or lose more fluid than you take in and your body doesn't have enough water and other fluids to carry out normal function), hypoxemia (an abnormally low level of oxygen in the body), and acute-on-chronic renal failure (a rapidly progressive impairment of kidney function that results in fluid and electrolyte derangement and retention of normally excreted substances in the blood). A closed record review was conducted for Patient 1 on 2/26/14. Patient 1 was an 89-year-old male admitted to the facility on 7/21/10. Patient 1's diagnoses included diabetes, hypertension, dementia, with history of prostatic and bladder malignancy. The Physician orders for Patient 1's morning medications included Aricept 23 mg (a medication used to treat mild to moderate Alzheimer's Disease), Lisinopril 2.5 mg (a medication used to lower the blood pressure), Furosemide 20 mg (a potent diuretic which, if given in excessive amounts, can lead to a profound diuresis with water and electrolyte depletion), Klor-con 10 meq tablet (a medication used to prevent and correct potassium deficiency), Prilosec DR 20 mg (a medication used to treat heartburn and symptoms of gastroesophageal reflux disease), Glipizide 5 mg (a diabetes medicine that helps control blood sugar levels), Metformin HCL 500 mg (a diabetes medicine that helps control blood sugar levels), Armour Thyroid 60 mg (a thyroid hormone replacement medication), and Vitamin D 1,000 units tablet (a medication used to reduce elevated parathyroid hormone).A concurrent interview was conducted with the Director of Nurses (DON) and Standards Compliance Coordinator (SCC) on 2/27/14 at 10 a.m. The DON stated the facility had a medication error involving LVN 1 and Patient 1. The DON stated LVN 1 gave Patient 1 medications intended for Patient 2. The DON stated Patient 1 received both, his morning meds along with Patient 2's 8 a.m. medications. The DON stated Patient 1 experience a decline in condition and had to be sent out to the hospital as a result of the medication error. The Standards Compliance Coordinator stated the medication error occurred on 7/17/13, and it involved a registry nurse (LVN 1). The Standards Compliance Coordinator stated LVN 1 admitted to not following procedures for identifying the residents prior to giving the medications.The facility's policy and procedure titled, "Administering Medications," dated December 2012, was reviewed on 2/27/14. The policy indicated, "The individual administering medications must verify the resident's identity before giving the resident his/her medications. Methods of identifying the resident include: a. Checking identification band; b. Checking photograph attached to medical record; and c. If necessary, verifying resident identification with another facility personnel..." The electronic Progress Notes indicated that on 7/17/13, a medication error occurred during the 8 a.m. medication pass when Patient 1 was given medications that had been prescribed to another patient (Patient 2). Patient 1 received his 8 a.m. medications along with Patient 2's 8 a.m. medication. Patient 1 received ten additional medications in error that had not been prescribed to him by the physician. The medications given in error included:1.Furosemide 40 mg, Patient 1 had already received Furosemide 20 mg as ordered by his physician and with the additional 40 mg given in error, for a total 60 mg of Furosemide. 2. Aspirin 81 mg3. Diltiazem 180 mg (a calcium channel blockers, which works by relaxing the muscles of your heart and blood vessels). 4. Glipizide 5 mg (an oral diabetes medicine that helps control blood sugar levels). Patient 1 had already received Glipizide 5 mg as ordered by his physician and with the additional 5 mg given in error, for a total of Glipizide10 mg.5.Allopurinol 100 mg (reduces the production of uric acid in your body). 6.Mucinex ER 600 mg (an expectorant that helps loosen congestion in your chest and throat). 7. Metoprolol 50 mg (a beta-blocker that affects the heart). 8. Isosorbide 30 mg (which widens blood vessels, making it easier for blood to flow through and easier for the heart to pump). 9. Ferrous Sulfate 325 mg (a type of iron).10.Docusate Sodium 250 mg (a stool softener). The Progress Notes dated 7/17/13 at 11:21 a.m., indicated, "Med error by assigned nurse." The progress notes further indicated that the physician had been notified and orders were given to continue vital signs every 30 minutes for 24 hours, and to send resident to emergency department if there was a significant change in mental status and in vital signs if systolic below 98, diastolic below 55, pulse below 50.Progress Notes indicated first set of vitals taken at 10 a.m. were: blood pressure 132/60, pulse 73, and at 10:45 a.m. blood pressure was 118/58 and Pulse 75.At 7 p.m., Patient 1's blood pressure was 79/40 and pulse 43. Patient 1 was not taken to the hospital for treatment for an additional six hours, at 1 a.m., when his pulse dropped to 33. Progress Notes, dated 7/18/13 indicated Patient 1 was sent to the hospital at 1 a.m. for evaluation and treatment due to hypotension (low blood pressure), bradycardia (low heart rate), and irregular pulse. The hospital records were reviewed on 2/26/14. Patient 1 was hospitalized for two days in the intensive care unit. The hospital History and Physical indicated Patient 1 had, "Acute on chronic renal failure." The hospital Physician Discharge Orders, dated 7/20/13 at 1 p.m. indicated Patient 1 was treated for an accidental drug overdose, hypotension, bradycardia, dehydration, hypoxemia, acute on chronic renal failure. According to Best Practice Journal 46 (2012): 10-15. Print, "Acute-on-Chronic Kidney Disease: prevention, diagnosis, management and referral in primary care." "It is also being recognized that even small impairments to renal function, changes too small to be recognized as organ failure, have a significant effect on patient morbidity and mortality...A reduction in blood flow to the kidney is the most common cause of acute kidney injury...Acute kidney injury should be considered a medical emergency..." Progress Notes dated 7/20/13 at 10:10 p.m., indicated Patient 1 was readmitted to the facility at 7:40 p.m. The progress notes indicated, "He is very weak and is unable to stand on his own. He needs total assistance for care. He was admitted with pull-ups on and wanted them taken off. This writer instructed him that we wanted to leave them on for a few days to see how he is doing...He needed to have the paramedic assist him in turning to sit on the recliner. He was unable to get out of the recliner on his own. When taken to the bathroom, he was unable to transfer from w/c (wheelchair) to toilet on his own. When he had to stand up for his body assessment, he was very weak and not able to hold on to the handrail...He cannot dress himself, unable to hold his arm up to put his shirt on..." The electronic Progress Notes dated 7/21/13 and 7/22/13 indicated that Patient 1 needed extensive assistance due to weakness and was unstable on his feet.Electronic Progress Notes dated 7/23/13 at 9:27 a.m., indicated Patient 1 continues to be very unsteady on his feet and remained at risk for falls. Resident was placed on one to one assist as he fell on 7/23/13 at 2:40 a.m. Patient 1 sustained a laceration to mid posterior side of his head. Patient 1's Minimum Data Set (MDS)(an assessment tool), with an assessment reference date of 4/23/13 was reviewed. The area of functional status of the MDS indicated that on 4/23/13, Patient 1 was independent on all activities of daily living and that Patient 1 was independent and required no help or physical assistance from staff for bed mobility, transfer, walking in room, walking in corridor, locomotion on and off unit, dressing, eating, toilet use, personal hygiene, and bathing. Patient 1's MDS, dated 7/29/13, indicated under ADL-Functional status, that Patient 1 had a recent hospitalization and had generalized weakness impacting his functional abilities and balance.The MDS, dated 7/29/13, indicated under Indicators for Fall Risk, "Resident with acute illness resulting in his instability impacting his increase risk for falls...Resident has balance issues with standing up, transferring, turning around and walking. He had incident and is on 1:1 CNA for fall. Resident with generalized weakness post-acute care and was started on ABT (antibiotic) for a UTI (urinary tract infection), all these factors impacting his balance issues." LVN 1 stated during an interview on 7/22/13 at 11 a.m., that she went straight to work on the floor after she received her assignment by the RN. The LVN stated she was never given the facility's med pass policy and procedure and was not aware of the facility's medication pass procedure prior to the incident. LVN 1 stated Patient 1 was in the same room as Patient 2. LVN 1 stated she was told by the RN to give Patient 2 his medication. LVN 1 stated she thought Patient 1 was Patient 2 and she gave Patient 1 medications intended for Patient 2. LVN 1 stated she did not ask Patient 1 what his name was and did not check the resident's name badge. The LVN further stated pictures of the residents were supposed to be part of the resident's MAR (Medication Administration Record), but there was no picture of Patient 2 in the MAR, and Patient 1 did not have a name badge on. LVN 1 stated as a registry nurse she was not given access to the computerized MAR being used by the facility nurses. RN 1 had already given Patient 1 his 8 a.m. medications and it was documented on the computerized MAR, but LVN 1 did not have access to that. LVN 1 stated she realized she gave medications to the wrong patient around 10 a.m., when Patient 1 walked by the medication cart and RN 1 identified Patient 1. LVN 1 stated she immediately reported the medication error to RN 1 and took Patient 1's vitals.The above violation had a direct or immediate relationship to the health, safety,or security of patients. |
| 630013558 |
VETERANS HOME OF CALIFORNIA - WEST LOS ANGELES |
170010638 |
B |
12-May-14 |
PKSQ11 |
4484 |
The facility did not comply with the above regulation when it failed to ensure that Resident A was properly assessed to safely drive a new motorized scooter. This failure resulted in a scooter accident in which Resident A suffered a cervical (neck) fracture and a hip fracture. A facility self- reported incident was investigated on 4/14/14 involving Resident A who sustained fractures when her motorized scooter overturned in the facility. Review of Resident A's clinical record on 4/14/14 revealed that Resident A was a 99 year old female admitted to the facility on 8/19/13, with diagnoses which included Congestive Heart Failure and Osteoarthritis. Further review showed Resident A was sent out by ambulance on 4/5/14 at 5:25 PM after she fell off her motorized scooter. Registered Nurse 1 (RN 1) stated in an interview on 4/14/14 at 11:40 AM, that she (RN 1) had found Resident A tipped over with her scooter. RN 1 stated that the incident was unwitnessed. She stated that since Resident A's return from the hospital she was not interviewable at times due to her routine pain medications. On 4/14/14 at 10:45 AM, an unsuccessful interview with Resident A was attempted.Certified Nursing Assistant 1 (CNA 1) stated during an interview on 4/14/14 at 11:00 AM that before the scooter accident, Resident A was alert, oriented, and attended many daily activities off the unit. CNA 1 stated that Resident A ambulated without assistance and independently drove her motorized wheelchair.RN 2 stated during an interview on 4/14/14 at 11:20 AM that Resident A's motorized wheelchair had broken and that Resident A received a new motorized scooter on 4/ 3/14.During a concurrent interview with the facility Physical Therapist (PT) and the Occupational Therapist (OT) on 4/14/14 at 11:45 AM, the OT stated that Resident A originally had a motorized wheelchair and that it had been altered by the facility to go slower for safety reasons because Resident A tended to drive it too fast. The OT stated that after her wheelchair had broken, Resident A was referred to an outside hospital where she was evaluated and deemed safe to be given a "Go Go" scooter. The OT stated that the Go Go scooter is one of the fastest scooters available.The PT and OT stated that they had not evaluated Resident A's ability to control the new Go Go scooter after she had received it on 4/3/14. Resident A's scooter accident with injuries occurred on 4/5/14. They stated that the outside Hospital did the evaluations and patient teaching with the resident, and then sent Resident A back to their facility with her new scooter. On 4/14/14 at 11:55 AM, in the presence of both the PT and the OT, Resident A's old motorized wheelchair and her new motorized scooter were observed. The following differences were noted: The old wheelchair had a single joystick type acceleration control that could be used with one hand, it hand four wheels The new scooter had dual utilized thumb controls; left thumb for reverse and right thumb for front acceleration, it had three wheels. Review of Resident A's Interdisciplinary Progress Note (IDN) dated "4/9/14" (four days after her scooter accident) documented the following nursing entry: "...a new 3-wheel scooter was given to [Resident A] by [outside hospital's name] the scooter is a high speed scooter; [Resident A] has always had a very low speed wheelchair. The three wheel scooter with high speed given to [Resident A] is not suitable for her, considering the fact that she is always speeding when powering her wheelchair..."Review of Resident A's medical record failed to show a documented Plan of Care for safety regarding the motorized scooter before Resident A's fall on 4/5/14.A review of a physician's note revealed Resident A was readmitted to the facility on 4/8/14, from the hospital with diagnoses which included a "minimally Displaced C2 [bone in the neck] fracture...and...left Acetabular [hip] Fracture." The Standards Compliance Coordinator (SCC) stated during interview on 4/14/14 at 1:05 PM, that the facility did not currently have a policy and procedure on electric scooter/wheelchair safety, however one was being drafted. The Policy and Procedure titled, "Accident Prevention", dated 9/18/13 showed that the facility will routinely assess each residents risk for accidents and implement preventative measures to decrease risks of an accident. The above violation had a direct or immediate relationship to the health, safety, or security of residents. |
| 220001018 |
VALLEY HOUSE REHABILITATION CENTER |
220012393 |
B |
15-Jul-16 |
H7LN11 |
2356 |
F226, 483.13(c) DEVELOP/IMPLEMENT ABUSE/NEGLECT, ETC POLICIES The facility must develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. Review of Resident 21's Minimum Data Set (MDS, an assessment tool), dated 5/18/16, indicated the resident had impaired cognition. Review of Resident 35's MDS, dated 4/12/16, indicated the resident had impaired cognition. Review of Resident 21's Interdisciplinary team (IDT, staff members from different departments who coordinate a resident's care) Post Fall Assessment, dated 1/26/16, indicated Resident 35 intentionally pushed Resident 21 off her chair and Resident 21 should not have fallen from her chair. During an interview with licensed vocational nurse F (LVN F) on 6/29/16 at 4:15 p.m., LVN F stated he witnessed Resident 21 sitting on a chair next to Resident 35, and Resident 35 pushing Resident 21 off her chair causing her to fall on the floor. During an interview with the director of nursing (DON) on 6/29/16 at 4:45 p.m., she stated the incident between Residents 21 and 35, should have been investigated and reported. During an interview with the administrator (ADM), on 6/29/16 at 1:40 p.m., he stated the incident involving Residents 21 and 35 was not investigated and reported to the ombudsman or the California Department of Public Health (CDPH). He stated the incident should have been investigated and reported. Review of the facility's 8/2011 policy, "Abuse Prevention And Reporting of Alleged Abuse and Suspicion of Crime", indicated complaints, observation, suspicions, or reporting of incidents, falls, bruises, and skin tears will be investigated to rule out abuse. All mandated reporters are required by law to report incidents of known or suspected abuse in two days by telephone immediately or as soon as practically possible to the local ombudsman or the local law enforcement agency and by written report using the Department of Social Services Form (SOC 341) within two working days. Therefore, the facility failed to ensure staff members followed the facility abuse policy to notify the ombudsman or the California Department of Public Health (CDPH) of the allegation of abuse. This violation had a direct or immediate relationship to the health, safety, or security of the residents. |
| 230000504 |
Vibra Hospital of Northern California D/P SNF |
230009273 |
B |
17-May-12 |
GBXP11 |
3522 |
F 0323 - 483.25(h) Free of Accident Hazards/supervision/devices - G The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. Based on interview and record review, the facility failed to prevent an avoidable fall with injury when one of two sampled residents (Resident 1) was left alone and unsupervised in the bathroom. This failure resulted in Resident 1 falling and sustaining a broken right leg, skin tear, and pain. Findings: Resident 1 was admitted on 3/11/12 with diagnoses that included rehabilitation following rectal surgery and dementia. The Minimum Data Set (MDS, an assessment tool), dated 3/18/12, reflected that Resident 1 was severely cognitively impaired and required physical assistance with toilet use, transferring, and walking.During an interview with Administrative (Admin) Nurse A on 4/4/12 at 10:15 am, she reported that Resident 1 had been assisted into the bathroom by Certified Nursing Assistant B (CNA) on 3/22/12 at approximately 2:45 pm. Resident 1 requested that CNA B give her some privacy and so after situating Resident 1 on the toilet, CNA B closed the bathroom door, leaving it ajar so that she could monitor Resident 1. While Resident 1 was on the toilet, CNA B responded to another resident who had cried out for assistance. CNA B went to assist the other resident during which time another staff member found Resident 1 on the floor. Resident 1 complained of right hip and leg pain and had a skin tear on her right elbow.During an interview with Resident 1 on 4/4/12 at 10:30 am, she was unable to recall the event but did report that her pain is being controlled following breaking her leg.Resident 1's Fall Care Plan, initiated on 3/11/12, indicated that Resident 1 had the potential to fall and/or sustain an injury due to gait (walking ability) and/or balance problems, weakness, cognitive impairment and poor safety awareness. The care plan indicated that Resident 1 was considered a high fall risk, and therefore, would be identified as a high risk by wearing a yellow armband.During an interview with CNA B on 4/4/12 at 5:30 pm, she reported that she was assisting Resident 1 into the bathroom on 3/22/12. Resident 1 was wearing a yellow arm band, which indicated she was a high fall risk. CNA B explained that after she got Resident 1 onto the toilet, she requested some privacy. CNA B stated that she closed the bathroom door, but kept it cracked so that she would be available as needed. CNA B stated at this time, the resident next door started yelling out for assistance and she left Resident 1 unsupervised to respond to what CNA B explained as an urgent call for assistance. CNA B reported that she had been out of visual contact with Resident 1 for less than 5-minutes when she heard another staff member yell for assistance. That staff member had found Resident 1 on the floor. Resident 1 sustained a skin tear on her elbow and was complaining of pain in the right leg. CNA B reported that Resident 1 was transferred to the hospital after an x-ray showed that she had fractured her leg. CNA B acknowledged that she should have never left Resident 1 unsupervised.During a review of the facility's policy and procedure, titled, "Fall Program, TCU" revised 3/12, read, "High Risk Fall Precautions; place a yellow armband to identify as high fall risk... Maintain visual observation when resident is in the bathroom or shower..." |
| 240000152 |
Valley Healthcare Center |
240008920 |
B |
18-Jan-12 |
BPWU11 |
15376 |
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. And72311 (a) Nursing Service shall include, but not be limited to, the following: (3) Notifying the attending physician promptly of: (B) Any sudden and/or marked adverse change in signs, symptoms, or behavior exhibited by the patient.The facility staff failed to implement their policy by failing to notify the charge nurse of Patient A's fall prior to moving the patient from the floor. On September 23, 2010, Patient A had an assisted fall to the floor and sustained an injury to her left ankle. The facility failed to promptly notify the physician of the patient's continued pain and swelling of her left ankle, following the completion of the treatment on September 26, 2010. Patient A fell on the morning of September 23, 2010 while being assisted by her assigned Certified Nursing Assistant (CNA). The CNA did not report the incident to the charge nurse and Patient A was not assessed for injuries prior to movement of the patient, as stipulated in the facility's policy. On September 23, 2010 at 1:00 PM, Patient A complained of leg pain to the charge nurse. The patient was assessed and new orders were received from the physician for treatment of the patient's injury.However, there was no documentation in the medical record that the patient's injury was assessed and that the physician was notified of continued swelling, bruising and severe pain to the left ankle following the completion of the treatment on September 26, 2010.On September 30, 2010 at 1:00 PM, Patient A's left ankle was observed to be "very swollen" with visible bruising (more than it was on September 26, 2010); the physician was notified. Repeat x- rays showed a fracture (broken bone) to the left ankle.On September 29, 2010, Patient A's medical record was reviewed. Patient A was admitted to the facility on March 24, 2005, with diagnoses that included cerebral vascular accident (CVA or a stroke, is a sudden loss of consciousness resulting when the rupture or blockage of a blood vessel leads to lack of oxygen in the brain) and hemiplegia (the inability to move a group of muscles in one side of the body).The Minimum Data Set (MDS is a comprehensive assessment of the patient) completed on July 2, 2010 indicated that the patient had no memory problems and had modified independence in cognitive skills for daily decision making. The patient required extensive physical assist for transfers and toileting.A review of the licensed nurses progress notes (LNPN) dated September 13, 2010 at 1:00 PM indicated that Patient A reported to the licensed nurse that her left leg was hurting. When asked what happened, the patient stated that CNA 1 had hurt her leg when she went to the floor. The left leg was assessed for injury; there was no swelling or bruising but the patient complained of pain to the left leg. A review of the LNPN dated September 13, 2010 at 1:20 PM, indicated that the charge nurse asked CNA 1 about Patient A's injury. CNA 1 responded that after he assisted the patient to the toilet, he left the patient sitting in the shower chair next to the bed and the transfer pole (a pole that is stationary by the bed that the patient hold on to for support while transferring in and out of bed) and went into the bathroom to get something for the patient. CNA 1 observed the patient as she stood up and lost her balance. CNA 1 caught the patient and assisted her to the floor. The physician was notified and X-rays were ordered due to complaint of increased pain to the left leg. A review of the facility policy titled, "Accidents/Incidents," undated, stipulated, "......Should an employee witness an accident, or find it necessary to aid an accident victim, the employee should: a. Render immediate assistance. Do not move the victim until he/she has been examined for possible injuries. b. Summon the charge nurse to evaluate and determine if the individual is to be moved. If assistance is needed, summon help. If the victim cannot be left alone, ask someone to report to the nurses' station that help is needed, or if possible, use the call system located in the resident's room to summon help...."A review of the LNPN dated September 24, 2010 at 6:00 AM, indicated that the X-ray results revealed no fractures. Patient A continued to complain of pain to the left leg, knee and ankle. A review of the LNPN dated September 24, 2010 at 10:00 AM, indicated that Patient A's left ankle was swollen and bruised. Orders were received for icepacks four times daily for 3 days and bed rest (the patient to stay in bed) with the left ankle elevated (up) for 3 days. A review of the LNPN dated September 24, 2010 at 8:00 PM, indicated that Patient A complained of left ankle pain and that the ankle was swollen. A review of the LNPN dated September 25, 2010 at 7:00 AM, indicated that the left ankle was swollen and that the patient was medicated for pain. A review of the LNPN dated September 25, 2010 at 4:00 PM, indicated that an ice pack was placed on the left ankle for complaints of pain and medication was given as ordered. A review of the LNPN dated September 25, 2010 at 10 PM, indicated that an ice pack was placed on the left ankle and that the patient verbalized relief. A review of the LNPN dated September 26, 2010 at 6:00 AM, indicated that the left ankle had minimal swelling and discoloration and that an ice pack was applied. The patient complained of pain, which was relieved with pain medication. A review of the LNPN dated September 26, 2010 at 6:00 PM, indicated that the patient complained of moderate left pain that was relieved with medication.A review of the LNPN failed to show documented evidence of an assessment after September 26, 2010 at 6:00 PM until September 30, 2010 at 1:00 PM. There was no documentation in the medical record that the physician was notified after the completion of the three days of ordered treatment that the patient's left ankle was still swollen, bruised and that the patient continued to complain of severe pain to the left ankle. There was no documentation in the medical record on September 27, September 28 or September 29, 2010 regarding the status of Patient A's left ankle.Documentation dated September 30, 2010 at 1:00 PM, indicated that the physician was notified that Patient A's left ankle was still swollen and bruised; orders were received to repeat X-rays to the left ankle. A review of the X-ray results dated September 30, 2010 indicated that Patient A had fractures to the distal (away from the body) tibia and fibular bones (ankle fracture). A review of the physician telephone orders dated September 23, 2010 included the following: "X-ray of the left leg, left knee, left tibia, left ankle and left foot due to increase pain. To be done STAT (immediately) today." A review of the physician orders recapitulated (summarized) September 2010, included the following: "8/4/08, Restorative Nursing Aide (RNA) to do standing in the parallel bars daily 5 x a week. 9/30/09, Vicodin (a narcotic pain medication) 5/500 milligrams (5 mg of hydrocodone and 500 mg of acetaminophen) 1 tablet by mouth (PO) every (Q) 4 hours as needed (PRN) for severe pain. Not to exceed 4 grams of acetaminophen in 24 hours. 8/2/10, Motrin 800 mg PO Q 6 hours PRN for pain." A review of the physician telephone orders dated September 24, 2010 included the following: "Elevate left leg while in bed." "Apply ice packs QID (4 times daily) for 3 days." "Bed rest for 3 days due to increased pain and swelling." A review of the physician telephone orders dated 9/30/10 included the following: "X-ray of left ankle to be done today (recheck) due to increased swelling and bruising." "Send patient out to acute care emergency for evaluation of left foot fracture." "Follow up with Orthopedic (specialized in bone and tissue injuries) consultant." "Left splint (a support) to the left foot."A review of the Medication Administration Record (MAR) indicated that Patient A was administered Vicodin (a narcotic pain medication) 5/500 milligrams (mg), one tablet, for severe pain beginning with one dose on September 23, 2010, September 25, 2010, September 27, 2010, September 29, 2010 and September 30, 2010 and 2 doses on September 26, 2010. There was no documentation on the MAR for the month of September 2010 indicating that Patient A was administered the as needed Vicodin prior to September 23, 2010 fall. On September 29, 2011 at approximately 2:05 PM, an interview was conducted with the Director of Nursing (DON) and Patient A's medical record was reviewed. The DON was not employed at the facility at the time of the incident. The DON responded that the patient's incident was considered a fall and that the CNA should have reported the incident right away in order for the charge nurse to evaluate the patient for injuries, before the patient was moved from the floor, as stipulated in the policy. The DON stated that she could not respond as to why documentation regarding Patient A's left ankle stopped on September 26, 2010 at 6:00 PM, even though Patient A continued to experience left ankle pain and swelling. The DON stated that the staff usually monitors and documents for 72 hours after a fall. The DON was asked what happened after 72 hours of monitoring if the problem was not resolved and the treatment was ordered for only 3 days. The DON responded that the licensed nursing staff should have reassessed the patient's injury and reported the findings to the physician. The DON could not locate documentation in patient's medical record that the physician was notified after the treatment was completed on September 26, 2010 that Patient A's left leg injury persisted.On October 3, 2011 at 12:05 PM, an interview was conducted with CNA 1; the CNA was assigned to provide care for the patient at the time of the incident on September 23, 2010. CNA 1 stated that he left Patient A sitting on the shower chair next to the transfer pole by her bed and went into the bathroom to get a wash cloth. As he came out of the bathroom, he observed the patient standing, holding on to the transfer pole as she was losing her balance. He rushed over and caught the patient before she fell. He supported the patient, slid her to the floor and called for help. CNA 2 assisted him in putting the patient on the bed. The patient then requested to get up into the wheel chair and CNA 1 and CNA 2 assisted the patient into the wheel chair. CNA 1 acknowledged that he did not report the incident to the charge nurse because he was not aware that the incident was considered a fall. On October 5, 2011 at 9:50 AM, an interview was conducted with Registered Nurse (RN) 1, the Day Supervisor. Patient A's LNPN dated September 23, 2010 to September 30, 2010 were reviewed. RN 1 confirmed that there was no documented evidence in the medical record between September 26, 2010 at 6:00 PM and September 30, 2010 at 1:00 PM indicating the status of Patient A's left ankle/leg or that the physician was notified after the treatment was completed on September 26, 2010, that the patient continued to experience severe pain, swelling and bruising to the left ankle. RN 1 stated that the facility usually monitored incidents for 72 hours, but if the problem continued, the patient should have been reassessed and the physician notified right away for new orders. RN 1 stated that she was not sure if there was a facility policy that provided that information. On October 5, 2011 at 9:58 AM, an interview was conducted with Licensed Vocational Nurse (LVN) 1, who was responsible for the supervision of Patient A's care on September 23, 2010; the date of the incident. LVN 1 stated that Patient A reported the incident to her on September 23, 2010 at 1:00 PM. CNA 1 did not report the incident when it occurred earlier that morning because CNA1 insisted that a fall did not occur; he slid the patient to the floor. LVN 1 stated that she assessed the patient and reported her findings to the physician. LVN 1 stated that the documentation on September 26, 2010 at 6:00 PM was the last time she had worked with Patient A until she returned to work on September 30, 2010.LVN 1 stated that when she returned to work on September 30, 2010, she observed that Patient A's left ankle was "very swollen with visible bruising" and that the patient was still complaining of severe pain to the left ankle. LVN 1 stated that she notified the physician and repeat X-rays were ordered. The X-rays results indicated that Patient A's left ankle was fractured (broken). LVN 1 stated that she did not know why Patient A's left ankle injury was not assessed and why the physician was not notified earlier. On October 5, 2011 at 10:50 AM, an interview was conducted with Restorative Nursing Aide (RNA) 1, who was assigned to provide therapy to Patient A on September 27, 28 and 29th (2010). RNA 1 stated that the patient refused therapy on all three days, which included standing and transferring using the transfer pole at the bedside from the bed to the shower chair. RNA 1 stated the patient complained that her leg was hurting. Documentation on the RNA flow sheet indicated that the patient refused treatment; however, there was no documentation of the reasons or that the charge nurse was notified. RNA 1 stated that she reported the patient's complaints of leg pain to the charge nurse at the time, but could not recall who the charge nurse was. RNA 1 stated that she was not aware of the patient's incident on September 23, 2010, or that the patient was on bed rest. On October 5, 2010 at 11:00 AM, an interview was conducted with RNA 2. RNA 2 stated that she provided treatment to Patient A on September 23, 24 and September 30, 2010. RNA 2 stated that the patient transferred in and out of the bed using the transfer pole to the shower chair. RNA 2 stated that she also assisted the patient with transfers to the bathroom as part of the therapy. A review was conducted of RNA 2 weekly summary dated September 28, 2010; it included, "...Resident also continues to do standing in parallel bars daily, 5 times a week with RNA. A belt is used for safety and support. Balance is fair. No complaint of pain." RNA 2 confirmed that she had documented the RNA weekly summary dated September 28, 2010. RNA 2 stated that she recalled that the patient was weaker than usual during therapy on September 30, 2010. RNA 2 stated that she was not aware of the incident on September 23, 2010 and was not notified that the patient was on bed rest or had restrictions On October 5, 2010 at 11:15 AM, an interview was conducted with the DON. The DON stated that she could not locate a policy specific to post fall assessment and reporting.The facility staff failed to follow the "Accidents/Incidents" policy and report Patient A's fall to the charge nurse at the time of the incident. Patient A was not assessed for possible injuries prior to being moved from the floor. In addition, the licensed nurses failed to continue to assess and report the status of Patient's A injured ankle to the physician.The violation of the above regulations had a direct relationship to the health, safety, or security of patients. |
| 240000152 |
Valley Healthcare Center |
240009055 |
B |
05-Mar-12 |
KDZ411 |
7158 |
REGULATION VIOLATION: Title 22 72319 Nursing Service-Restraints and Postural Supports and 72311 Nursing Service-General 72319 (k) "Postural support" means a method other than orthopedic braces used to assist patients to achieve proper body position and balance. Postural supports may only include soft ties, seat belts, spring release trays or cloth vests and shall only be used to improve a patient's mobility and independent functioning, to prevent the patient from falling out of a bed or chair, or for positioning, rather than to restrict movement. These methods shall not be considered restraints. (1) The use of postural support and the method of application shall be specified in the patient's care plan and approved in writing by the physician or other person lawfully authorized to provide care. AND 72311 (a) Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (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 ensure the physician's order for a non-release seat belt when Patient 1 was up in a wheelchair was implemented. This resulted in Patient 1 sustaining a fractured hip when Patient 1 got up from the wheelchair and attempted to walk. The facility failed to ensure the safety and prevent harm to Patient 1, by failing to review and update Patient 1's care plan to include use of a postural support (non-self release seat belt) that was ordered by the physician in writing. Review of Patient 1's medical record on August 16, 2010 showed that Patient 1 was an 88 year old female admitted to the facility on May 13, 2010, with diagnoses including dementia (a loss of brain function, such as, memory, thinking, language, judgment, and behavior, that occurs with certain diseases), abnormality of gait, muscle disuse atrophy (wasting away of a body part or tissue), and syncope (loss of consciousness caused by insufficient blood to the brain) and collapse.Patient 1's MDS (Minimum Data Set, a tool used to document an assessment done by the various care professionals providing care to the patient) with ARD (Assessment Reference Date) of May 21, 2010 showed Patient 1 had problems with short and long term memory and was severely impaired cognitively. Patient 1 required extensive to total assistance with all ADL (activities of daily living) except eating, where she was able to eat without assistance. Patient 1 could walk but with assistance only. Patient 1 was not able to move her wheelchair about without assistance. Patient 1 was incontinent of bowel and bladder requiring at least one person to assist Patient 1 to the toilet. Patient 1's physician ordered a non-self release safety belt while up in a wheelchair. The ordered was dated July 16, 2010 at 8:30 AM. There were no review or update of Patient 1's care plans to include the new treatment of non-self release seat belt for Patient 1's safety. Licensed Nurses Progress Notes showed that a note was documented on July 16, 2010 at 7:20 PM as follows: "...Resident was found on the floor by CNA. Resident [Patient 1] was sitting in her wheelchair when she took off her safety belt to walk. ...Resident [Patient 1] c/o (complained of) pain 6/10 (refers to a method of determining how much pain a person is having on a scale of 1 to 10 with 1 being lest pain ever suffered and 10 being the most pain ever suffered) to rt (right) hip, small abrasion on the rt side of her nose made from her glasses....". A physician's order dated July 16, 2010 at 8:30 PM was as follows, "X-ray right hip due to resident being found on floor." A Licensed Nurses Progress Notes dated July 17, 2010 at 1:00 PM, showed that a x-ray was received indicating that Patient 1 had sustained an acute right hip fracture. On August 16, 2010 at 4:40 PM, an interview was conducted with CNA 1. CNA 1 stated that on July 16, 2010, he was going to his lunch break when he saw, from the hallway, Patient 1 lying in the floor in front of her wheelchair. CNA 1 called the charge nurse and Patient 1 was assessed and assisted into bed. The Patient Transfer Record with a date of July 17, 2010, indicated that Patient 1 was transferred to the acute care hospital for a right hip fracture. Review of Patient 1's acute care hospital medical records on September 15, 2010 showed that Patient 1 was admitted to the acute care hospital on July 17, 2010 at 7:39 PM for an admitting diagnosis of a right hip fracture. The operative report dated July 18, 2010 showed that Patient 1 had the surgical procedure, "intramedullary rodding, right hip using DePuy short trochanteric nail" (surgical procedure to repair the fracture of the large thigh bone at the right hip joint). An interview was conducted with LVN 1 by telephone on September 13, 2010 at 11:20 AM. LVN 1 stated that she remembered when Patient 1 fell on July 16, 2010 at around 8:00 PM. LVN 1 stated that she clearly remembered the incident and that when she was called by CNA 1 to Patient 1's room, she found Patient 1 on the floor in front of her wheelchair. LVN 1 assessed Patient 1 and the patient was assisted into bed. LVN 1 stated that she clearly remembered that the seat belt on Patient 1's wheelchair was a self release safety belt with a button in the buckle that was pushed to release the safety belt, which lay in the patient's lap and attached to each side of the wheelchair. An interview was conducted with the facility's DON (Director of Nurses) on September 13, 2010 at 11:45 AM. During the interview, the DON stated that she had also confirmed with LVN 1 that the seat belt in use at the time of Patient 1's fall on July 16, 2010 at 7:20 PM was attached to the wheelchair on both sides with a self release buckle on the patient's mid-waist. The DON confirmed the physician's ordered dated July 16, 2010 at 8:30 AM was for a non-self release seat belt. The DON confirmed that the patient's care plan had not been reviewed and updated to include the treatment for safety with a non-self release seat belt. The DON stated that she knew she would get a deficiency for the wrong type of safety belt being used when Patient 1 got out of her wheelchair and fell with the resulting hip fracture. The DON confirmed that the facility had not updated or initiated a care plan for the new physician's order for a non-release seat-belt to be used when Patient 1 was up in a wheelchair for safety. The facility failed to ensure the safety and prevent injury to Patient 1, by failing to: 1. Review and update Patient 1's care plan to include use of a postural support (non-self-release seat belt) that was ordered by the physician in writing. 2. Follow the physician's order for a non-release seat belt when Patient 1 was up in a wheelchair, resulting in a fall with Patient 1 suffering a fractured hip. These facility failures had a direct or immediate relationship to the health, safety, or security of long-term health care patients or residents. |
| 240000047 |
Vista Cove Care Center At Rialto |
240009891 |
B |
15-May-13 |
K6MT11 |
21542 |
REGULATION VIOLATION: CFR 483.25 F309 Quality of Care Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. During an investigation of a complaint that began on October 25, 2011, it was determined that the facility staff failed to ensure Resident A was provided position changes and preventative skin care in accordance with Resident A's needs to maintain his highest practicable physical and mental well-being, which resulted in a scrotal injury requiring surgical intervention for Resident A. Record review showed Resident A was transferred to the acute care hospital from the skilled nursing facility (SNF 1) on October 10, 2011 at approximately 7:00 PM. The hospital emergency department (ED) admission records indicated that Resident A arrived at 7:24 PM, with a scrotal injury that was bleeding. Resident A was found at SNF 1 with "De-gloving (scrotal skin being sheared off, usually as a result of trauma) of both testes." The hospital admitting physician's history and physical note (H&P) dated October 10, 2011, indicated the following, "The patient was admitted to the hospital under the care of the internal medicine team with a diagnosis of scrotal avulsion (tearing away or separation of skin from scrotum) and suspicion of adult abuse and was taken to the operating room on the morning of October 11, 2011 for debridement (surgical removal of any damaged tissue) and closure of scrotal avulsion." A review of the ED triage assessment notes dated October 10, 2011 at 7:24 PM, indicated Resident A's pain scale rating was "9-10" (on a scale of 0 to 10, 0 = no pain, 10 = worst pain). Further review of the hospital records indicated Resident A was aphasic (a condition in which speech and language function is disordered because of a brain injury), and had limited movement in upper extremities (arms and hands), and as a result, Resident A was bed bound. A progress note dated October 17, 2011 at 4:30 AM, showed documentation that indicated the resident's upper arms/hands and lower legs were contracted on the right and left sides (a permanent tightening of muscles, tendons, and ligaments, which results in loss of motion in the affected joints). A review of the urologist's (a physician who specializes in the practice of the urinary tract) history and physical notes dated October 11, 2011 at 12:37 PM indicated that the injury appeared to be, "An incision with de-gloving of the scrotum." During a telephone interview with the urologist on November 3, 2011 at 9:30 AM, he stated the type of injury Resident A had "doesn't just happen." He further stated that he did not believe Resident A caused the injury to himself, given the resident's physical limitations of movement in the arms and hands, and he did not believe the injury to be self-inflicted. The physician further stated the resident was in a lot of pain, and the injury was a clean tear; "In my opinion, no way could the resident do that to himself; someone cut his scrotum." He stated his concern was that someone "forcefully tore it or cut it," because he (the urologist surgeon) did not have to debride any of the skin during the repair procedure. The physician stated that photographs were taken of the injury before and after the surgical repair. The four photographs were obtained and reviewed which showed an inverted U shaped wound to Resident A's scrotum. There were no jagged skin edges or tears evident; the edges appeared clean and precise.Further review of the hospital records showed a police report was taken at the hospital on October 11, 2011 at 1:00 AM. A review of the police report included three photographs of Resident A's scrotal injury, three photographs of his hands and four photographs of his bed/room at SNF 1.A review of the acute care hospital records showed that Resident A was hospitalized for nine days and on October 18, 2011, he was discharged and transferred to a different skilled nursing facility (SNF 2). On October 25, 2011 at 2:30 PM, an unannounced visit was made to SNF 2, and an interview was conducted with Resident A's primary care giver, a certified nurse assistant (CNA 1). She stated Resident A had arthritis to his entire body and only moved his head from side to side, and that two people were required to move or transfer him and that two people were required to pry his arms away from his upper body. She stated a lift was used to transfer him in and out of the bed. She stated, "He doesn't have full movement or extension in his upper arms." When asked, CNA 1 stated that she did not think he could straighten out his arms because she had not seen him do it. During an observation and interview conducted with Resident A, on October 25, 2011 at approximately 2:35 PM, accompanied by Resident A's CNA 1, the resident was in bed, awake and alert; he had minimal speech ability but was able to respond with a nod of his head, yes or no, and could mumble some words. CNA 1 asked the resident to grab and squeeze her hands as tight as he could. The demonstration confirmed Resident A had limited mobility and weakness in both arms and hands. Resident A's upper limbs were predominantly flexed at the elbows, with forearm and hands midline (in the middle) toward the chest area, and his hands were clenched closed. Resident A was asked for permission to look at his wound. When Resident A was asked how it happened, Resident A mumbled and shook his head as if to say he did not know how it happened. He denied scratching himself on the groin area; he denied self-inflicting the injury. When asked again how it happened, Resident A shook his head from side to side and mumbled, "I don't know." When asked if someone deliberately injured him, he shook his head indicating "No". Resident A then closed his eyes and when asked if he did not want to talk about the incident, he nodded to indicate he did not want to talk about it. During the observation, it was also noted that Resident A's legs were contracted upward, bent at the knees and inward with one knee over-lapping the other knee. Resident A required extensive assistance by CNA 1 to separate his legs to allow for a visual examination of the scrotal area injury. An unannounced visit was made to the facility (SNF 1) on October 26, 2011 to review the medical record for Resident A. A review of Resident A's admission face sheet indicated he was initially admitted on February 27, 2004, with diagnoses that included a history of traumatic brain injury post automobile accident, aphasia (a condition in which speech and language function is disordered because of a brain injury), gastrostomy feeding tube (a tube inserted through a hole outside the abdomen and into the stomach to deliver nutrition), degenerative arthritis (a disease in which deterioration of structure or function of tissue occurs). A review of the rehabilitation therapy notes (PT/OT) dated December 21, 2010 to December 28, 2010, indicated that Resident A had severe contractures of the lower extremities and required extensive assistance with mobility which included an assistive device called a Hoyer lift to transfer the resident in and out of bed. The evaluation notes indicated Resident A had a limited range of motion (ROM, which refers to the extent of movement of a joint to its full potential) of ten degrees (slightly bent) for the knees. [Normal ROM at the knee is considered to be zero degrees of extension (completely straight knee joint) to 135 degrees of flexion (fully bent knee joint)], and a strength level of -2 to -3 (measurements in the minus range means no strength or movement to that area). A review of the occupational therapy (OT) notes indicated Resident A's mobility to the upper extremities was limited due to increased tone. During an interview with the physical therapist (PT) on October 26, 2011 at 4:30 PM, he stated that Resident A had right side paralysis with a trace of muscle twitching in the legs; the resident did not have the strength to lift his legs up against gravity without assistance. He further stated the muscle tone of Resident A's arms was so bad that he was not able to use his hands. The physical therapist stated, "From what I read in Resident A's chart, he is incapacitated (deprived of strength or ability) in both the upper and lower extremities; a strength rating below [1] or [minus] means he only has twitching and no movement or strength to that body part." A review of the significant change in status full comprehensive minimum data set (MDS, a comprehensive assessment tool used to formulate a plan of care for each resident), dated January 1, 2011 (Section G), showed Resident A had impaired range of motion on both sides to the upper extremities (shoulder, elbow, wrist, hand) and impaired range of motion on one side to the lower extremity (hip, knee, ankle, foot). During an interview with CNA 2 on October 26, 2011 at 2:50 PM, she stated Resident A was assigned to her for care on October 10, 2011, on the day shift (7:00 AM to 3:00 PM). She indicated that Resident A was alert, but very contracted and stiff in the arms. She changed his incontinent (loss of bladder and bowel control) brief three times that shift. When asked, CNA 2 stated that Resident A had no skin breakdown in the groin or perineal (perineum) area (the area between the anus and the external genitalia), just mild dryness. She stated that she got Resident A up and sat him in a "Geri-chair" (a high backed cushioned recliner with a leg and foot rest). After lunch she checked him. He was slightly wet and she changed his brief again. She stated Resident A was rechecked again before change of shift at approximately 2:00 PM. She stated she reported off to (LVN 1) the licensed nurse that the resident was up in the chair and that she had changed him, but acknowledged that she did not give a verbal report to the next on-coming shift CNA. She stated that Resident A did not have the ability to extend his arms downward, that his arms and hands were drawn upward and stiff, and added, "The resident (Resident A) could not have injured himself that way." When asked, CNA 2 stated, she did not believe the scrotal injury was a result of any resident care equipment malfunction. An Interview was conducted with CNA 3, on October 26, 2011, at 2:30 PM. She stated Resident A was contracted in the arms and required total assistance with all cares (such as bathing, personal hygiene, dressing, toileting/incontinence care, eating, transfers from bed to chair to bed/mobility). An interview was conducted with CNA 4, on October 26, 2011 at 3:10 PM. She stated Resident A was much contracted in the arms and she stated Resident A had no wounds or open skin on the perineum or the buttocks areas. During an interview with CNA 5 on October 26, 2011 at 3:30 PM, she stated she heard about the incident. She stated, "The CNA (CNA 6) assigned to Resident A (on October 10, 2011) at about 6:30 PM, went to move the resident from the Geri-chair back to bed, and changed his brief and found his skin torn, and that the resident had blood and feces in the diaper." She stated that Resident A had a habit of screaming out when handled. "He was scared when touched, and when handled he was tense and screamed out." When asked, she stated the residents were supposed to be checked and changed every two hours or as needed and that on day shift, the last brief change was usually by 2:00 PM. On October 26, 2011, record review of the Weekly Nurses Progress Summary notes dated September 29, 2011 and October 6, 2011, showed no documentation that indicated Resident A had any skin breakdown/problems to the scrotal area prior to October 10, 2011.A review of the MDS assessments dated January 1, 2011, July 4, 2011 and October 10, 2011, showed no documented evidence that Resident A had skin ulcers or wounds present, prior to the October 10, 2011 incident. All three MDS assessments indicated that Resident A was always incontinent of bowel and bladder. Resident A's MDS assessments dated January 1, 2011, July 4, 2011 and October 10, 2011, Section G, Transfers B, were all coded as a 3, to indicate Resident A required two+ persons physical assist with transfers.The MDS assessment dated January 1, 2011, July 4, 2011 and October 10, 2011 also showed Resident A had total dependence on staff for activities of daily living (ADLs such as bathing, personal hygiene, dressing, toileting/incontinence care, eating, transfers from bed to chair to bed/mobility), which required full staff performance (assistance) every time, every day. A review of the care plan titled "ADL Functional," dated December 26, 2010 and revised in March 2011, indicated Resident A required total assistance of 1-2 staff for all ADLs, which included toilet use (incontinence care) and personal hygiene. The interventions stipulated: * Reposition every two hours and as needed. * Check every two hours for soiling or wetness, thoroughly cleanse after each episode of incontinence. On November 1, 2011 at 1:10 PM, an interview was conducted with CNA 6, who was assigned to Resident A and who reported the scrotal injury on October 10, 2011. He stated he arrived for duty October 10, 2011 at 3:00 PM, and received his resident care assignment at 3:40 PM. Resident A was assigned to him and he was also assigned dining room duties, which consisted of passing trays, help in feeding residents, and supervision of residents. CNA 6 went on to say that dining room duties also included the dining room clean up afterwards, and that this usually lasted from 4:30 PM to 5:45 PM. He stated, "I ran by the [resident] rooms and started fixing the linen cart. Around 6:30 PM, Resident A was up in the Geri-chair. I transferred him back (to bed) using the Hoyer lift."According to CNA 6, he transferred Resident A back to bed using the Hoyer lift and he was alone, even though Resident A's MDS assessments dated January 1, 2011, July 4, 2011 and October 10, 2011, Section G, Transfers B, were all coded as a 3, to indicate Resident A required two+ persons physical assist.CNA 6 also stated that Resident A had a habit/behavior to scream out before he was even handled. He said, "I noticed brownish feces looking stuff mixed with blood to his left hand." He said he did not want Resident A's bed soiled so he quickly cleaned Resident A's hand, removed his shirt, and then his pants. CNA 6 noticed that the left side tab of Resident A's brief was slightly open. He removed the brief and there was bowel movement (BM) all over back to front. CNA 6 said he used a towel with warm water and soap and that he used "Big towels" to clean the resident (Resident A), due to the amount of stool. He stated, "I couldn't...didn't know how his scrotum looked at the time; I left the towel on his scrotum right between his legs; I turned him to the left side, got the lower end of the towel and wiped him down; I noticed the severe injury he had, and the skin was already off his scrotum. I stopped right there, left the rest of BM, and went to call the charge nurse (LVN 2)." CNA 6 stated the charge nurse assessed Resident A's injury and called the nursing supervisor, who assessed Resident A and called 911 for transport to the hospital. Also during the interview, CNA 6 stated that the first time he "noticed" Resident A was at 4:30 PM, he was sitting in the [Geri] chair. At about 6:30 PM (4 to 5 hours had elapsed since the incontinence check by CNA 2 on the day shift) was the first time he checked Resident A. When asked what he (CNA 6) thought happened to Resident A, he stated he reported to work, but his resident care assignment was given to him late, he had fourteen to fifteen residents assigned to him, that Resident A was sitting in feces and urine, and then when he wiped [the scrotal area] with pressure, "Maybe the skin was already scratched off and he (CNA 6) made it worse." He said he did not notice the scrotal injury before wiping Resident A because there was stool around the area, and when he wiped with enough pressure to clean him, that is when he saw the skin tear to the area. CNA 6 stated Resident A had mobility to his left leg, but the right leg was fully contracted, and that the resident could move his arms and hands, but when he was touched he would stiffen up. "It's like he doesn't like to be touched. His hands are strong and he is able to push you away. I tell him to relax, that I just need to clean him up." CNA 6 stated the first time he took care of him, he asked another nurse to accompany him in Resident A's room. He stated Resident A's screams scared him and that the resident calmed down once the nursing cares were finished. He stated the behavior of screaming repeated each time care was rendered. When asked, CNA 6 said no other nurse was with him at the time of the incident. An interview was conducted on October 26, 2011 at 4:00 PM, with Resident A's roommate (Resident B). Resident B stated that he was in his room watching television the day of the incident, and was waiting to see if CNA 6 was going to give him a shower. He said the CNA was first with Resident A. He stated that it sounded like Resident A was agitated when he was changed and began to yell/mumble, "No, no." The roommate stated, "I could see it in his face (CNA 6) that there's a situation; he (CNA 6) was going back and forth, back and forth. The resident (Resident A) always yells out, but with this guy he does it more. He (Resident A) mumbles, no...no...no."Resident B added, "CNA 6 is a big guy." The roommate was asked if he had ever witnessed any aggressive behavior from CNA 6, and he (the roommate) stated he could not directly see what was going on because of the way the room was situated. An interview was conducted with the Administrator on October 26, 2011 at 6:00 PM to review the results of the facility's investigation report. She stated the conclusion of the investigation was that the resident mostly likely caused the injury to himself, when he was digging and scratching his scrotal area.A review of the facility's policy and procedure titled, "Perineal Care," revised September 2005, indicated, "The purpose of these procedures is to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition." The Perineal Care policy and procedure also indicated "the following equipment and supplies will be necessary when performing this procedure: 1. Washbasin. 2. Towels. 3. Washcloth. 4. Soap (or other authorized cleansing agent). 5. Personal protective equipment. Steps in the procedure: 1. Place the equipment on the bedside stand. Arrange the supplies so they can be easily reached... 10. For a male resident: a. Wet washcloth and apply soap of skin cleansing agent. b. Wash perineal area including the penis, scrotum, and inner thighs. c. Thoroughly rinse perineal area in same order, using fresh water and clean washcloth. d. Gently dry perineum following same sequence." A review of the facility's job description policy for nursing assistant titled, "Job Description Nursing Assistant (CNA, RNA)" indicated the following: "Job summary: Under the direct supervision of the charge nurse may be licensed vocational nurse or registered nurse (LVN, or RN), the CNA performs hands-on nursing care for the residents with emphasis on daily care needs, personal hygiene and cleanliness, grooming and skin care. The fundamental goal of the CNA is to promote the general well-being of residents assigned to him/her and to help conserve life, alleviate suffering, and promote health." "...2. Personal Care * Assists with, or performs personal hygiene for the resident, including washing the face, hand and all personal areas." "...3. Lifting and Moving residents * Repositions residents who cannot do so satisfactorily themselves, at least every two hours. * Repositions residents who are up in the chair at least every two hours, e.g., assist to lie down or ambulate as instructed by the licensed nurse." A telephone interview was conducted with the Director of Staff Development (DSD) on February 20, 2013 at 4:00 PM, for clarification of the facility's policy and practice protocols for perineal care services delivered to the residents. She stated that the CNA's (certified nursing assistants) were in-serviced (trained) and observed for adherence to the policy. She said big towels were not used in lieu of (instead of) washcloths for perineal care. Therefore, the facility failed to ensure Resident A was provided with position changes and preventative skin care in accordance with the resident's needs when the facility staff failed to ensure that: Resident A was repositioned every two hours in accordance with the facility policy and Resident A's plan of care on October 10, 2011 from 1:45 PM to 6:30 PM (a period of 4.5 hours). Resident A was checked every two hours for incontinence and that Resident A received prompt, proper incontinence care in accordance with the facility policy and Resident A's plan of care. The facility's failure resulted in a severe injury to Resident A's scrotum that required surgical intervention at an acute care hospital, which caused Resident A pain, bleeding and put Resident A at risk for complications including infection and sepsis (infection in the bloodstream or body tissues). This violation had a direct relationship to the health, safety, or security of the resident. |
| 240000152 |
Valley Healthcare Center |
240012156 |
B |
01-Apr-16 |
GSC511 |
7078 |
REGULATION VIOLATION: Title 22 72527 Patients' Rights. (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and 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.(12) To be treated with consideration, respect and full recognition of dignity and individuality, including privacy in treatment and in care of personal needs. The facility violated the above mentioned regulation by failing to: Protect one out of three sampled patients (Patient A) from verbal abuse by a staff member when a Certified Nurses' Aide (CNA 1) made disrespectful, sexual comments to her while providing perineal care (washing of the genital and rectal area of the body).On February 19, 2015 at 11:00 AM, an unannounced visit was made to the facility to investigate an entity reported incident of alleged abuse. The facility Administrator's typed report of the incident dated and received by the California Department of Public Health (CDPH) on February 10, 2015, indicated that on February 7, 2015, Patient A told staff (CNA 2) that on Wednesday, February 4, 2015, a certified nurse assistant (CNA 1) had asked her when the last time was that she had sex. Patient A further complained to CNA 2 that CNA 1 spent an excessive amount of time cleaning her after an episode of incontinence. The CNA reported this information to the charge nurse who notified the Administrator, who advised the charge nurse to initiate an investigation. During a review of the clinical record for Patient A, the face sheet (contains demographic information) indicated Patient A was admitted to the facility on February 3, 2015, with diagnoses which included: acute chronic respiratory failure (inability of the body to maintain adequate oxygen levels in the blood) and hypertension (high blood pressure). Review of the nurses' notes dated February 3, 2015 through February 9, 2015 indicated Patient A was alert, oriented, and able to make her needs known.During a review of the Social Service Designee (SSD) notes dated February 9, 2015, Patient A's roommate (Patient B) was interviewed. The documentation indicated Patient B overheard CNA 1 ask Patient A the following on February 7, 2015, at approximately 2:00 PM: (1) Did Patient A have a husband or boyfriend; and (2) When was the last time Patient A had sex. Patient B indicted she did not want the CNA to care for her anymore after the conversation she overheard between CNA 1 and Patient A.Review of the assignment list dated February 4, 2015 indicated CNA 1 was the CNA assigned to care for Patient A on February 4, 2015, and February 7, 2015 on the 7:00 AM to 2:30 PM shift.During an interview with CNA 1 on February 19, 2015 at 11:45 AM, CNA 1 stated that he did ask Patient A how long it had been since she had been with a man. He stated Patient A had begun the conversation and he had been attempting to be polite. During an interview with the facility Administrator on February 19, 2015 at 11:50 AM, the Administrator stated he had suspended CNA 1; however, he was unable to provide any documented evidence that CNA1 had been suspended. The Administrator stated the facility had, "redirected the CNA about the appropriate way to talk with residents, doesn't think this was abuse, and [CNA 1] was suspended, but brought back." The Administrator assigned CNA 1, "to the other side of the building."A review of the facility's conclusion to their investigation sent to CDPH, dated February 10, 2015, written by the Administrator indicated, "[Used CNA 1's name] has worked at [name of facility] for a number of years. He is in good standing. His English is not good at times, and he expressed he meant no offense. He just wants his patients to be clean. The patient was not comfortable with [used CNA 1's name] continuing as her caregiver; he did not sexually molest or exploit her, and intended not offense. It was decided to reinstate [CNA 1]; he will be assigned to the other side to the building and shall be provided training on dealing with sensitive issues and patient's privacy before he is brought back to work." During an interview with Patient A on March 19, 2015 at 4:00 PM, Patient A stated CNA 1 had taken about 10 minutes to clean her vaginal area and she felt this was too long. CNA 1 then asked her how long it had been since she had sex. Patient A stated she felt degraded and very upset by this. Patient A further stated CNA 1 still worked in the facility and a week after this incident he came into her room and tried to give her a bath. Patient A said she told CNA 1, "No," and told him to leave. Patient A expressed distress that CNA 1 was still employed at the facility, and she stated she felt he should not be working at the facility anymore. A review of CNA 1's employee file was conducted on March 19, 2015 at 4:20 PM. The documentation reviewed demonstrated CNA 1 had been disciplined as followed: a. May 29, 2010, "Final warning for leaving patients on toilet or commode without attendance." b. February 8, 2011, failed to position a patient by putting on pillow instead of gel cushion and the patient fell out of the wheelchair." c. May 10, 2011, "Did not provide ADL care. Patient has the right to be clean and dry with appropriate clothing." d. May 29, 2012, "Failed to make sure assignments are left is in a clean and, appropriate manner. Did not provide appropriate ADL care and cleanliness [to residents]." The file reflected CNA 1 had been trained on February 15, 2010, on which behaviors were considered abusive based on the facility's policy and procedure undated and entitled, "Reporting Abuse to Facility Management," The policy listed the definitions of abuse as follows: a. "Abuse- the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish... b. Verbal abuse- any use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families or within hearing distance..." c. Sexual abuse-is not limited to, sexual harassment, sexual cohersion or sexual assault....e. Mental abuse- is not limited to humiliation, harassment, threats of punishment or withholding treatment or services..." A review of the facility's policy and procedure entitled, "Abuse Prevention," dated October 11, 1999, reflected the following: "Our facility will not permit patients to be subjected to abuse by anyone, including staff members, other residents, consultants, volunteers, staff of other agencies serving the residents, family members, legal guardians, sponsors, friends, or other individuals."The facility failure had a direct or immediate relationship to the health, safety, or security of long-term health care facility patients or residents. |
| 240000152 |
Valley Healthcare Center |
240012184 |
B |
14-Apr-16 |
None |
6646 |
REGULATION VIOLATION: 72527(a)(10): (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right:(10) To be free from mental and physical abuse. FINDINGS: The facility violated the above mentioned regulation by failing to protect one out of three sampled patients (Patient A) from verbal abuse by a staff member when the staff member refused to take the patient to the bathroom and used vulgar language.On August 25, 2014 at 3:06 PM, an unannounced visit was made to the facility to investigate an entity reported incident of verbal abuse. During a review of Patient A's clinical record, the face sheet (contains patient demographics) indicated Patient A was admitted to the facility on June 25, 2014, with diagnoses which included: intracranial hemorrhage (bleeding within the skull), and hemiplegia (weakness of one side of the body). Review of the facility form, "History and Physical," dated June 30, 2014, and signed by the patient's physician indicated Patient A had the mental capacity to make and understand decisions.During an observation of Patient A on August 25, 2014 at 3:25 PM, the patient was observed sitting in a wheelchair engaged in activities. During an interview with Patient A on August 25, 2014 at 3:25 PM, the patient stated Certified Nurse's Aide 1 (CNA 1) had been mean to him and had refused to take him to the bathroom. The patient further stated CNA 1 informed him on August 12, 2014, he could only go to the bathroom three times during a shift. Patient A stated, "I got mad and told her that wasn't right." He stated the CNA then called him a "f-----g a--h---." Patient A stated his roommate was present and heard the exchange. He stated he was really upset and had informed the facility on August 12, 2014, and had not seen the CNA since then.During an interview with Patient A's roommate (Patient B) on August 25, 2014 at 3:30 PM, Patient B stated he was in their room and CNA 1 was helping his roommate. Patient B stated CNA 1 told his roommate that he could only go the bathroom three times. He further stated that his roommate had to go to the bathroom a lot since he was sick. He stated then CNA 1 called his roommate a "f-----g a--h---." Patient B stated he had never had a problem with the CNA before that.A review of social service notes for Patient A was completed on August 25, 2014.A note dated August 14, 2014, indicated that Patient A had, "voiced a concern over a staff member being verbally inappropriate." The note further indicated that the Administrator was notified, an investigation was started, and the Ombudsman and DPHS (Department of Public Health Services, now California Department of Public Health) had been notified of the allegation on August 14, 2014.A review of the assignment list was completed on August 25, 2014. The assignment list dated August 12, 2014, indicated CNA 1 was the CNA assigned to care for Patient A.A review of the employee file for CNA 1 was completed on August 25, 2014. The file reflected CNA 1 had been trained January 27, 2014, on which behaviors were considered abusive. A review of the facility policy and procedure entitled, "Abuse Prevention," dated October 11, 1999, and received from the facility administrator on March 9, 2015, under procedures listed, "...2...This training will include:a. Appropriate interventions to deal with aggressive and/or catastrophic reactions of patients; b. How staff should report their knowledge related to allegations without fear of reprisals; c. How to recognize signs of burnout, frustration and stress that may lead to abuse: and d. What constitutes abuse, neglect and misappropriation of patient property." A review of the same policy under, "Procedure...11. The Administrator or his or her appointed designee will report to the State Nurse Aide Registry or licensing authority any knowledge it has of any actions by a court of law which would indicate an employee is unfit for service, including known incidents of patient abuse..." A review of the facility's policy and procedure entitled, "Reporting Abuse to Facility Management," undated, and received from the facility administrator on March 9, 2015, listed under "Policy Interpretation and Implementation...2. To help with recognition of incidents of abuse, the following definitions of abuse are provided...b. Verbal abuse is defined as any use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents and their families, or within their hearing distance, to describe patients, regardless of their age, ability to comprehend , or disability..." During an interview with the facility Administrator on February 17, 2015 at 3:48 PM, the Administrator stated the incident had not been reported to the Certified Nurse's Aide Board. He further stated that he did not believe the allegation was true as the patient had a "Bathroom fetish." He stated the patient had a history of being inappropriate with female staff members.During an interview with CNA 1 on February 17, 2015 at 3:54 PM, the CNA stated that on August 12, 2014, she had been working with Patient A. She answered his call light and the patient needed to go to the bathroom. She told Patient A she needed to get a blanket for the patient next door. CNA 1 stated that she came right back and helped Patient A to the bathroom. She mentioned to the patient that she had noticed he had to use the bathroom a lot. She asked him if anything was wrong and maybe she should let the charge nurse know so she could check him. She stated he told her, "No, he was fine," and she told him, "Goodnight." She stated the roommate was in the room, but asleep. CNA 1 stated she never used foul language at all and would never use that type of language with a patient.Review of the facility policy and procedure entitled, "Abuse Prevention," dated October 11, 1999, and received from the facility administrator reflected the following: "Our facility will not permit patients to be subjected to abuse by anyone, including staff members, other patients, consultants, volunteers, staff of other agencies serving the residents, family members, legal guardians, sponsors, friends, or other individuals." The facility's failure had a direct or immediate relationship to the health, safety, or security of patients. |
| 240000152 |
Valley Healthcare Center |
240012399 |
B |
19-Jul-16 |
ZFNM11 |
9961 |
REGULATION VIOLATION: 72527(a)(10) Title 22, California Code of Regulations, Division 5, Chapter 3, Article 5, Section 72527 (a)(10): (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (10) To be free from mental and physical abuse. FINDINGS: The facility violated the above mentioned regulation by failing to: Protect one out of three sampled patients (Patient A) from physical and emotional abuse by a staff member when a Certified Nurse's Aide (CNA) was rough while changing Patient A's under pad in spite of the patient's request to stop because she was in pain. This resulted in Patient A experiencing physical and emotional abuse. On April 9, 2015, at 4:30 PM, an unannounced visit was made to the facility to investigate an entity reported incident of physical abuse of Patient A. During an interview with the Director of Nursing (DON) on April 9, 2015, at 4:30 PM, she described Patient A as, "nice, not an aggressive patient," and the DON said she, "doesn't recall an incident with other patients or staff." The DON stated, "It happened at NOC shift (night-11:00 PM to 7 AM) at around 2 to 3 AM, on April 6, 2015. It was reported CNA 1 was taking care of Patient A. The patient (Resident A) requested to be cleaned up, and later said, 'don't clean me up.' This was stated by the roommate (Patient B) who was alert. The curtain was pulled around Patient A's bed, and the roommate (Patient B) did not hear Patient A stating she was being hurt. CNA 1 reported to the charge nurse [Registered Nurse Supervisor] that she was pinched by Patient A. We did an investigation and interviewed Patient A. She [Patient A] stated CNA 1 was upset that she [Patient A] could not help with the turning, and said sometimes CNA 1, "had two personalities, sometimes she's nice and sometimes she's not." During a phone interview with the Administrator on April 9, 2015, at 5:00 PM, he was asked if he knew about the allegation made by Patient A about CNA 1. The Administrator stated, "I am aware about it, early in the day on April 6, 2015, Patient A talked with the DON and said that CNA 1 was rough. I talked with the CNA over the phone. I had the Social Services Director (SSD) interview Patient A. The SSD stated that Patient A told her everything was okay. The next day (April 7, 2015) she (SSD) went to interview her (Patient A) again. She (Patient A) stated CNA 1 had a problem with her. According to CNA 1, she was changing Patient A and the resident stated that she was hurting her. Patient A pinched CNA 1. CNA 1 asked the patient why she was pinched and Patient A responded that she was hurting (to CNA 1). Both CNA 1 and Patient A stated this happened." The Administrator stated Patient A was coherent and was able to tell staff what she needs. The Administrator stated, "We assigned CNA 1 to another group of people (patients) on April 7, 2015, when Patient A retracted her allegation that everything was wonderful. The investigation started on April 6, 2015." When asked why CNA 1 was placed back on schedule while the investigation was in process on April 7, 2015, the Administrator stated, "If the Patient said differently, then we would not have let her work. The SSD talked to Patient A again on April 7, 2015. CNA 1 was suspended on the 7th, and was terminated on the 8th of April 2015." A review of the SSD note dated April 7, 2015, at 4:38 PM, indicated the SSD and Corporate Quality Assurance Nurse met again with Patient A and asked if anything had occurred on April 6, 2015, with a staff member. Patient A stated, "A CNA (CNA 1) was rough during providing care and she felt fearful of her (CNA 1) due to the CNA was walking back and forth past her doorway and it made her feel fearful." An interview was conducted on April 21, 2015, at 10:55 AM, with the Social Services Director (SSD). When asked if she was aware of the incident between Patient A and CNA 1, the SSD stated, "Yes. The Quality Assurance Nurse and me [I] met with Patient A, we asked if there was something that concerns her. Patient A said, 'yes' and said that there was a particular CNA (CNA 1) who was turning her, was rough during turning, and she did not feel comfortable with the CNA. The resident thought that the CNA was bipolar (a mood disorder with unpredictable swings from happy to angry and sad)." The SSD stated when she had visited Patient A after she had reported the incident on April 6, 2015, Patient A told the SSD everything was okay. On the visit on April 7, 2015, Patient A shared about the incident with CNA 1 and stated, "It sounded like the incident really happened for her to be so upset like that." Patient A said she felt safe, but we decided to re-locate her to another room, near the nurse's station where she sees a lot of people." An interview was conducted with Patient A on April 21, 2015, at 11:15 AM. She was asked if she remembered an encounter with a CNA (CNA 1). Patient A said, "Yes, that particular CNA (CNA 1) was changing my under pad and pulled it too hard that it hurt me. I told her I was hurting, but she kept going so I tried to stop her, and told her, 'don't do it because I'm hurting.' She had done it several times. I couldn't take the pain anymore, that's why I had to hold her hand to stop her. I repeatedly say, "don't do it I'm hurting." The CNA (CNA 1) is nice, she took care of me, but sometimes she was rough so I had to say something. She (CNA 1) did it before. I did not want to say anything just to get things done, but that time it was really hurting me. I felt like she (CNA 1) was intentionally hurting me, that was why I had to tell and stop her. I want to walk again, both of my legs hurts, my back hurts. I was told my spine has a fracture that's why it hurts." During a clinical record review for Patient A, the face sheet (a document containing demographics) indicated Patient A was admitted to the facility on February 10, 2015, with the diagnosis which included: Chronic pain, lack of coordination, abnormality of gait, muscle weakness-general. The Physician Orders dated April 2015, indicated the following narcotic medications were ordered for pain: "Tramadol HCL 50 MG (milligram) PO (by mouth) Q (every) 6 hours for pain and Norco 10-325 1 tablet PO Q 4 hours PRN (as needed) pain." During a review of Patient A's Minimum Data Set (MDS- computerized assessment) dated February 23, 2015, under section C0500:Cognitive/Decision making, revealed Patient A's cognitive level was 15 (translated as coherent and appropriate). In section E0100 and E0200: Mood/Behavior/Psychosocial: No noted untoward behavior towards others was listed. In section G0100: ADL (activities of daily living), Patient A was noted to need extensive assistance, G0400- B lower extremity, Noted: 0 (no impairment), on section G0100- C, D: Ambulation: Noted: 8 (8 means activity of ambulating never occurred.) During an interview on April 21, 2015, at 11:35 AM, with the Director of Staff Development (DSD), the DSD was asked to describe CNA 1. The DSD stated, "I like [used CNA 1's name], she was an employee of the month. When I check her assigned rooms they look great; she was always in a good mood; and I had no other concerns until this case (incident of rough handling of Patient A)... I actually like her, she's always happy, that's why this shocked me." During a review of CNA 1's employee file, the file indicated that she was hired on April 26, 2013, and had initial abuse training on April 26, 2013, which included the following: a. Persons who are required to report Abuse b. Persons who are subject of the report c. When reporting abuse is required d. Penalty for failure to report e. Confidentiality of reporting and abuse reports f. Abuse that must be reported g. Definitions of abuse h. Where to call in and send the written abuse report A review of the document entitled, "Employee Separation Report," located in CNA 1's employee file, indicated the separation date was April 8, 2015. The reason for termination was listed in the section, "Reason for Discharge: Acts of or threats of violence, other misconduct, Explanation: Resident reported allegation employee was rough when providing care for patient." The form contained only the Administrator's signature and was dated April 8, 2015; CNA 1 had not signed the separation notice. A review of the facility's policy and procedure entitled, "Abuse Prevention," dated October 11,1999, indicated under the, "Policy Statement: Our facility will not permit residents to be subjected to abuse by anyone, including staff members, other residents". The policy further indicated, "Procedures, 9. Employees of this facility that have been accused of resident abuse will be reassigned to non-resident care duties or removed from the schedule until the results of the investigation have been reviewed by the Administrator." A review of the, "Witness Statement Form," dated April 6, 2015, documented by the Registered Nurse (RN) supervisor, indicated Patient A had reported the incident of rough handling by CNA 1 to her and had requested another CNA take care of her. The RN Supervisor documented she informed Patient A she would report the incident to the Administrator and DON. There was no documented evidence CNA 1 was removed from Patient A's care on April, 6, 2015. The failure of the facility to protect Patient A from rough handling and unnecessary pain during care provided by CNA 1 resulted in emotional and physical abuse for Patient A. The violation was determined to cause or under circumstances likely to cause significant humiliation, indignity, anxiety or other emotional trauma to the patient. |
| 250000026 |
Vista Cove Care Center at Corona |
250009586 |
B |
14-Nov-12 |
LVKN11 |
3636 |
72527 (a) (9) 72527 (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (9) To be free from mental and physical abuse.The facility failed to ensure Patient A was free from physical abuse by failing to ensure CNA 1 (Certified Nursing Assistant) did not handle the patient roughly, when the patient refused to be showered. Patient A sustained a large bruise on her left outer ankle measuring 6.5 cm (centimeter) x 6 cm.An unannounced visit was made to the facility on August 18, 2011, at 2:10 p.m., to investigate an entity reported incident. Patient A was physically abused by CNA 1, resulting in Patient A sustaining a large bruise to her left outer ankle. The record for Patient A was reviewed on August 18, 2011. Patient A is a 99-year old female who was admitted to the facility on December 2, 2008, with diagnoses that included senile dementia (a progressive condition when a person loses ability to think properly). A quarterly MDS (Minimum Data Set), an assessment tool, dated June 29, 2011, indicated Patient A required extensive assistance with transfers, dressing, toilet use, personal hygiene and bathing. The MDS also indicated the patient had no memory problem, was independent in daily decision making and had no behavior problem. A review of the daily licensed nurses notes dated August 12, 2011, at 7:10 a.m., written by LVN 1, indicated, "While receiving report fr (from) noc-shift nurse (in front of room 170), I overheard resident yelling out "You're too rough with me; You're hurting me, leave me alone..." The note also indicated LVN 1 noted dark purple skin discoloration to the left lower extremity above the ankle.An interview was conducted with Patient A on August 18, 2011, at 2:20 p.m. Patient A stated CNA 1 was, "Rough with me... she hurt my leg, I ended up with a big bruise." Patient A also stated, "She forced me (CNA 1) to get in the shower chair. I was afraid I was going to get hurt." Patient A's left ankle was noted with red and purple bruising measuring 2 inches x 3 inches. On August 18, 2011, at 2:45 p.m., LVN 1 (Licensed Vocational Nurse) was interviewed. LVN 1 stated she was getting report from the night shift, when she overheard Patient A yelling out, "You are being too rough with me!" She stated when she got to the room, she saw CNA 1 exiting the room with Patient A on the shower chair, at which time she noted the bruise on the patient's left ankle. She stated Patient A told her, "She did this to me", while pointing at her left ankle. An interview was conducted with the DON (Director of Nursing) on August 18, 2011, at 3:45 p.m. The DON stated CNA 1 had been terminated. He stated CNA 1 should have stopped the procedure when Patient A refused to be showered. He stated CNA 1 should have got some help from another staff or return at a later time to try to shower the patient again.CNA 1 was not available for interview due to being terminated as of August 18, 2011. The facility failed to ensure Patient A was free from physical abuse by failing to ensure CNA 1 did not rough handle the patient when the patient refused to be showered. Patient A sustained a large bruise on her left outer ankle measuring 6.5 cm x 6 cm. These violations had a direct relationship to the health, safety, or security of Patient A. |
| 250000026 |
Vista Cove Care Center at Corona |
250009639 |
B |
06-Dec-12 |
J29N11 |
2906 |
Health and Safety Code 1418.91(a)(b)(c)(d) (a) A long-term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the department immediately, or within 24 hours. (b) A failure to comply with the requirements of this section shall be a class "B" violation. (c) For purposes of this section, "abuse" shall mean any of the conduct described in subdivisions (a) and (b) of Section 15610.07 of the Welfare and Institutions Code. (d) This section shall not change any reporting requirements under Section 15630 of the Welfare and Institutions Code, or as otherwise specified in the Elder Abuse and Dependent Adult Civil ProtectionAct, Chapter 11 (commencing with Section 15600) of Part 3 of Division 9 of the Welfare and Institutions Code.The facility failed to report the allegation of abuse of Resident A by a Certified Nursing Assistant (CNA) 1, as reported by Resident A to facility staff on December 4, 2011, at 3:45 p.m., to the California Department of Public Health (CDPH) immediately, or within 24 hours. The facility initially reported the alleged incident of abuse to the CDPH office on December 5, 2011, at 9:41 p.m. (24 hours, 56 minutes after the incident), via fascimile. On December 4, 2011, at 3:45 p.m., the Daily Licensed Nurses Notes, recorded by the Licensed Vocational Nurse (LVN) 1 indicated Resident A had complained of staff abuse, noted as follows:"Resident noted with behavior problems - has been verbally and physically abusive to staff. Blaming staff for hitting or slapping her. And causing harm to her. This evening she was accusing a CNA for hitting + slapping her. Since this very CNA has not even worked with her. Then she is telling everybody about this incident--..." The facility investigation indicated LVN 1 did not report the allegation of abuse to the nurse supervisor. The facility investigation indicated in a statement, written by LVN 1 on December 6, 2011, LVN 1, "...did not perceive that as an abuse because this is her usual behavior...."The facility policy, titled "Reporting Resident Abuse," indicated, "An employee of this facility shall not knowingly: ....Fail to report an incident or suspected incident of abuse." The policy further indicated, "Any employee who has knowledge or reason to believe that a resident has been a victim of abuse is under a duty to immediately report such incident or suspicion to the nurse supervisor."The policy indicated, "The nurse supervisor must complete a Resident Incident Report..." The facility failed to report the allegation of abuse of Resident A by a staff member immediately, or within 24 hours, and failed to implement the policy, "Reporting Resident Abuse." These failures placed all residents at the facility in potential danger due to the risk for abuse. These violations had a direct relationship to the health, safety, or security of the residents. |
| 250000036 |
Valencia Gardens Health Care Center |
250009662 |
B |
06-Dec-12 |
PQ6H11 |
6423 |
CITATION Facility name: Chapman Convalescent Hospital Complaint #: CA00126165 Class "B" Citation Title 22:72311 (a) (1) (c): (a) Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (C) Reviewing, evaluating and updating of the patient care plan as necessary by the nursing staff and other professional personnel involved in the care of the patient at least quarterly, and more often if there is a change in the patient's condition.The facility failed to ensure that staff followed the two-person assist procedure when transferring Patient A. As a result of CNA 1 attempting to transfer Patient A by herself, Patient A suffered an injury to her left hand.An unannounced visit was conducted on September 13, 2007, to investigate a self-reported incident in which CNA 1 caused injury to Patient A's left hand during a transfer.An interview was conducted with Patient A, on September 13, 2007, at 12 p.m. Patient A had a bluish-grey bruise around the top of her left hand and around her fourth ring finger. The bottom of Patient A's left hand was completely bruised (bluish-black and grey in color). Patient A stated, "Some girl squeezed my hand and bruised it. She hurt me! She's not here anymore. It hurt!" An interview was conducted with RN 1, on September 13, 2007, at 12:15 a.m. RN 1 stated, "I was sitting at the desk and heard the patient screaming out, 'She broke my hand! She broke my hand!'" RN 1 stated she ran to Patient A's room and saw that Patient A was sitting on the bedside commode. CNA 1 was holding Patient A's hands, and stating "I don't feel comfortable." RN 1 stated Patient A continued screaming, "She broke my finger!," and CNA 1 continued stating she didn't feel comfortable having her sit on the commode to eat. RN 1 stated CNA 1 was trying to get Patient A off the commode by herself and get her to sit in her wheelchair or bed to eat dinner. CNA 1did not utilize the assistance of another nursing staff to assist Patient A with the transfer. RN 1 stated she had to tell CNA 1 to calm down and let go of Patient A several times, before CNA 1 listened to her. RN 1 stated Patient A's left ring finger started to swell immediately. RN 1 stated Patient A's hand was bruised, and that it was not like that prior to the incident with CNA 1. An interview was conducted with CNA 1, on September 13, 2007, at 7 p.m. CNA 1 stated, "I tried to sit her up. She can be feisty; nine out of ten times she's O.K. with it. Unfortunately, I don't know how it happened, her finger popped. It was a complete accident. I don't believe in forcing people to do things, but she eats and voids at the same time. I don't feel that is right. I don't feel comfortable with that. I think it is abusive to sit there that long, 1-11/2 hour at a time while she eats and voids at the same time." CNA I stated the patient became argumentative with her when she tried to get her to move off the commode. A review of Patient A's medical record was conducted on September 13, 2007. Patient A was a100 year-old female admitted to the facility on September 7, 2006, with diagnoses that included hypertension (high blood pressure), dementia (Impairment of intellectual capacity and personality integration due to damaged neurons in the brain), and diabetes (disorder characterized by elevated sugars that can cause increased urine production). The Minimum Data Set Assessment (MDS) dated September 5, 2007, indicated that Patient A required a one person physical assist for bed mobility, walk in room, and toilet use. Patient A was unable to test for balance without physical help.The care plan dated, September 14, 2006, for "Requires mod-max total assist with ADLs," indicated, "Assist with transfers to and from bed."The care plan dated, November 10, 2006, for, "At risk for falls and injury related to confusion related to dementia," indicated, "Weakness, unsteady, requires assist with mobility." The care plan dated, September 13, 2006, for "Episodes of confusion, forgetfulness, can be argumentative, easily angered and uncooperative," indicated, "If she becomes too argumentative, and angered/angry suspend care if safe to do so and return at a later time." In an interview with the RN on September 13, 2007, at 12:25 a.m., the RN stated CNA 1 did not follow the plan of care and continued to insist on transferring Patient A from the commode even after Patient A became uncooperative and resistive to CNA 1's care.An interview was conducted with the DON, on September 24, 2007, at 6:25 p.m. The DON stated that Patient A was a "two person transfer," and required two staff members to assist when transferring every time. The DON stated, "The two person transfer/assist should be written in the care plan." The DON further stated that there would be a green dotted sticker on Patient A's bed to let the CNAs know that Patient A is a two person transfer. The facility policy and procedure, titled, "Assisting a Resident from Chair to Bed," indicated, "If a resident cannot stand alone, two persons (one on each side) should lock arms with the resident, gently stand..."At 6:37 p.m., on September 24, 2007, it was observed there were two green circle stickers on Patient A's bed. Interviews were conducted with nursing staff on September 24, 2007. Five of eight CNAs did not know what the green sticker indicated and were not aware that Patient A required two persons for transfer. The facility failed to ensure that a two person transfer was followed by all staff for Patient A, per policy and procedure. A review of CNA 1's personnel file was conducted on September 13, 2007. CNA 1 was hired on July 25, 2007. CNA 1 was on a 90 day probation period. The facility suspended CNA 1 on September 10, 2007. Her employment was terminated on September 11, 2007, due to the incident with Patient A on June 10, 2007, and for "insubordination to a supervisor during patient care."The facility failed to ensure Patient A's care plan included two person assist transfer.The facility failed to ensure that all staff followed the two person assist procedure when transferring Patient A. As a result of CNA 1 attempting to transfer Patient A by herself, Patient A sustained pain and injury to her left hand.The above violations, either jointly, separately, or in any combination, had a direct or immediate relation to patient health, safety, or security. |
| 250000026 |
Vista Cove Care Center at Corona |
250009918 |
B |
30-Jul-13 |
TRC311 |
8159 |
Vista Cove Care Center Class B Citation F465?section 483.70(h) Other Environmental Conditions The facility must provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public. During the investigation of a complaint, initiated on December 20, 2010, it was determined that the facility failed to implement satisfactory corrective actions to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public, from significant ceiling water intrusion (instability of the surrounding wall/ceiling areas due to water saturation) due to severe roof leaks. On December 20, 2010, the census report was obtained from administrative staff. The census report, dated December 19, 2010, indicated there were 88 resident rooms, with three rooms closed. There were 85 occupied resident rooms, and the census was 160.On December 20, 2010, at 12:50 p.m., the lobby was observed to have three containers on the floor, and water was dripping into the containers. In the area of a fluorescent light fixture, which was illuminated, three ceiling tiles were removed and one tile was partially removed. The floor was visibly wet. During a concurrent interview with the Administrator, the Administrator stated there were ?diverting water pumps on the roof.? On December 20, 2010, beginning at 12:50 p.m., a tour of the facility was conducted with the Director of Nursing (DON). The facility had significant damage throughout the building from severe ceiling water intrusion, including the hallways, resident rooms, kitchen, utility, nursing stations, and common rooms. The following summaries outline the hazards observed on December 20, 2010.The resident rooms, common rooms, common areas, utility rooms, and nurse stations, listed below, had one or more of the following hazards observed: water coming from the ceiling and/or water in overhead electrical light fixtures; buckled, peeling, missing, and/or loose ceiling tiles or sheetrock; debris from the unstable ceiling tiles or sheetrock and/or plastic sheeting hanging down from the ceiling; black, brown, gray, pink, and/or yellowish discoloration and/or fuzzy growth on the ceiling, wall, and/or floor; wet and/or buckled floors; towels, blankets and/or receptacles to catch water on the floors; wet, bubbled, and/or spongy walls; peeling paint; a musty odor; and severe water intrusion. Affected Open Common Areas (according to facility map): --Main Lobby --Main Dining Room --Hallways: Diamond View, Emerald Crest (Rose Garden) and small hallway, Sapphire Terrace, Topaz Court, Pearl Vista, main corridor, hallway by Ice Cream Parlor; --Nurse Stations: North Nurse Station, common area, and clean utility room; Room 20 Nurse Station; South Nurse Station, common area, and housekeeping closet --Shower Rooms: Emerald Crest (Rose Garden), South Nurse Station Affected Occupied Resident Rooms: --105, 108, 111, 113, 116, 123, 141, 143, 147, 150, 151, 152, 159, 162, 163, 164, 172, 174, 178, 180, 181, 183, 184, 185, 187, 188 Affected Closed Resident Rooms: --160, 182, 186 Affected Closed Common Areas: --Ice Cream Parlor --Conference Room --Occupational Therapy --Social Dining Room --Chapel Other Open Affected Areas: --KitchenDuring the tour, concurrent interviews were conducted during the observations.Resident 1?s room had a plastic bag hanging from the ceiling, with water dripping down it into a container. There were white fragments (i.e., from the ceiling) on the floor. During a concurrent interview, Resident 1 stated, ?We?ve got rain coming down the window. B-bed is sopping wet.? The DON verified the ceiling had grayish spots that were circular and irregular, and that there was a beige-colored substance on the ceiling tiles. Room 123 had an area, approximately four foot by three foot, which was brown, buckled, cracked, with fuzzy brown and black growth over the A-bed, which was occupied by a resident. During a concurrent interview, the DON noted that the growth was green/gray fuzz. The wall at the head of the bed in Resident 2?s room was buckling. One corner had a patch that was peeling. The ceiling had brown spots and brown discoloration. During a concurrent interview, the family stated, ?We come out of the rain, into the rain.? In Room 182, there was water dripping. The ceiling had a black tarp. The ceiling was loose and wet. The floor was covered with water, and the floor was buckling. There were three containers on the floor, catching water. In a concurrent interview, the DON described the odor in the room as ?musty.? On December 21, 2010, the Department of Public Health, Riverside County Community Health Agency, Senior Industrial Hygienist, investigated the facility with visual inspection, air samples, and tape samples. The findings from the investigation included:Visual Inspection: ?Seven days of continuous rain produced many locations in the facility with water leaks.? Indoor Air Quality Samples: Five indoor air samples were taken. Mold spores (Aspergillus/Penicillum, Stachybotrys, and/or hyaline spores--dangerous molds which can cause pneumonia) tested positive in the lobby, kitchen, dishwasher room, south nurse station, and Room 123. Adhesive Tape Samples: ?Four adhesive tape samples were taken of the discoloration from the drywall in the hallway ceiling, next to the kitchen door, south nurse?s station and north nurse?s station, and the ceiling in the rose garden hallways?.Results of the tape sample showed Stachybotrys spores in all the samples?? The Senior Industrial Hygienist recommended prevention of future leaks, removal of sheetrock that had been wet for more than 48 hours, techniques to dry the environment, mold remediation (to fix in order to prevent further potential danger to humans), and additional mold air sampling clearance. The severe water intrusion created a hazardous environment, with the potential for injury, falls, fire, explosion, toxicity, and foodborne illness, as follows: Potential for Injury: Water was dripping and/or streaming from the ceiling. The ceiling tiles and sheetrock were unstable and had the potential to collapse. Potential for Falls: Floors were wet in patient care areas and common areas from water leaks throughout the facility. The floors were wet, which created a risk for slips and falls. There were containers on the floors, to catch water, which created a trip hazard. Potential for Fire: Electrical light fixtures had water leaking in and around the fixtures. Water was pooled in the covers of overhead fluorescent fixtures. Sheetrock, which represents a one-hour fire membrane according to the Office of Statewide Health Planning and Development Officer, was not present on some of the ceilings. Potential for Explosion: The area around the electrical panels in the secured unit (Emerald Crest hallway, known as the Rose Garden) was surrounded by water intrusion (wall, ceiling, floor, and adjacent hallway wall), which created a risk for explosion if the water penetrated the electrical panels.Potential Toxicity: Fuzzy growth and/or a musty odor was present on ceilings and walls in resident rooms, the shower room, the kitchen, the room with the ice machine, and common areas, such as hallways. According to the Centers for Disease Control (?Mold,? updated February 10, 2012), ?Mold growth?can smell musty?.Immune-compromised people and people with chronic lung illnesses, such as obstructive lung disease, may get serious infections in their lungs when they are exposed to mold.? In addition, mold spores aerosolize (suspend in the air?see results of air quality samples), increasing the risk of transmission, not only in the immediate area, but through the heating/ventilation system.Potential for Foodborne Illness: The kitchen had water leaks over the cold food preparation area, the hot food preparation area, and the dish room. These leaks created the potential to contaminate resident food, beverages, and dishes. The dining room had debris dropping from the ceiling. The above violations either jointly, separately, or in any combination had a direct or immediate relation to patient (resident) health, safety, or security. |
| 250000155 |
VISTA PACIFICA CENTER |
250010020 |
B |
30-Jul-13 |
6HFR11 |
6604 |
HSC 1418.91(a) A long-term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the department immediately, or within 24 hours. HSC 1418.91(b) A failure to comply with the requirements of this section shall be a class "B" violation. On May 17, 2012, at 11 a.m., an unannounced visit was made to the facility to investigate a complaint. During the investigation, it was determined the facility failed to report the allegation of abuse of Resident 1 by Resident 2, to the California Department of Public Health (CDPH) immediately, or within 24 hours.On May 17 and August 22, 2012, the record for Resident 1 was reviewed. Resident 1 was readmitted to the facility on March 11, 2011, with diagnoses including schizoaffective disorder (a disorder characterized by delusions/hallucinations and alternating episodes of depression and mania-abnormally high mood, overexcitement). The psychologist note, dated March 21, 2012, indicated, Resident 1 had "good insight." The Interdisciplinary Progress Note, dated May 15, 2012, at 4:15 p.m., indicated, "PC (Program Counselor 1) met w/resident (with Resident 1) due to resident (Resident 1) stating, 'I was raped!' PC discussed w/resident the details of incident in which resident stated, 'He (Resident 2) touched my chest.' PC counseled resident helping her differentiate rape and being touched w/out permission ...."On May 17 and August 22, 2012, the record for Resident 2 was reviewed. Resident 2 was readmitted to the facility on April 7, 2011, with a diagnosis of schizoaffective disorder. The psychologist note, dated May 1, 2012, indicated Resident 2, "has been very agitated and verbally aggressive ...issues of jealousy ...very irrational ..."On May 17, 2012, at 11:30, Resident 1 was interviewed. Resident 1 stated she was in her room on May 9, 2012, and had taken her shirt off, "to be comfortable." Resident 2 came into the room at approximately 6 p.m. Resident 2 began to "rub" Resident 1's breasts, and Resident 1 told him, "...No ....No ....I pushed him ....I gave up ...." Resident 1 stated, Resident 2 "sucked my" breasts; he was "sucking and sucking and it hurt."Resident 1 stated she told Mental Health Counselor 1 (MHC 1), during an outing in the community, on May 10, 2012, about the incident on May 9, 2012. Resident 1 said she used the word "rape."On May 17, 2012, at 1:20 p.m., Resident 3 was interviewed. Resident 3 had shared the room with Resident 2 (they were roommates on May 9, 2012). Resident 3 stated she witnessed the incident. Resident 3 stated, "(Resident 2) ...comes in room. He was trying to touch her, and she kept telling him not to touch her ...She was fighting him." On May 17, 2012, beginning at 11:50 a.m., MHC 1 was interviewed. MHC 1 stated Resident 1 reported to him, during an outing in the community on May 10, 2012, that Resident 1 "had been touched on the chest" by Resident 2. MHC 1 stated, back at the facility, Resident 1 said Resident 2 "never touched me. He came at me with his hands up." MHC 1 asked Resident 1 if it was a "delusional episode (delusion: false belief)," and she said, "'No, I don't think so.'" The Interdisciplinary Progress Note, dated May 15, 2012, at 4:15 p.m., indicated PC 1 "met w/resident (with Resident 1) in 1:1 (one-to-one) counseling due to resident stating, 'I was raped!'"On May 17, 2012, beginning at 11:50 a.m., PC 1 was interviewed about the one-to-one counseling. PC 1 stated, "(Resident 1) was scared ...didn't know what to do ...(I) tried to calm her down, and she gave me information regarding the incident." PC 1 referred to her notes and stated, "She made delusional statements for rape ....(e.g.) 'I kept pushing him off.'" PC 1 stated she (PC 1) "clarified it wasn't rape ...wasn't the penetrating." PC 1 stated, "I noticed story's (story is) changing all the time ...fondling chest ...(with) delusion(s) ...stories change frequently."On May 17, 2012, at 12:15 p.m, the Program Director (PD) was interviewed. The Program Director stated the determination was that it (Resident 1's allegation) was delusional, as Resident 1 stated, in the community, that she was "raped;" then, at the facility that "he (Resident 2) didn't touch her." The PD stated, "Our determination was (it was the same) incident ...with story changes." The PD stated the facility did not do a physical examination, as the PD did not hear an allegation of Resident 2 sucking or biting Resident 1's breasts. The PD stated, "A lot of her (Resident 1's) behaviors are attention-seeking ...(to) shout them (out) ...at community setting ...looking for attention from these outside sources ...."On May 17, 2012, at 1 p.m., a concurrent interview and record review was conducted with the Administrator. The Administrator stated there had been no incidents of abuse or altercations in May (2012).The facility "Abuse Prevention Program Policies and Procedures" were reviewed.The policy, titled "Facility Management Abuse Investigation," indicated: -"The resident has the right to be free from verbal, sexual, physical and mental abuse ..." -"When an alleged ...case of ...abuse is reported, the facility ...will notify the following ...agencies of such incident ...The State licensing/certification agency ..." -"Sexual abuse is defined as, but not limited to, sexual harrassment, sexual coercion, or sexual assault ...." -"Upon receiving reports of physical or sexual abuse, a licensed nurse or physician shall immediately examine the Resident ...."The policy, titled "Resident-to-Resident Abuse," indicated, "Should a resident be ...accused of seriously abusing another resident, our facility will implement the following actions ...Report incidents, findings, and corrective measures to appropriate agencies ..." The policy, titled "Reporting Abuse to State Agencies and Other Entities/Individuals," indicated, "Should an alleged ...abuse ...be reported, the facility ...will promptly notify the following ...agencies ...of such incident ...The State licensing/certification agency ..." The facility failed to report, to the California Department of Public Health, the allegation of sexual abuse of Resident 1 by Resident 2. Resident 1 made the facility aware of the alleged sexual abuse on May 10, 2012, and the facility failed to notify the California Department of Health of the allegation until May 17, 2012 (seven days later). The facility's failure to implement its abuse policies and procedures put all the residents at risk for potential abuse. These violations had a direct relationship to the health, safety, or security of patients. |
| 250000116 |
VILLA WOODS HOUSE |
250010026 |
B |
30-Jul-13 |
PSMK11 |
2490 |
1418.91 (a) A long-term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the department immediately, or within 24 hours.On April 12, 2012, at 2:55 p.m., a visit was made to the facility for the purpose of investigating a complaint allegation. Based on record review and interview, the facility failed to ensure one client's (Client 1) injuries of unknown origin were immediately reported to the California Department of Public Health, which resulted in the potential for a delay of investigation and potentially placing Client 1 at risk for further injury of her clavicle (collar bone).Findings: On April 12, 2012, a visit was made to the facility for the purpose of investigating a client injury that was reported to the California Department of Public Health (CDPH) by another agency. Client 1 had a history of Osteoporosis and Seizures.During a review of the facility's Special Incident Report, the document indicated that on March 25, 2012, at 1 a.m. and 4 a.m., the client was assisted to the bathroom. At 6:15 a.m., the client was assisted by Direct care Staff (DCS) to start the client's daily routine. When the DCS was changing the client's clothes at 8 a.m., a bruise was found on the client's left clavicle. Further record review revealed the Qualified Mental Retardation Professional QMRP and Registered Nurse (RN) were notified, and Client 1 was transported to the acute care hospital. Client 1 was assessed and an x-ray was done showing the left clavicle fracture.The physician documented risk factors as: multiple fractures, seizures, abnormal gait, and frailty. On April 12, 2012, at 3 p.m., the RN stated the client has Osteoporosis and her bones are brittle. On April 12, 2012, at 3:55 p.m., an interview was conducted with DCS 1. She stated, "She [Client 1] came in at 6 a.m., with another DCS. She was brought to the living room for her medications. At 8 a.m., I started to dress her and found the bruise. There were no falls." A review of the facility's documents indicated, the client's mother, the medical director, the day program, transportation and another agency were notified of Client 1's fractured clavicle, however, the facility failed to report the fracture immediately to the Department. On July 11, 2012, during an interview with the QMRP, she stated, "I can't remember the reason the incident wasn't reported to CDPH. It went to corporate and they felt they didn't need to report to CDPH. |
| 250000036 |
Valencia Gardens Health Care Center |
250010061 |
B |
15-Aug-13 |
90K911 |
4525 |
Title 22 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. The facility failed to implement the plan of care of assisting Patient A with transfer after toilet use to prevent a fall that occurred on 7/15/09. The fall resulted in a left hip fracture. Patient A, an 82-year-old female, was admitted to the facility on 10/11/08, with diagnoses that included congestive heart failure, hyperlipidemia (high cholesterol), and dementia (memory problems). Patient A was discharged to the acute care hospital on 7/16/09, for fracture of the left leg. At noon on 7/21/09, an unannounced visit was made at the facility to investigate a facility reported incident regarding Patient A's fall that resulted in a left hip fracture. The administrator was interviewed at noon and indicated that Patient A was transferred to the acute care hospital after the patient fell on her bathroom floor and sustained hip fracture. During an interview with Licensed Nurse 1 (LN 1) on 7/21/09, at 12:15 p.m., she stated that CNA 1 took Patient A to the bathroom and placed the patient on the toilet. She stated that CNA 1 left Patient A alone on the toilet while she went into another room to help a second patient who had called for assistance. When CNA 1 returned to Patient A's room, she found the patient on the floor. CNA 1 asked for help, and two nursing staff helped CNA 1 transfer Patient A into a wheelchair and then onto the patient's bed.The physician was notified and ordered an x-ray (photographic film used to diagnose) for Patient A. The x-ray indicated that the patient had a hip fracture, and she was transferred to the acute care hospital for evaluation and treatment of hip fracture. An interview with CNA 2 was conducted on 7/21/09, at 1:15 p.m. She stated that Patient A required moderate assist with one person physical help for transfers. She stated, "The patient (Patient A) cannot pivot during transfer, and required one person assist with moderate assist for toilet use." On 7/21/09, Patient A's record was reviewed. Patient A's current Minimum Data Set (MDS), an assessment tool, dated 4/24/09, indicated the patient had short and long term memory deficits and required extensive assistance for transfers and toilet use. The "Fall Risk Assessment," dated 4/4/09, indicated Patient A's fall assessment total score was 16. The fall assessment indicated a total score of 10 or above was a high risk for fall. In an interview with CNA 1 on 7/22/09, at 9:42 a.m., she stated that Patient A required moderate assist with one person physical help for transfers and toilet use. CNA 1 stated that on 7/15/09, at approximately 2:30 p.m., she took Patient A to the bathroom, put the patient on the toilet, and left the room to help another patient in the other room. When she returned to Patient A's room, she found the patient on the bathroom floor. Two nursing staff helped her to transfer Patient A into the wheelchair and onto the patient's bed. A review of the facility's summary of the investigation for Patient A's fall indicated that CNA 1 placed Patient A on the toilet and did not stay with the patient.Further review of Patient A's record revealed a care plan, "Potential for injury R/T (related to) Hx (history) of falls, Fall Risk Score-18 continued Functional decline with Gen (general) weakness." The care plan was dated 10/25/08, and included an approach plan to, "Assist w/ (with) all transfers." Review of the "Physician Orders" included a telephone order, "May have x-ray to left hip for left hip pain," dated 7/15/09, at 3:15 p.m. An entry in the "Licensed Personnel Progress Notes" (LPPN),on 7/15/09, at 2:25 p.m., read, "Pt (patient) was in restroom and tried to get up without assistance and fell pt (patient) was found lying on left side on bathroom floor c/o (complain of) pain to left hip..." An entry at 10 p.m., read, "...Received notification from x-ray lab that resident has an acute left hip fracture...Dr called..." An entry on 7/16/09, at 10:30 a.m., indicated Patient A was transferred to the hospital emergency room for possible surgery of left hip fracture. Therefore, the facility failed to implement the plan of care for assisting Patient A with transfer after toilet use to prevent a fall on 7/15/09, which resulted in a left hip fracture.The above violation had a direct or immediate relationship to the health, safety, or security of patients. |
| 250001233 |
VERBENA HOUSE |
250010129 |
B |
09-Sep-13 |
XOW411 |
2989 |
The specific citation tag was W156 483.420(d)(4) The facility failed to report sexual abuse and results of all investigations must be reported to the administrator or designated representative or to other officials in accordance with State law, within five working days of the incident. An unannounced visit was made to the facility on November 14, 2012, to investigate a self-reported incident of medications not being administered to one client (Client B). During the course of the investigation, it was discovered Client A and B had an incident of oral sex, on July 20, 2012, during the night shift. This incident was not reported to California Department of Public Health (CDPH).It was determined the facility failed to report the incidence of sexual abuse to CDPH within five working days. Client A was admitted to the facility on February 2, 1996, with diagnoses that included severe intellectual disability. Client B was admitted to the facility on June 29, 2001, with diagnoses that included profound intellectual disability. On November 14, 2012, the record for Client A was reviewed. The facility document titled, "QMRP/QIDP (Qualified Intellectual Disability Professional) Notes," dated July 21, 2012, was reviewed. The document revealed, "...DCS (direct care staff) reports that he observed mutual kissing and oral copulation (sex) between Client A and Client B. Client A was performing oral sex on the other consumer. Per DCS, the activity appeared to be mutually consensual..." Additional documentation in the "QMRP/QIDP Notes," revealed, on July 23, 2012, QMRP (QIDP) discussed sexual activity with psychiatrist. The psychiatrist advised that given education, residents' developmental age', that neither resident had the ability to consent and that both residents should be redirected and therefore protected..." On November 14, 2012, at 3:10 p.m., the DCS staff was interviewed. The DCS staff stated Client A went to Client B's room and had oral sex. Client A ambulated at night when he was restless..." Further review of Client A's record, on the RN (Registered Nurse) Notes, dated July 20, 2012, revealed, "...(Client A) had been observed sexually involved with the other resident when his penal (sic) (Client B's) shaft in his mouth..." Client B's record indicated the duplicate documentation. The facility failed to report to CDPH within five working days, the witnessed sexual abuse between Client A and Client B. On November 14, 2012, the facility policy and procedure titled, "Policy: Prevention of Abuse, Neglect and Mistreatment," was reviewed. The policy revealed, "...The purpose of these procedures is to ensure prompt detection of abuse, neglect, or mistreatment; provide appropriate and thorough investigation; provide resolution for any occurrence of abuse, neglect or mistreatment; and ensure reporting as specified in federal, state and local regulation..." This failure had a direct or immediate relationship to the health, safety, or security of clients. |
| 250001233 |
VERBENA HOUSE |
250010131 |
B |
09-Sep-13 |
XOW411 |
3266 |
The specific citation tag was W157 483.420(d)(4)The facility failed to ensure clients at the facility were free from sexual abuse by a peer/client. An unannounced visit was made to the facility on November 14, 2012, to investigate a self-reported incident of medications not being administered to one client (Client B). During the course of the investigation, it was discovered Clients A and B had an incident of oral sex. Client A was admitted to the facility on February 2, 1996, with diagnoses that included severe intellectual disability. Client B was admitted to the facility on June 29, 2001, with diagnoses that included profound intellectual disability. On November 14, 2012, the record for Client A was reviewed. The facility document titled, ?QMRP/QIDP (Qualified Intellectual Disability Professional) Notes,? dated July 21, 2012, was reviewed. The document revealed, ??DCS (direct care staff) reports that he observed mutual kissing and oral copulation(sex) between Client A and Client B. Client A was performing oral sex on the other consumer. Per DCS, the activity appeared to be mutually consensual?? Additional documentation in the ?QMRP/QIDP Notes,? revealed, on July 23, 2012, QMRP discussed sexual activity with psychiatrist. The psychiatrist advised that, ?Given education residents? developmental age?, that neither resident had the ability to consent and that both residents should be redirected and therefore protected?? On November 14, 2012, at 3:10 p.m., the DCS staff was interviewed. The DCS staff stated Client A went to Client B?s room and had oral sex. Client A ambulated at night when he was restless?? Further review of Client A?s record, on the RN (Registered Nurse) Notes, dated July 20, 2012, revealed, ??(Client A) had been observed sexually involved with the other resident when his penal (sic) (Client B?s) shaft in his mouth?? On November 14, 2012, Client A?s record contained a document titled, ?Human Sexuality Interview,? was reviewed. The document had nine pages of questions regarding sexual issues, Client A was unable to respond verbally to any of these questions. Client B?s record indicated the duplicate documentation. On November 14, 2012, Client B?s record contained a document titled, ?Human Sexuality Interview,? was reviewed. The document had nine pages of questions regarding sexual issues, Client B was unable to respond verbally to any of these questions.On November 14, 2012, the facility policy and procedure titled, ?Policy: Prevention of Abuse, Neglect and Mistreatment,? was reviewed. The policy revealed, ??The purpose of these procedures is to ensure prompt detection of abuse, neglect, or mistreatment; provide appropriate and thorough investigation; provide resolution for any occurrence of abuse, neglect or mistreatment; and ensure reporting as specified in federal, state and local regulation??There were no Individual Service Plans (ISP) for Clients A or B for behavior goals for participating in sex with peers. There was no documentation that the QIDP or RN were monitoring for further sexual activity for Clients A or B. The facility failed to ensure Clients A and B were free from sexual abuse. This failure had a direct or immediate relationship to the health, safety, or security of clients. |
| 250000155 |
VISTA PACIFICA CENTER |
250010421 |
B |
06-Feb-14 |
CIFE11 |
4159 |
CFR 483.13 (b) CFR 483.13 (c) (1) (I) (b) Each patient shall be treated as individual with dignity and respect and shall not be subjected to verbal or physical abuse of any kind. The facility failed to ensure Resident 1 was treated with dignity and respect, and was not subjected to verbal abuse from a facility staff member on December 28, 2013. An interview was conducted with Certified Nursing Assistant 1, (CNA 1) on December 31, 2013, at 10:55 a.m. CNA 1 stated he was assisting CNA 3 with the check- in of residents coming back to the facility from a pass on December 28, 2013, at 8:15 p.m. CNA 1 and CNA 3 checked the returning residents for potential contraband (Items not allowed in the facility for safety reasons). CNA 1 stated he put Resident 1's hat back on Resident 1's head after checking it. Resident 1 expressed that he did not like staff members placing the hat back on his head. CNA 1 stated he apologized to Resident 1 for placing his hat on his head. Resident 1 had made some derogatory (belittling) statements to CNA 1and CNA 3 about the hat placement. CNA 1 stated CNA 3, "Responded by calling (Resident 1) a faggot." CNA 2 continued to state, "There was another confrontation in the television room with Resident 1 and CNA 3."CNA 1 further stated, CNA 2 "[Name Withheld] saw this."An interview was conducted with a CNA 2 on December 31, 2013, at 12 noon. CNA 2 stated, "Staff (CNA 3) crossed the line with the resident."CNA 2 reported she was, " Walking in the hallway near the television room with (CNA 3)" when Resident 1 came up to CNA 3 and stated, "You wanted to kick my ass ... he(CNA 3) said, " Yes I did ...what are you going to do about it ...if you ' re not going to do anything about it walk away. " CNA 2 stated Resident 1 then became agitated. CNA 1 stated, "He started pacing and seemed upset. " CNA 2 stated she, "Assisted Resident 1 back to his room." CNA 2 stated she "Did not want to leave the unit to report the incident, with what had taken place between Resident 1 and CNA 3 [Names Withheld]. CNA 2 stated she, "Waited ten minutes for her supervisor to return from lunch." An interview was conducted with the evening Charge Nurse on December 31, at 11:55 a.m. The Charge Nurse stated, "CNA 2 [Names Withheld] came to me around 8:45 p.m. and told me there was an incident between Resident 1 and CNA 3." The Charge Nurse stated, "He (CNA 3) called Resident 1 a faggot ...and said if you want to fight we could fight right now." An interview was conducted with Resident 1's conservator on December 31, 2013, at 12:30 p.m. The conservator stated that she was not called regarding the verbal incident which took place between Resident 1 and CNA 3. She stated, "I had to call the next day after he (Resident 1) had called me and told me he had a fight with a worker." An interview was conducted with Resident 1 on December 31, 2013, at 9 a.m. Resident 1 was asked about the incident that took place with CNA 3. Resident 1 stated, (he) "Did not want to go there." An interview was conducted with the Program Director/Administrative Assistant (PDAA) on December 31, 2013, at 9 a.m. The PDAA stated CNA 3 "was in complete denial of his actions ...blaming the resident (Resident 1) all the way up until (CNA 3's) termination." A record review of Resident 1's clinical record conducted on December 31, 2013, indicated, Resident 1 was admitted November 14, 2013, with diagnoses paranoid schizophrenia (chronic belief of persecution) and depression. A review of the facility undated document conducted on December 31, 2013 titled, "Patients' Rights/Confidentiality, "indicated ... "Policies and procedures shall ensure that each patient admitted to the facility shall have the following rights and be notified of the facility ' s obligations ... (10) To be treated with consideration, respect and full recognition of dignity, and individuality, including privacy in treatment and care of personal needs." The facility's failure to ensure Resident 1 was treated with dignity and respect " caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety, or other emotional trauma to patients." |
| 250000154 |
VISTA PACIFICA CONVALESCENT HOSPITAL |
250010505 |
B |
28-Feb-14 |
N8HS11 |
4422 |
1418.91(a)(b) Reports of incidents of alleged abuse or suspected abuse of residents. (a) A long-term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the department immediately, or within 24 hours. (b) A failure to comply with the requirements of this section shall be a class ?B? violation. The facility failed to notify the Department of the alleged verbal abuse of Resident A by CNA 1 (Certified Nursing Assistant) immediately, or within 24 hours. On September 29, 2011, the facility reported an incident of verbal abuse to the Department. CNA 1 allegedly called Resident A, ?You f?ing crazy old man.? On October 3, 2011, at 3:25 p.m., an unannounced visit was made to the facility to investigate the entity-reported event regarding the alleged verbal abuse of Resident A by CNA 1. CNA 2 was interviewed on October 3, 2011, at 3:45 p.m. CNA 2 stated she heard CNA 1 say to Resident A, "You f?ing crazy old man. I'm going to take you back to your room and tell your roommate to abuse you sexually." CNA 2 stated she had not reported the incident to the CN (Charge Nurse) on duty because the CN only worked at the facility one or two times a month and she didn?t know him. CNA 2 indicated she was then off for two days and reported the incident to CN 1 when she returned to work. CN 1 was interviewed on October 3, 2011, at 4:00 p.m. CN 1 stated that CNA 2 reported the incident to her on September 27, 2011, at 10:00 p.m. CNA 2 indicated the incident happened about a week earlier. CN 1 stated CNA 2 reported that CNA 1 told [Resident A], "That man (Resident A's roommate) is going to rape you in the ass if you don't stay in bed." CN 1 stated she did not report the incident to the Director of Nursing until the next day. Resident A`s record was reviewed on October 3, 2011. Resident A was admitted to the facility on May 18, 2011. Diagnoses included Alzheimer's disease, (a chronic progressive degenerative cognitive disorder causing significant functional disability), depressive disorder, psychosis (a mental disorder with severe loss of conscious reality), and heart complications. The "Resident to Resident Investigation Report Form", dated October 3, 2011, was reviewed. Documentation indicated that on September 27, 2011, at 10:00 p.m., CNA 2 reported to CN 1 that approximately one week earlier, she heard CNA 1 tell Resident A, "If you keep getting out of bed, the black man in the bed next to you is going to rape you." The report also indicated on September 24, 2011, CNA 2 heard Resident A tell CNA 3 that he did not want to go to bed because he did not want his roommate to rape him. CNA 1 was terminated from employment on October 3, 2011. A follow-up visit to the facility was conducted on November 3, 2011, at 8:55 a.m. The facility's policy and procedure titled, "Reporting Abuse to Facility Management" was reviewed. The policy indicated: ?It is the responsibility of our employees...to promptly report any incident or suspected incident of neglect or suspected abuse...The administrator and director of nursing services must be promptly notified of suspected abuse or incidents of abuse. If such incidences occur or are discovered after hours, the administrator and director of nursing services must be called at home or must be paged and informed of such incident...?The policy titled, ?Preventative Abuse and Reporting Policy? indicated, ?Any reasonable suspicion of a crime?requires the report to be made to CDPH and local law enforcement within twenty four hours..." CNA 2 failed to immediately report the witnessed verbal abuse toward Resident A, by CNA 1, for over a week. CNA 3 failed to immediately report the allegation of verbal abuse toward Resident A, by CNA 1, to facility administration staff. Charge Nurse 1 (CN 1), failed to immediately report the allegation of verbal abuse and the verbal threat toward Resident A, by CNA 1, for an additional 24 hours. The facility did not implement their resident abuse policy and procedure and failed to report the allegation of abuse to the Department within 24 hours.This failed practice placed Resident A and other residents at risk for abuse by CNA 2. The above violation caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety, and/or other emotional trauma to Resident A with the potential to affect the safety of other residents. |
| 250000154 |
VISTA PACIFICA CONVALESCENT HOSPITAL |
250010506 |
B |
28-Feb-14 |
N8HS11 |
4502 |
CLASS B CITATION - ABUSE483.13(b) (F223) The resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. The facility failed to ensure Resident A was protected from the verbal abuse of CNA 1 (Certified Nursing Assistant).On September 29, 2011, the facility reported an incident of verbal abuse to the Department. CNA 1 allegedly called Resident A, "You f...ing crazy old man." On October 3, 2011, at 3:25 p.m., an unannounced visit was made to the facility to investigate the entity- reported event regarding the alleged verbal abuse of Resident A by CNA 1. CNA 2 was interviewed on October 3, 2011, at 3:45 p.m. CNA 2 stated she heard CNA 1 say to Resident A, "You f...ing crazy old man. I'm going to take you back to your room and tell your roommate to abuse you sexually." CNA 2 stated she had not reported the incident to the CN (Charge Nurse) on duty because the CN only worked at the facility one or two times a month and CNA 2 didn't know the CN. CNA 2 indicated she was then off for two days and reported the incident to CN 1 when she returned to work. CN 1 was interviewed on October 3, 2011, at 4:00 p.m. CN 1 stated that CNA 2 reported the incident to her on September 27, 2011, at 10:00 p.m. CNA 2 indicated the incident happened about a week earlier. CN 1 stated CNA 2 reported that CNA 1 told [Resident A], "That man (Resident A's roommate) is going to rape you in the ass if you don't stay in bed." CN 1 stated she did not report the incident to the Director of Nursing until the next day. Resident A`s record was reviewed on October 3, 2011. Resident A was admitted to the facility on May 18, 2011. Diagnoses included Alzheimer's disease, (a chronic progressive degenerative cognitive disorder causing significant functional disability), depressive disorder, psychosis (a mental disorder with severe loss of conscious reality), and heart complications. The "Resident to Resident Investigation Report Form", dated October 3, 2011, was reviewed. Documentation indicated that on September 27, 2011, at 10:00 p.m., CNA 2 reported to CN 1 that approximately one week earlier, she heard CNA 1 tell Resident A, "If you keep getting out of bed, the black man in the bed next to you is going to rape you." The report also indicated on September 24, 2011, CNA 2 heard Resident A tell CNA 3 that he did not want to go to bed because he did not want his roommate to rape him. CNA 1 was terminated from employment on October 3, 2011. A follow-up visit to the facility was conducted on November 3, 2011, at 8:55 a.m. The facility's policy and procedure titled, "Reporting Abuse to Facility Management" was reviewed. The policy indicated: "It is the responsibility of our employees...to promptly report any incident or suspected incident of neglect or suspected abuse...The administrator and director of nursing services must be promptly notified of suspected abuse or incidents of abuse. If such incidences occur or are discovered after hours, the administrator and director of nursing services must be called at home or must be paged and informed of such incident..."The Minimum Data Set (an assessment tool), completed for Resident A, indicated extensive dependency on staff for all personal care was needed and a wheel chair for locomotion was utilized. The policy titled, "Preventative Abuse and Reporting Policy" indicated, "Any reasonable suspicion of a crime...requires the report to be made to CDPH and local law enforcement within twenty four hours..." CNA 2 failed to immediately report the witnessed verbal abuse toward Resident A, by CNA 1, for over a week. CNA 3 failed to immediately report the allegation of verbal abuse toward Resident A, by CNA 1, to facility administration staff. Charge Nurse 1 (CN 1), failed to immediately report the allegation of verbal abuse and the verbal threat toward Resident A, by CNA 1, for an additional 24 hours. The facility did not implement their resident abuse policy and procedure by failing to: protect Resident A from being abused; follow the facility policy and procedure regarding resident abuse; report the allegation of abuse to the Department within 24 hours.These failed practices caused Resident A to experience fear, anxiety, and humiliation. The above violation caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety, and/or other emotional trauma to Resident A with the potential to affect the safety of other residents. |
| 250000155 |
VISTA PACIFICA CENTER |
250010560 |
B |
20-Mar-14 |
HP0311 |
2982 |
Class B Citation F 226: 42 CFR 483.12 (C) The facility failed to report an allegation of resident to resident abuse to The Department within 24 hours, per the facility's policy and procedure. The facility failed to report to an allegation of physical abuse between Residents A and B within 24 hours to The Department, per facility policy and procedure. The facility reported the incident physical abuse between Resident A and Resident B to The Department three days later. On April 2, 2012, at 10:45 a.m., an announced visit was made to the facility to investigate the report of physical abuse between Resident A and Resident B.An Interdisciplinary Progress Noted, written by Licensed Vocational Nurse 1 (LVN 1) for Resident 2, dated March 24, 2012, 3:00 p.m., indicated, "At approx (approximately) 1:00 p.m., the Resident (Resident A) approached the nurses station and asked where [name of administrator] was I told him [name of administrator] was @ (at) lunch. He then walked away and proceeded to go into Room [room number of Resident B)] where Resident (B) was visiting other residents. This Resident (A) the struck Resident (B) on the back of the head x (times) 2. At that point Resident (B) turned around and struck Resident (A), leaving a 6" (six inch) scratch on his forehead..." The Resident to Resident Investigation Report form, completed by LVN 1 on March 24, 2012, indicated the Administrator, Director of Nurses, Program Director, and Ombudsman, were notified of the incident of physical abuse (between Residents A and B) on March 24, 2012. The same form indicated the facility's Program Director notified Department of Health on March 27, 2012, three days after the incident occurred. The Administrator was unavailable and a concurrent interview was conducted with the Program Director (PD). The PD stated that the report of physical abuse between Resident A and Resident B should have been reported within 24 hours and was not reported until March 27, three days after the incident occurred.A facility policy and procure titled, "Reporting Abuse to State Agencies and Other Entities/ Individuals" indicated, "Should an alleged/suspected violation or substantiated incident of mistreatment ...or abuse occur ...the facility administrator or his/her designee will promptly notify ...the State Licensing/Certification agency responsible for surveying/licensing the facility ...verbal notices to the State/Licensing Agency will be made within 24 hours of the occurrence of such an incident." The facility failed to ensure that a report of physical abuse between Residents A and B was reported to The Department within 24 hours, per facility policy and procedure. The facility reported the incident of physical abuse occurring, March 24, 2012, between Residents A and B, to The Department three days later, on March 27, 2012. The above violations either jointly, separately, or in any combination, had a direct or immediate relation to patient health, safety or security. |
| 250001233 |
VERBENA HOUSE |
250012607 |
B |
21-Oct-16 |
19I611 |
3620 |
W149 483.420(d)(1) The facility must develop and implement written policies and procedures that prohibit mistreatment, neglect, or abuse of the client. The facility failed to ensure Client 1's right to be free from sexual abuse. An unannounced visit was made to the facility on January 22, 2015, to investigate a entity reported incident that Client 1 was sexually abused by Client 2. On January 22, 2015, at 2:15 p.m., the Program Manager (PM) was interviewed. The PM stated at 6 a.m. on January 16, 2015, the doorbell rang at the facility. The night shift staff went to open the door for the day shift direct care staff (DCS). DCS 1 was at the door. On the same date, the facility document titled, "Staff Report Form," was reviewed. The document indicated, "...Date of event 1-16-15... Time of event 6:20 a.m....Describe what happened: Staff walked into Client 1's bedroom and found Client 2 performing an oral sex act on him. Review of the facility document with the night shift staff's declaration indicated, "On 1-16-15, I walked into (Client 1's) room to do my client check shortly after I had opened the door for my co-worker. Upon entering (Client 1's) room, I encountered (Client 2) performing an oral sex act on him..." The facility document titled, "Special Incident Report," dated January 16, 2015, indicated, "...Additional Explanation or Comments: There have been interactions between these two individuals in the past reported to CDPH (California Department of Public Health).. Noc (night) staff reported that this morning (Client 2) detached the sensor for the alarm in his room, preventing the function of the alarm, before exiting then entering the room of (Client 1)..." The facility document titled, "Psychological Assessment," for Client 2, dated June 12, 2013, indicated, "...Test Results Bayley Scales of Infant Development Age Equivalent Mental = 17 months..." The facility document titled, "Psychological Assessment," for Client 1, dated June 12, 2013, indicated, "Test Results Bayley Scales of Infant Development Age Equivalent Mental = 18 months..." The facility documents titled, "Noc (night) Check Report (complete every 15 minutes noting status)," indicated the following: a. On January 14, 2015, night shift DCS did not document from 10:45 p.m. to 11:45 p.m. for Client 1, that room checks were completed; b. On January 16, 2015, night shift DCS did not document from 9 p.m. to 9:45 p.m., for Client 2 that room checks were completed; c. On January 15, 2015, night shift DCS did not document from 9 p.m. to 9:45 p.m. for Client 2 that room checks were completed. On May 11, 2015, at 7:20 p.m., DCS 1 was interviewed. DCS 1 stated, on January 16, 2015, he completed his 15 minute checks on the two clients at 6 a.m. Client 2 appeared to be sleeping in his room. DCS 1 went to answer the door for the day shift staff. DCS 1 stated he would shower Client 1 at this time in the morning. When DCS 1 entered Client 1's room, he observed Client 2 performing an oral sex act on Client 1. DCS 1 stated he had never witnessed this between Clients 1 and 2. On May 11, 2015, an undated facility policy and procedure titled, "Policy: Prevention of Abuse, Neglect and Mistreatment," was reviewed. The policy indicated,"...The purpose of these procedures is to ensure prompt detection of abuse, neglect, or mistreatment; provide appropriate and thorough investigation; provide resolution of any occurrence of abuse, neglect or mistreatment..." The facility failed to ensure Clients 1 and 2 were free from sexual abuse. This failure had a direct relationship to the health, safety, or security of clients. |
| 970000009 |
VIEW PARK CONVALESCENT CENTER |
910010563 |
B |
22-Mar-14 |
H93E11 |
6286 |
F164 483.10(e) Privacy and Confidentiality The resident has the right to personal privacy and confidentiality of his or her personal and clinical records. The resident's right to refuse release of personal and clinical records does not apply when the resident is transferred to another health care institution; or record release is required by law.The facility must keep confidential all information contained in the resident's records, regardless of the form or storage methods, except when release is required by transfer to another healthcare institution; law; third party payment contract; or the resident.On January 16, 2014 at 8 a.m. an unannounced visit was made to the facility to initiate the annual Recertification survey. Based on observation, interview, and record review, the facility failed to ensure certified nursing assistant 1 (CNA 1) did not disclose the resident private health history to another resident (3). This resulted to Resident 13 feeling violated, angry, humiliated, frustrated, and embarrassed which caused the resident to isolate himself.During the group meeting of alert and oriented residents on January 18, 2014, at 11:10 a.m., Resident 13 announced in the presence of the other residents and two evaluators, that he had been violated and requested to communicate with the evaluators after the group meeting.During an interview with Resident 13 on January 18, 2014, at 11:55 a.m., he stated he was very depressed by the way he was being treated by the staff who worked in the facility. He said a staff member disclosed his personal health history to Resident 3. Resident 13 said he was newly admitted and had only been in the facility for two weeks before the problems began. He said on January 7, 2014, CNA 1 told Resident 3, who was at that time a good friend of his, about his health history. Resident 13 said he could not believe it when Resident 3 angrily confronted him demanding to know if what she had been told by CNA 1 was in fact truth or a lie. Resident 13 said he told Resident 3 that CNA 1 had no right to reveal his private health history to her or anyone else. After Resident 3 found out his health history, she didn't want to be friends.The resident said initially he was very angry, embarrassed, and miserable that his private health history had been disseminated (spread) throughout the survey. Resident 13 was in tears when he said he felt "totally violated, rejected, and isolated as an individual." During an interview with the director of nurses (DON) on January 18, 2014, at 3:05 p.m., she stated the incident of the staff disclosing the resident personal health history occurred when she was on vacation. However, when she returned to duty she was made aware of the incident and was informed by the administrator that he had taken care of the incident. The DON said she did not do anything regarding an investigation, nor did she provide additional psychological support to Resident 13.During an interview with the director of staff development (DSD) on January 18, 2014, at 3:15 p.m., she stated she was informed of the incident by Resident 13. She said Resident 13 informed her that CNA 1 disclosed his personal health information to Resident 3 and as a result of the staff disclosure he felt violated and isolated. She said CNA 1 was terminated for failing to comply with the terms of her new hire agreement. When asked if the facility provided psychological support for the resident she stated the facility staff received in-service training.During an interview with the administrator on January 18, 2014, at 3:25 p.m., he stated on January 7, 2104, Resident 13 approached him and communicated to him a major concern that caused him great pain. The administrator said he then began to receive phone calls from Resident 13's sister and primary physician who expressed their outrage and disappointment regarding the dissemination of the resident private health history by the facility's staff to other residents. The administrator said he had not followed up with the resident regarding making sure the incident would not reoccur. During an interview with the social worker designee on January 18, 2014, at 3:40 p.m., she stated Resident 13 approached her and informed her that he was very unhappy because CNA 1 disclosed his personal health history to Resident 3, and that since the breach of confidentiality the residents residing in the facility began to treat him differently. She said since the incident, Resident 13 has remained sad and isolated. She said she has attempted to reach out to him but that he remains unhappy. The social worker designee stated the facility had not provided an opportunity for the resident to talk about his feelings to a trained behaviorist or psychologist (professional in psychology). Resident 13's admission record indicated the resident was admitted to the facility on December 30, 2013, with the diagnoses that included human immunodeficiency virus (HIV [virus disabling immune system]), and depression.The Minimum Data Set (MDS) a standardized assessment and care screening tool, dated January 10, 2014, indicated the resident had the capacity to understand, and had no cognitive impairment. A review of the physician's summary, nursing summary, and social worker designee notes indicated no documented evidence of the incident regarding the violation of Resident 13's privacy rights or the concern of the resident health history disclosure.There was no plan of care initiated/developed to ensure the incident did not happen again. There was no documented evidence the facility provided psychosocial assistance to Resident 13 as verified during the previous interviews with the DSD and the social worker designee.The facility policy and procedure titled, "Privacy" indicated the resident has the right to privacy of health information.The facility failed to ensure certified nursing assistant 1 (CNA 1) did not disclose the resident private health history to another resident (3). This resulted to Resident 13 feeling violated, angry, humiliated, frustrated, and embarrassed which caused the resident to isolate himself.The above violations caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety, or other emotional trauma to Resident 13. |
| 910000016 |
VERMONT HEALTHCARE CENTER |
910010651 |
B |
21-Apr-14 |
TGIC11 |
7599 |
F309 483.25 Quality of Care Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. On January 9, 2014 at 7 a.m. an unannounced visit was made to the facility to initiate an annual Recertification survey. Based on observation, interview, and record review, the facility failed to provide the necessary care and services by failing to:1. Ensure Resident 19's left hand and leg were assessed for the cause of pain. 2. Ensure Resident 19 was monitored for the effectiveness of the as needed (PRN) pain medication. 3. Ensure Resident 19?s physician was notified of the ineffectiveness of the PRN pain medication so they could obtain an order for other interventions to relieve the resident's pain.On January 10, 2014 at 10:45 a.m., Resident 19 was observed in the front lobby, sitting in a wheelchair with both lower extremities elevated on a pillow. The resident was wearing plastic braces on both lower extremities and her left leg had slid off the footrest and was resting on a pillow between the two footrests. Resident 19 was crying and said her left leg was hurting. Staff members were observed walking by the resident in the lobby but no staff members stopped and asked the resident why she was crying. The assistant director of nurses (ADON) saw and heard the resident crying out and he came over and took the resident to her room.In another observation on January 10, 2014 at 11:10 a.m., Resident 19 was sitting in a wheelchair in the dining room. The resident was crying, frowning holding her left hand up and said her hand was hurting. The activity staff kept telling the resident to wait a minute and she would be right there, but continued assisting other residents in the dining area for approximately 5 minutes. The activity staff left the dining area and went across the hall to the smaller dining area without assisting Resident 19 or reporting to the nursing staff that the resident was complaining of pain in her left hand. At that time the evaluator intervened and asked the activity staff member what had been done to address the resident's complaint of pain. She stated she should have reported to the charge nurse that the resident was in pain.According to the admission record, Resident 19 was admitted to the facility on May 7, 2010, with diagnoses that included pneumonia (an infection of the lung), and cerebral vascular accident (stroke) with left hemiparesis (weakness on one side of the body).The Minimum Data Set (MDS), a standardized assessment and care screening tool, dated April 9, 2013, indicated Resident 19 had no cognitive impairment and was able to make her needs known. The resident required extensive assistance and was totally dependent on staff for all her care needs, and had functional limitation in range of motion to her upper and lower extremities. The MDS indicated the resident had frequent pain that was moderate in intensity. The physician's orders, dated February 14, 2011, indicated an order for Tylenol 650 milligrams (mg) by mouth every six hours as needed for pain and temperature greater than 100.5 Fahrenheit, and Vicodin 5/500 mg one tablet twice a day as needed for severe pain.A care plan dated January 13, 2014, for at risk for deformities, fractures and pain related to osteopenia (bone loss)indicated to observe the resident for joint bone pain and stiffness, and to notify the physician accordingly.The Pain Assessment Flow Sheet for January, 2014, indicated the resident had last received Vicodin 5/500 mg for pain in her left hand on January 9, 2014, at 5 p.m.During an interview conducted with Resident 19 on January 14, 2014 at 7:45 a.m., she stated she had pain in her left hand due to arthritis (a medical condition affecting a joint or joints, causing pain, swelling, and stiffness) and the nurses were giving her pain medication, but it does not work. Resident 19 stated on a pain scale of 1 to 10 (10 being the worst pain a person could experience), her pain level was between 9 and 10 on the pain scale.On January 15, 2014 at 3:15 p.m., during an interview, licensed vocational nurse 11 (LVN 11) stated the resident was able to make her needs known, and was able to say what her pain scale level was on a level of 1 to 10. LVN 11 stated she did not think the pain medication was effective for Resident 19, but she did not give the Vicodin every day, and she waits until the resident asks her for the Vicodin. She stated she should have called the physician and informed him that the Vicodin was not working and requested an order for administration of routine pain medication.During an observation on January 10, 2014 at 4:10 p.m., Resident 19 was heard moaning, and when asked, the resident stated she had pain in her left hand on a pain scale level of 10. The resident stated she had pain daily and the pain pills were not working.Resident 19's Pain Assessment Flow Sheet, dated January 10, 2014 at 4:30 p.m., indicated the resident's pre-analgesic (before) pain level was 7 out of 10. Vicodin 5/500 milligrams (mg) tablet was given. The post-analgesic (after) pain level documentation indicated 0 out of 10 at 5:30 p.m. However, the time of record review was 4:32 p.m., a discrepancy of 58 minutes from the time documented on the form.During concurrent interview with LVN 12, who administered the Vicodin on January 10, 2014, at 4:30 p.m., she stated she intended to go back and re-assess the resident's pain, but she did not and documented the post-analgesic result without assessing Resident 19. LVN 12 stated post-analgesic assessments should be done 30 minutes to an hour after the pain medication was administered.A review of the Pain Assessment Flow Sheet indicated from December 1 to 27, 2013, Resident 19 received Vicodin 5/500 mg 21 times for severe left hand and lower extremities pain.During an interview and record review with the assistant director of nurses (ADON) on January 10, 2014, at 4:45 p.m., he confirmed Resident 19 had been complaining of severe pain to her left hand. The ADON stated the licensed nurses should have assessed the resident's left hand and notified the physician to identify the cause of the resident's pain and to obtain an order for routine pain medication. The ADON also stated Resident 19's pain should have been reassessed 30 minutes to an hour after the pain medication was administered.The facility's policy and procedure titled, Pain-Clinical Protocol, dated January 29, 2013, indicated the staff will evaluate and report how much and how often the individual asks for as needed (PRN) pain medication. If more than occasional analgesic requests, and depending on the success of non-pharmacological (interventions that does not involve drugs) interventions, the physician will consider changing to regular administration of at least one analgesic with another medication for PRN use, increasing the standing dose of an existing analgesic, or switching to another analgesic. The facility failed to provide the necessary care and services by failing to:4. Ensure Resident 19's left hand and leg were assessed for the cause of pain. 5. Ensure Resident 19 was monitored for the effectiveness of the as needed (PRN) pain medication. 6. Ensure Resident 19?s physician was notified of ineffective PRN pain medication and to obtain an order for other interventions to relieve the resident's pain.The above violations had a direct relationship to the health, safety, or security of Resident 19. |
| 910000016 |
VERMONT HEALTHCARE CENTER |
910012300 |
A |
10-Jun-16 |
POFQ11 |
10024 |
F323 CFR 483.25(h) Accidents The facility must ensure that ? (1) The resident environment remains as free from accident hazards as is possible; and (2) Each resident receives adequate supervision and assistance devices to prevent accidents. On January 14, 2011, at 8:45 a.m., an unannounced visit was made to the facility to investigate a complaint regarding Resident 1, who was hospitalized. The resident had a seizure while sitting in a shower chair in the shower room and fell from the shower chair onto the floor. Based on observation, interview and record review, the facility failed to: 1. Implement the facility?s shower policy and procedures to ensure Resident 1 had a seat belt on while sitting in a shower chair, during shower. On December 16, 2010 at 8:50 a.m., Resident 1 had a seizure and slid out of the shower chair, which did not have a seat belt, and fell on his face on the floor. Resident 1 sustained bilateral nasal bone fractures and nasal septal deviation with deformity of zygomatic arch (cheek bones). A review of the facility?s undated policy titled, ?Shower, Methods and Important Points?, indicated to cover the resident with a bath blanket and assist the resident to the shower room in the appropriate mode of transportation (usually a shower chair) with seat belt supports for safety at all times. According to the admission record, Resident 1 was readmitted to the facility on XXXXXXX with diagnoses that included dementia (loss of brain function caused by a series of small strokes), cerebrovascular accident (stroke) with right hemiparesis (body weakness), and Parkinson?s disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movement). The Minimum Data Set (MDS, a standardized resident assessment care and screening tool), dated June 5, 2010, indicated Resident 1?s cognitive skills for daily decision-making were moderately impaired. The patient?s speech was clear and was usually able to understand others and make himself understood. The resident required extensive assistance from the staff with transfers and was totally dependent for bathing. The resident had functional limitations in range of motion with partial loss to both sides of his arms and hands. The plan of care dated June 21, 2010, indicated a potential for injury from tremors and involuntary movements and a high risk for falls/accidents due to Parkinson?s disease. The nursing approaches included to monitor the environment for special chair needs and for involuntary movements which put the resident at risk for injury. A review of the Fall Risk Assessment dated December 10, 2010, indicated the resident had a score of 17. The form indicated if the total score is 10 or greater, the resident should be considered at high risk for falls. The resident status/condition checklist indicated the resident had intermittent confusion or poor safety awareness, history of one to two falls in the last thirty days, was chair bound, with a balance problem while standing and walking, required use of assistive devices, had one-two medications, and had a predisposing disease such as stroke and Parkinson?s disease, which increased the resident?s potential for falls. The licensed personnel weekly progress notes dated December 16, 2010, at 8:50 a.m., indicated the assigned certified nursing assistant (CNA 1) reported Resident 1 had a seizure, started shaking and became stiff while receiving a shower. The notes indicated CNA 1 was unable to control the resident and the resident slid from the shower chair and fell on his face on the floor. The resident was taken from the shower room and assisted back to his bed. The notes indicated the patient?s blood pressure was 140/90 (Normal range (120/80), pulse rate 167 (Normal rate 60 - 100 beats per minute, respiratory rate 22 (Normal respiratory rate 12?20 breaths per minute), and an oxygen saturation of 85 percent (Normal blood oxygen level 95-100 percent) room air. The notes indicated the resident sustained a « inch laceration (cut) on the bridge of his nose with a small amount of blood. At 9:10 a.m., the paramedics were called and responded in three minutes and took over the care of the patient. Resident 1 was taken by the paramedics to the acute hospital. A review of the General Acute Care Hospital (GACH?s) Discharge Summary dated January 11, 2011, indicated Resident 1 was admitted on XXXXXXX with a principal diagnoses of interventricular subdural hemorrhage (a bleeding into the brain spaces) and hypoxic respiratory failure (occurs when there is insufficient oxygen for the body tissues to function). The hospital course indicated Resident 1had a history of dementia (progressive deterioration of mental and physical functioning), and degenerative (progressive) brain disease, status post ground level fall after a seizure, having suffered interventricular subdural hemorrhage on December 16, 2010, and later progressing into hypoxic respiratory failure on December 18, 2010, at which point the resident was transferred to the intensive care unit (ICU). The discharge notes indicated that the resident had a past medical history that included a stroke with previous right sided hemiparesis (one sided weakness), coronary artery disease (blockage of one or more arteries that supply blood to the heart), congestive heart failure (when heart is unable to pump sufficiently to maintain blood flow to meet the body's needs), and atrial fibrillation (abnormal heart rhythm characterized by rapid and irregular beating). The notes indicated when the resident first presented to the GACH, the resident required acute admission for medical management of acute intracranial bleed (bleeding within the skull). The resident received computed Tomography (CT, pictures of structures within the body created by a computer that takes the data from multiple X-ray images and turns them in pictures) showing a small left intrahemispheric subdural hematoma (bleeding into the brain spaces), moderate chronic (old) periventricular deep white matter disease, lacunae or small old infarcts at the basal ganglia, and bilateral nasal bone fractures and nasal septal deviation as well as deformity of the left zygomatic arch (cheek bones). During a telephone interview on July 18, 2011 at 2 p.m., with licensed vocational nurse (LVN 1), she stated, while she was passing medications, Resident 1 fell in the shower room. LVN 1 stated she was called to the shower room, and found the resident on the floor of the shower room bleeding all over his face. The resident fell from the shower chair and Certified Nursing Assistant (CNA 1) was unable to hold the resident sitting in the shower chair. LVN 1 stated, CNA 1 had a lot of soap on her hands and her hands were slippery due to all the soap on her hands and could not hold the resident well. LVN 1 stated the soap and water was all over the shower floor. LVN 1 stated the resident was not on medication for seizures. During an interview on July 20, 2011, at 1:30 p.m., with CNA 1, she stated she was assigned to Resident 1 the day he fell in the shower room. The resident was unable to stand or walk without assistance. The resident was pushed to the shower room in a shower chair. The shower chair did not have a belt. CNA 1 stated she turned on the water, set it to warm, and was washing the patient, when the resident started shaking. CNA 1 stated she had soap on her hands, and was unable to hold the resident in the shower chair. The resident fell from the shower chair to the floor on his face. CNA 1 stated she called for help. During an interview on July 21, 2011, at 2:30 p.m., with registered nurse supervisor (RNS 1), she stated the resident fell in the shower room on December 16, 2011. CNA 1 reported to LVN 1 that the resident was sitting in a shower chair, receiving shower when the resident started shaking. CNA 1 was unable to control/hold the patient, and the resident fell on the floor. RNS 1 stated the resident was not on any medication for seizure, had diagnosis of Parkinson?s disease but not on medication. RNS stated that the resident had right sided weakness due to CVA (stroke). The resident slid out of the shower chair and fell on the floor, and was assessed with a 0.5 inch laceration (cut) to his nose. On August 29, 2011, at 11:30 a.m., during a second interview with CNA 1, she stated she was almost finished with Resident 1?s shower, when the resident started shaking in the shower chair, and she was unable to control/hold the patient. CNA 1 stated the shower chair had no seat belt. On August 29, 2011, at 3 p.m., during an interview with the director of staff development (DSD), she stated on the patient?s shower day, the resident can either be pushed to the shower room on a shower chair, on the reclining shower chair or the gurney used for showers. The regular shower chair has no safety belt. The DSD stated an In-Service was given to the nursing staff prior December 16, 2010. A review of the undated facility?s policy and procedures titled, Shower, Methods and Important Points, indicated cover the resident with bath blanket and assist the resident to the shower room in the appropriate mode of transportation (usually a shower chair) with seat belt supports for safety at all times. The facility failed to: 1. Implement the facility?s shower policy and procedures to ensure Resident 1 had a seat belt while sitting in a shower chair, during a shower. On December 16, 2010 at 8:50 a.m., Resident 1 had a seizure and slid of a shower chair which did not have a seat belt, and fell on his face on the floor. Resident 1 sustained bilateral nasal bone fractures and nasal septal deviation with deformity of zygomatic arch (cheek bones). The above violation presented either imminent danger that serious harm would result, or a substantial probability that serious harm would result to Resident 1. |
| 920000027 |
VERDUGO VALLEY SKILLED NURSING & WELLNESS CENTRE |
920009239 |
A |
19-Sep-12 |
OE3411 |
15273 |
?483.25 Quality of CareF329Each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used in excessive dose (including duplicate therapy); or for excessive duration; or without adequate monitoring; or without adequate indications for its use; or in the presence of adverse consequences which indicate the dose should be reduced or discontinued; or any combinations of the reasons above.Based on a comprehensive assessment of a resident, the facility must ensure that residents who have not used antipsychotic drugs are not given these drugs unless antipsychotic drug therapy is necessary to treat a specific condition as diagnosed and documented in the clinical record; and residents who use antipsychotic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs. Based on interview and record review, the facility staff failed to adequately monitor Resident 1 for adverse drug reactions (ADRs). The resident was receiving Heparin 10,000 units per day and Coumadin 5 milligrams (mg) per day, both anticoagulant (blood thinning) drugs. The staff failed to adequately monitor Resident 1 by failing to:1. Develop a plan of care that included interventions to detect early signs and symptoms of the ADRs of anticoagulant therapy such as bruising and bleeding.2. Implement the physician orders for Resident 1?s laboratory tests to monitor the therapeutic effectiveness and safe continued use of the anticoagulant drugs. On August 4, 2010, at 3:30 p.m., an unannounced complaint visit was initiated to investigate the above allegations.The Admission and Discharge Summary form indicated Resident 1 was a 30 year old male originally admitted to the facility on March 11, 2010 and then readmitted on April 27, 2010. He had diagnoses that included infected decubitus ulcers (lesions caused by unrelieved pressure that results in damage to the underlying tissues), paraplegia (inability to voluntarily move the lower extremities), postural fatigue (shoulders round forward with the inability to sit straight when tired), right lower leg deep vein thrombosis [(DVT) the formation of a blood clot in a deep vein, most commonly of the legs], and renal insufficiency (also known as renal failure, is a condition where the kidneys fail to adequately filter toxins and waste products from the blood). A review of the history and physical examination record obtained from the General Acute Care Hospital, (GACH), dated January 20, 2010, indicated Resident 1 was a paraplegic due to a gunshot wound that occurred ten years ago. He had an indwelling catheter. The physical examination also indicated the resident had an ulceration in his right internal thigh area with induration (abnormally hard spot or place). The resident had a history of right lower extremity DVT with ?possible? placement of an inferior vena cava (the large vein that carries de-oxygenated blood from the lower half of the body into the right heart) filter.The admission Minimum Data Set (MDS) assessment, dated May 7, 2010, indicated Resident 1 was moderately impaired with cognitive skills for daily decision-making, was totally dependent on the facility staff for activities of daily living, and required one to two or more persons for physical assistance. The disease diagnoses section listed the resident currently had septicemia and wound infection. The nutrition section indicated the resident was 70 tall inches and weighed 149 pounds. The skin condition sections indicated he had one Stage III and four Stage IV pressure ulcers. A review of the May 7, 2010, Resident Assessment Protocol Summary (RAPS) indicated Resident 1 had pressure sores, and the risk factors and compounding factors involved included paraplegia, decreased mobility, and right lower leg DVT. The RAPS indicated to proceed with care planning for present sores to improve in stage and size.The resident had the following physician's orders: 1. Heparin 5000 units subcutaneously twice a day (10,000 units per day) for thrombosis (blood clots) prophylaxis (prevention treatment), dated April 27, 2010. According to the Medication Administration Record (MAR), the physician's order for the Heparin was scheduled to be administered at 9 a.m. and 9 p.m. daily.Heparin is a medication used to treat and prevent blood clots in the veins, arteries, or lungs. The adverse drug reaction of Heparin includes hemorrhage and overly prolonged clotting time. The therapeutic effectiveness and the adverse effects of Heparin is monitored by laboratory tests such as PTT (partial prothrombin time), blood platelet count and monitored clinically by regularly inspecting the resident for bleeding gums, bruises on the arms and legs, nose bleeding, tarry stools, irritation and hematoma formation, peptic ulcer disease, and increased capillary permeability (Nursing Drug Handbook Pages 499-502). 2. Coumadin 5 milligrams (mg) by mouth dated May 20, 2010, (no reason for administration stated). According to the MAR, the physician's order for the Coumadin was scheduled to be administered at 5 p.m. daily. Coumadin is also known as Warfarin. It is an anticoagulant (blood thinning) drug used to treat or prevent clots in the veins, arteries, lungs, or heart. The therapeutic effectiveness of Coumadin is monitored by the blood laboratory tests Prothrombin Time (PT) and International Norm Ratio (INR), [reference range for PT and INR is 11.1 to 13.5 and 2 to 3 respectively]. The adverse drug reaction of Coumadin includes overly prolonged clotting time and life-threatening bleeding if there is a significant increase in PT and INR, (State Operations Manual, October 2010, Page 366).3. PT ? INR to be done on May 25, 2010, dated May 20, 2010.According to the resident's clinical record, the physician's orders for Heparin and Coumadin were active and there was no physician's order to discontinue either drug. The resident?s care plan was reviewed and there was no plan of care developed for using anticoagulant therapy to monitor the adverse drug reactions of the drug.A review of the medication administration record (MAR) from April 27 to July 20, 2010, indicated the following:1. From April 28, 2010 to April 30, 2010, the resident received a total of six doses of 5,000 units Heparin. 2. From May 1, 2010 to May 31, 2010, the resident received 51 doses of Heparin, 5,000 units.3. Coumadin 5 mg was administered from May 21 to 23 and on May 25, 2010 every 5 p.m. The MAR also indicated that PT/INR laboratory tests were to be done on May 25, 2010. There was no documentation of the test results. 4. From June 1, 2010 to June 30, 2010, the resident received 50 doses of Heparin, 5,000 units. 5. From July 1, 2010 to July 19, 2010, the resident received 13 doses of 5,000 units eparin; Resident 1 received the last dose of Heparin, 5,000 units on July 19, 2010, at 9 p.m., the night before he expired.There was no documented evidence that the licensed staff monitored Resident 1 for potential clinical signs of ADRs from the use of Heparin and Coumadin. There was also no documented evidence that the therapeutic effectiveness of both drugs were monitored by means of physician ordered specified laboratory tests for anticoagulant (blood thinning) drugs. Both the effect of the drugs on the resident's ulcers, and on the integrity of the blood vessels surrounding the ulcers were not monitored to detect early warning signs and symptoms for bleeding from the ulcers, especially from the chronically infected, deeply ulcerated wound on the resident's right groin from where his bleeding was coming.On October 14, 2010, at 3:25 p.m., during an interview with the Certified Nursing Assistant (CNA) 1 who was assigned to the resident on July 20, 2010, on the 11 p.m. to 7 a.m. shift, stated she heard Resident 1 screaming. When she entered the room, Resident 1 was heavily bleeding from the groin region and screaming "Help! Help! I do not want to die!?CNA 1 said that RN 1 was already in the resident's room, and was attempting to stop the bleeding with a bed sheet. RN 1 instructed (anyone) to call 911, which was done. CNA 1 stated the resident was lying on the bed with his head at an approximate 45 degree angle, his feet were placed flat on the bed, the bed was soaked with blood, and there was dripping blood on the floor. On October 14, 2010, at 3:55 p.m., during an interview, RN 1 stated that on July 20, 2010, at 2:15 a.m., she heard the resident screaming. When she entered the room, she observed Resident 1 bleeding profusely from his right groin area. According to RN 1, she went out and got gloves and linens and when she returned, she applied direct pressure to the resident?s right groin area. She yelled at the CNAs who were gathering outside the room to call 911. RN 1 stated that when she asked the resident what happened, he stated that he started bleeding when he turned on his right side and did not know what caused the bleeding. RN 1 was asked if she was aware that Resident 1 was receiving Heparin and Coumadin and she stated that she was, that she knew the resident well, and that she had been taking care of him since he was first admitted. RN 1 also knew the resident had treatment to his right groin for a wound, but didn?t know the extent of the wound because she did not provide the treatments. She stated that there was no care plan developed to ensure safe administration of Heparin and/or Coumadin to prevent the risk of excessive bleeding from the unmonitored use of those drugs.A review of the documentation by RN 1's entry dated July 19, 2010, at 2:20 a.m., in the Licensed Personnel Progress Notes indicated that RN 1 was alerted when the resident was yelling and screaming in his room. She went and checked the resident immediately and found he had excessive bleeding from his right groin and she applied direct pressure to the area. According to the resident, he just turned himself to the right side and started to bleed and that was the reason he was yelling for help. It was documented that the Paramedics were called for assistance. The facility staff applied oxygen at two liters per minute by nasal cannula (via the nose). The resident?s oxygen saturation level after the oxygen was applied was 98 percent. The normal range is 95 to 100 percent. The resident became diaphoretic (excessive sweating) and the bleeding from his right groin area was continuous. At 2:30 a.m., the paramedics came in and the resident was transferred to the general acute care hospital (GACH).The physician was contacted and made aware of the resident's condition.On January 19, 2011, at 3 p.m., during a concurrent interview and record review, the Director of Nursing (DON), said that she was not able to find the test results for INR and PT to determine that continued administration of the anticoagulant drugs posed no risk to the resident. She stated that a blood test should have been done to monitor the effectiveness of Heparin and Coumadin. She also stated that a care plan was not developed to monitor the ADRs of anticoagulant therapy. A review of the Fire Department Emergency Medical Services Report Form (Paramedics), dated July 20, 2010, indicated they arrived at the facility at 2:38 a.m., and found Resident 1 in bed, alert, awake, and oriented, with the chief complaint documented as bleeding ulcers from between the legs. Resident 1 was very agitated/combative and swinging his arms, and he stated he just moved his leg and he began to bleed. There were towels on the floor soaked with approximately 200 to 300 cubic centimeters (cc) of blood.According to the Paramedics notes, they were unable to access an IV (intravenous) line. A staff member of the facility informed the paramedics that the resident was bleeding for approximately fifteen minutes. Resident 1's vital signs were: blood pressure 66/38, pulse 85 beats per minute, and the respiratory rate was 18 breaths per minute. The resident was pale and was placed on six liters of oxygen by nasal cannula with 95 percent oxygen saturation after administration of oxygen. The resident was transferred to the GACH emergency room (ER). According to the Emergency/Nursing Assessment, dated July 20, 2010, at 3:09 a.m., upon arrival to the ER, the resident was alert but disoriented, incoherent, pale and with dry skin, and unable to follow commands, with dilated eyes that were non-reactive to light. The assessment also indicated the resident had labored breathing, lung sounds were diminished, no oxygen saturation, had sinus tachycardia (rapid heartbeat) on the cardiac monitor, and was in a state of hemorrhagic shock.The ER assessment indicated the resident had a bleeding wound noted to his right groin area. The dressing and linens were soaked with ?bright red blood.? The resident was intubated (insertion of a tube into the wind pipe to assist with mechanical breathing) and received two units of "O" Negative blood. The resident went into ventricular fibrillation (irregular rapid heart rate) followed by asystole (cardiac/heart standstill with no cardiac output and absence of pulse). Cardiopulmonary resuscitation (CPR) was initiated without success and the resident expired. According to the ER records, History and Physical, dated July 28, 2010, indicated the resident was brought to ER by emergency medical services (EMS) from a nursing home because of bleeding from the groin decubitus ulcers. Paramedics were unable to start an IV line and no pressure dressing was applied to the wound. On admission, the resident was restless, lethargic, anxious, and agitated. He appeared pale and dusky and his skin was cool and clammy and his pulse was weak. We immediately placed the pressure dressing on the groin and attempted to start IV lines. He went to ventricular fibrillation and went to asystole. CPR was started according to ACLS protocol. He was intubated. He was transfused with two units of O negative blood. The record also indicated hemorrhagic shock and full arrest. The Autopsy Report dated August 3, 2010, indicated the cause of death was a sequelae (a pathological condition resulting from a prior disease, injury or attack) of gunshot wound. The injury occurred from a gunshot wound by another person 11 years prior to death (history), and neglect by provider(s) of care.Facility staff did not adequately monitor Resident 1 for adverse drug reactions (ADRs). The resident was receiving Heparin 10,000 units per day and Coumadin 5 milligrams (mg) per day, both anticoagulant (blood thinning) drugs. The staff failed to adequately monitor Resident 1 by failing to:1. Develop a plan of care that included interventions to detect early signs and symptoms of the ADRs of anticoagulant therapy such as bruising and bleeding.2. Implement the physician orders for Resident 1?s laboratory tests to monitor the therapeutic effectiveness and safe continued use of the anticoagulant drugs. The above violations presented either imminent danger that death or serious harm would result or substantial probability that death or serious physical harm would result. 1 |
| 920000027 |
VERDUGO VALLEY SKILLED NURSING & WELLNESS CENTRE |
920009667 |
B |
10-Dec-12 |
QLS611 |
9631 |
Section 72311(a)(1)(A)(a) Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (A) Identification of care needs based upon an initial written and continuing assessment of the patient's needs with input, as necessary, from health professionals involved in the care of the patient. Initial assessments shall commence at the time of admission of the patient and be completed within seven days after admission. Based on interview and record review, the facility failed to identify patient care needs to prevent injury by failing to: 1. Develop a plan of care for a patient who had a history of hearing voices that were telling him to cut his wrists or overdose on medication. The patient cut his left forearm with a razor and had to be transferred to an acute care hospital via 911. 2. Monitor the patient for delusional thoughts as ordered by the physician. 3. Ensure that a suicidal patient threatening to cut his wrists or overdose on medication did not have access to razors and other harmful objects.On February 6, 2012, an unannounced visit was made to the facility to investigate a complaint alleging Patient 1 had cut himself on the forearm with a razor.A review of the medical record revealed a Psychiatric Evaluation from the acute care hospital dated May 11, 2011, that Patient 1 told the board and care staff, where he previously resided, that he felt suicidal and was planning to cut his wrists or overdose on medication. The evaluation also indicated the patient told the staff that the voices were becoming loud telling him he must cut his wrists or kill himself. He voluntarily admitted himself because he was afraid he was going to act on the voices command. Patient was discharged from the acute care hospital behavioral unit on May 17, 2011, and admitted to the facility. The admission information indicated that Patient 1 was admitted to the facility on May 17, 2011, with diagnoses that included psychosis, depression, seizure disorder and hypertension.The physician's order indicated the Patient 1 was to receive the following medication: 1. Trileptal 150 milligrams (mg) twice a day for seizures 2. Risperdal 2 mg twice a day for psychosis 3. Lexapro 10 mg every morning for depression 4. Metoprolol 25 mg twice a day for hypertension The care plan dated May 17, 2011, indicated Patient 1 needed the use of anti-psychotic medication due to psychosis manifested by him hearing voices that were not there. The interventions included to encourage the patient to verbalize his feelings and concerns, encourage the patient to be involved in activities of choice, and listen attentively and attempt to resolve or discuss areas of concern. The care plan also indicated the patient had a potential for or actual alteration in psychosocial well-being, psychosis and depression. The interventions were as follows: To talk to the patient about his fears, discuss his fears with an open accepting attitude, praise constructive steps toward adjustment and to notify the physician if the resident displays inappropriate or endangering behavior. There was no plan on how the facility was going to prevent the patient from injuring himself. The Minimum Data Set (MDS - a standardized comprehensive assessment of the patient's problems and conditions), dated May 21, 2011, indicated Patient 1 had clear speech, could be understood and understand others. The MDS also indicated the patient was feeling depressed, had trouble falling asleep, was tired or had little energy and required assistance from staff for activities of daily living. The Licensed Personnel Progress Notes, dated May 21, 2011, at 11 a.m., indicated Patient 1 approached the charge nurse and said, "I feel like getting a sharp object and cut myself on the wrist." It was reported to the supervisor and the patient was put on 1:1 monitoring. Patient 1 was also given 1 mg of Ativan. At 12 noon, Patient 1 reported to the nurses that the Ativan did not help and he still felt like cutting himself. The physician was called, and he gave an order to administer Ativan 2 mg IM (intramuscularly) one time. At 3 p.m., Patient 1 continued on 1:1 monitoring and repeated the same suicidal ideations. At 4:45 p.m., the resident was picked up by an ambulance and transported to an acute care hospital. The Psychiatric Progress Note from the acute care hospital dated December 27, 2011, indicated the patient still felt hopeless, anhedonic, (inability to experience pleasure) depressed, and his insight and judgment was poor. Patient 1 was readmitted to the facility on December 28, 2011, with diagnoses that included schizophrenia, depression and hypertension. The physician's orders dated December 28, 2011, indicated the patient was to receive the following: 1. Prozac 20 mg every morning for depression 2. Trileptal 150 mg every morning and at bedtime for seizure disorder 3. Risperdal 2 mg every morning and every evening for psychosis. According to the Licensed Personnel Progress Notes dated January 5, 2012, Patient 1 was transferred to an acute care hospital emergency room for evaluation and treatment due to chest pain. Patient 1 was readmitted to the facility on January 7, 2012, with diagnoses that included schizophrenia, depression, angina pectoris, abnormal posture and difficulty walking. The physician's orders dated January 7, 2012, indicated the patient was to receive the following: 1. Prozac 20 mg daily for depression 2. Risperdal 2 mg twice a day for psychosis 3. Trileptal 150 mg twice a day for seizure disorder 4. Metoprolol 25 mg twice a day for hypertension. According to the physician?s order, the staff was to monitor the patient's psychosis that was manifested by delusional thoughts. The medication record (the form used to document episodes of behavior) from January 7, through 19, 2012, revealed there was no documentation to show the facility staff were monitoring the patient for delusional thoughts as ordered by the physician.The care plan dated January 7, 2012, revealed there was no documentation to show the staff identified that the patient had a history of delusional thoughts of hearing voices telling him to cut his wrists or take an overdose of medication or a plan to prevent access to sharp objects. The Licensed Personnel Progress Notes dated January 13, 2012, indicated the patient verbalized he wanted to inform his physician that he changed his mind to take Lexapro 10 mg as a replacement of Prozac.The physician was notified and ordered the change in medication The Licensed Personnel Progress Notes dated January 19, 2012, at 11 a.m., indicated the patient was refusing his morning medications. The patient's physician was called and left a message with the physician's nurse practitioner. At 5:25 p.m., the note indicated that the certified nursing assistant (CNA) and the charge nurse (CN) noticed the patient walking down the hallway with blood dripping from his left hand. The CN assessed the patient and noted a superficial laceration on his left hand and first aid was administered. When asked what happened, the resident said he cut himself with a razor as he heard voices telling him to cut himself. 911 was called and the paramedics arrived and assessed the patient. The patient was transferred to an acute care hospital for evaluation and treatment. The Incident Report dated January 19, 2012, indicated the CNA and CN saw the patient holding his arm with a scarf, and razor blade came from under the scarf.During an interview on February 6, 2012, at 4:45 p.m., the director of nurses (DON) said she was not aware that the patient was suicidal. She went on to say if she knew the patient was suicidal she would not have accepted him because the facility is not equipped to handle suicidal patients.On March 23, 2012, during an interview with the Ombudsman, she said that on January 20, 2012, at 4 p.m., she observed uncovered razors left in both the east and west shower rooms in the facility during her tour. Patient 1 told the Ombudsman he got the razor he used to cut his wrist from one of the shower rooms in the facility. On April 2, 2012, at 8:45 a.m., during a phone interview with Patient 1, he said that the day he cut his wrist he was hearing voices telling him to cut himself. He said he told the facility staff but they did not do anything. The voices got so strong he could not resist anymore. Patient 1 said he took a razor from another resident, went into the shower room and cut himself and left the blade in the shower. After the staff saw him bleeding he was transferred to the hospital. When asked where the other patient got the razor from, he replied from the staff that was passing them out to everyone. Patient 1 also stated that he observed razors lying on the shower room floors many times. Patient 1 described how he broke down the razor and took the blades out.The facility failed to identify patient care needs to prevent injury by failing to: 1. Develop a plan of care for a patient who had a history of hearing voices that were telling him to cut his wrists or overdose on medication. The patient cut his left forearm with a razor and was transferred to an acute care hospital via 911. 2. Monitor the patient for delusional thoughts as ordered by the physician. 3. Ensure that a suicidal patient threatening to cut his wrists or overdose on medication did not have access to razors and other sharp objects. The above violation had a direct and immediate relationship to the health, safety and security of Patient 1. |
| 920000057 |
VALLEY PALMS CARE CENTER |
920010199 |
B |
17-Oct-13 |
2ONZ11 |
1647 |
California Health & Safety Code 1418.21 (a) (1) (A) (B) (C) (a) A skilled nursing facility that has been certified for purposes of Medicare or Mecaid shall post the overall facility rating information determined by the federal Centers for Medicare and Medicaid Services (CMS) in accordance with the following requirements;(1) The information shall be posted in at least the following locations, in the facility:(A) An area accessible and visible to members of the public.(B) An area used for employee breaks.(C) An area used by residents for communal functions, such as dining, resident council meetings, or activities. The facility failed to post the overall rating information (Five-Star Quality Rating) determined by the Centers for Medicare and Medicaid Services (CMS) in the required areas for review by the residents, staff, and the public. During the Annual Recertification survey, from February 1, 2013, at 5:40 p.m., to February 3, 2013, at 8:35 a.m., the overall facility rating information determined by the federal Centers for Medicare and Medicaid Services (CMS) was not observed in two dining rooms and in the employee lounge. On February 3, 2013, at 8:35 a.m., during an interview with the administrative staff, she stated the overall facility rating information should have been posted on the wall in the two dining rooms and the employee lounge. Failure of the facility to post the overall rating information (Five-Star Quality Rating) determined by the Centers for Medicare and Medicaid Services (CMS) in the required areas for review had a direct relationship to the health, safety and security of all residents. |
| 920000027 |
VERDUGO VALLEY SKILLED NURSING & WELLNESS CENTRE |
920010821 |
B |
18-Jun-14 |
1YY811 |
8837 |
Code of Federal Regulations 483.13(c) F226 The facility must develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. Based on interview and record review, the facility failed to develop and operationalize policies and procedures for screening and training employees, protection of residents and for the prevention, identification, investigation, and reporting of abuse for one resident (2) by failing to: a. Thoroughly investigate a resident?s allegation of possible abuse to Resident 2. b. Protect all residents, including Resident 2, pending the results of the investigation. c. Report alleged abuse to the appropriate agencies.On March 23, 2012, an unannounced visit was made to the facility to investigate a complaint regarding an incident of alleged resident abuse. The director of nursing (DON) was informed of the nature of the complaint and a tour of the facility was initiated. At 8:10 a.m., in an interview with Resident 1, she said while wheeling down the hallway she saw one staff member?s arm which was behind a half pulled curtain, pulling up Resident 2 by his hair like he was being scalped, in order to feed him. When asked when the incident occurred the resident said she could not recall the exact day or time. She said she could not recall if it was a male or a female staff member. Resident 1 said she had informed the director of staff development (DSD) about what she thought she saw, and that she thought it occurred a week and half ago. She said she got upset because the facility kept telling her she was just re-admitted back from the acute care hospital and the incident would not have taken place a week and a half ago. The resident said they concentrated so much on the timeline instead of just looking at different staff who worked different shifts. A review of Resident 1?s Admission and Discharge Summary indicated she was initially admitted to the facility on May 14, 2009, and re-admitted on February 27, 2012, with a diagnosis of psychosis. A review of the Minimum Data Set (MDS - a standardized comprehensive assessment of the resident's problems and conditions), dated January 19, 2012, indicated Resident 1 was assessed as being alert and oriented. On March 23, 2012, at 9:35 a.m., in an interview with the social service designee (SSD), he said he heard about Resident 2?s alleged abuse during stand-up meeting and went to interview Resident 2, who was outside in the smoking area, but was not able to do so. He said he and the MDS Coordinator went back to Resident 2?s room the next day and asked him if the allegation was true, and the resident said no. The SSD said the facility then concluded that the allegation was not true. The SSD was asked if he had interviewed any other residents of the facility about the care and services provided by their staff members in order to further investigate the allegation, and he said no.On March 23, 2012, at 11:10 a.m., in an interview with the DSD, he said the morning of March 5, 2012, during his morning rounds, Resident 1 informed him that about a week and a half ago she saw a male staff member in Resident 2?s room holding him by his hair in order to feed him. The DSD said he told the Interdisciplinary Team (IDT) members during their morning stand-up meeting and after the meeting the DSD went to interview Resident 2.The DSD said he knew there were no male CNAs working, so he just concentrated on the certified nursing assistants (CNA 1 and CNA 2) because Resident 1 could not identify any particular staff members and or dates. And since these two CNAs usually took care of Resident 2, he just interviewed those two staff members. The DSD said he asked CNA 1, who was working on the same day about the allegation and she denied it. The DSD was asked if CNA 1 was ever suspended pending the investigation, and he said no. The DSD said he also called CNA 2, who was off that day. She called him back the next day and also denied the allegation. The DSD further explained CNA 1 was not suspended because Resident 2 denied the allegations the next day. However, DSD was informed that according to the SSD, Resident 2 was not interviewed until the next day, March 6, 2012, and at that time he denied the allegation. The DSD was asked why CNA 1, who was a possible suspect, was allowed to remain working in the facility when the investigation was still ongoing, however he did not have an answer.On March 23, 2012, at 3 p.m., in an interview with the administrator, he said he was not in the facility the day of Resident 1?s allegation. He said he heard about the incident the next day in the stand-up meeting and was told everything was all right.A review of the Resident Grievance Form, dated March 6, 2012, filled out by the SSD, indicated that during the IDT meeting Resident 1 said she saw a CNA pull Resident 2?s hair back like they were scalping him in order to feed him. The resident was asked if it was a male or a female nurse, the resident said she did not see who it was and could not remember because it was a week and a half ago. Review of the investigation indicated the SSD and the Admissions Coordinator went to Resident 2 and asked him if anyone had pulled him up by the hair in the last week, and Resident 2 said, ?No.? The form indicated that it was signed by the facility?s SSD and the administrator. On March 23, 2012, at 3 p.m., in an interview with the facility?s administrator, he said he never reported this incident to the State Agency, Ombudsman?s office, and or any other agency because he didn?t think this was anything and because Resident 2 said it did not happen. The administrator agreed that this qualified as an alleged abuse. When he was asked how the facility protected the residents while the investigation was in progress and if the investigation was not completed until the next day, the administrator could not produce any evidence of the facility?s residents being protected while this investigation was ongoing. The administrator was asked if CNA 1, who was a possible suspect, was ever suspended pending the results of the investigation, and he said no.On March 23, 2012, at 2:30 p.m., the DSD was interviewed while reviewing the Personnel File of CNA 1 and CNA 2. CNA 2?s file indicated she was hired in 2002 and submitted a social security card (SSN) with her application. However, review of the Employment Screening company form, which screens for potential employees to prevent falsified or fraudulent data, negligent hiring, employee theft and violence in the workplace, dated October 19, 2011, indicated that upon re-checking, the SSN did not match Social Security Administration?s records, and therefore never issued. The DSD said the facility wanted to re-check all current employees but was informed by the Union the practice was illegal. When asked how the facility is ensuring the safety of all of its residents when they cannot screen current employees especially if there is an allegation of abuse, he did not have an answer.A review of the SSD Personnel File indicated the resume on file had no prior employment verification indicated. The SSD said he was hired by the corporate office and his information was probably at that office. There was no verification of the SSD?s qualifications as a social worker in his file.A review of the facility?s policy and procedures on Abuse indicated that whenever possible check references from previous employers prior to hiring a new employee, review the completed resident abuse report form, and interview staff members who have had contact with the resident during the period of the alleged incident. The policy and procedure entitled ?Reporting Abuse? failed to address the reporting of alleged abuse to the State agency, and to all other agencies as required. The facility?s policy said that if an incident of abuse is ?substantiated?, the administrator or the DON will report the findings to the Department of Health Services, the local Ombudsman, the resident?s family or representative of record, law enforcement official, and the resident?s attending physician.Therefore the facility failed to the facility failed to develop and operationalize policies and procedures for screening and training employees, protection of residents and for the prevention, identification, investigation, and reporting of abuse for one resident (2) by failing to: a. Thoroughly investigate a resident?s allegation of possible abuse to Resident 2. b. Protect all residents, including Resident 2, pending the results of the investigation. c. Report alleged abuse to the appropriate agencies.This violation had a direct relationship to the health, safety, or security of all residents. |
| 920000027 |
VERDUGO VALLEY SKILLED NURSING & WELLNESS CENTRE |
920011265 |
A |
05-Feb-15 |
BS4U11 |
10648 |
F323 Free of Accident Hazards/Supervision/Devices 485.23(h) The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. The facility staff failed to ensure Resident 1 was provided with and used her walker (assistive device to stabilize a person when walking). Resident 1 walked by several staff on her way to the patio, and who saw her without her walker, but did not provide it to her in accordance with her plan of care. This deficient practice resulted in an avoidable fall and fracture to Resident 1's right ankle, and four days of hospitalization.On December 5, 2014, at 5 p.m., during an investigation of an entity reported incident (ERI), Resident 1 was observed awake and in bed. She was dressed, and had a splint and wrap covering her right foot and leg up to her knee. She appeared to understand, but generally answered with a "ya", "no", or "okay". When asked if she was in pain, she said no. She was not able to describe what happened to her ankle. The director of nursing (DON) was present, and stated that Resident 1 "always" walked without using her walker. When asked if the resident had her walker with her when she fell, the DON said no, that she left her walker in her room.On December 5, 2014, at 6:45 p.m., during an interview with the physical therapist (PT), she stated that Resident 1 was always "noncompliant" with using her walker.She stated that Resident 1's walker had a big sign with the resident's name on it, and "everyone" knew if they saw her walker to find the resident and give it to her. A review of Resident 1's medical record revealed she was originally admitted to the facility on August 13, 2011. She was readmitted on November 19, 2014, after the November 15, 2014, fall incident when she fractured her right ankle. She had diagnoses that included diabetes (high blood sugar), high blood pressure, and dementia (thinking processes are deteriorating, affecting the person's ability to carry out daily activities). She was assessed as being at moderate risk for falls on September 22, 2014, and October 14, 2014.A review of the current Minimum Data Set (MDS), an assessment and care screening tool, dated September 22, 2014, revealed Resident 1 required one-person assist with transfers and walking, and she required a front wheel walker (FWW) to assist her with walking. The care plan with the same date indicated problems of impaired decision making, impaired judgement, poor safety awareness, poor trunk control, unsteady balance, short term memory problems, and she had difficulty understanding others at times. The Interdisciplinary Team (IDT) notes dated November 5, 2014, indicated Resident 1 was not using her walker. Staff were to provide her with her walker and remind her to walk with her walker and reinforce education. There was a care plan dated November 5, 2014, for the problem of having episodes of not using her walker and forgetting its location. The goal was to ensure she use her walker when walking. The approach was the same as indicated in the IDT notes, for staff to provide her with her walker and remind her to walk with her walker, and reinforce education. The Charge Nurse Narrative Notes regarding the incident dated November 15, 2014, indicated that at 5:50 a.m., the resident was seen leaving her room without her walker; reminded resident to use her walker multiple times but resident "refused and continued walking down the hallway." The notes do not indicate that staff provided Resident 1 with her walker as indicated in the plan of care. A review of the facility's "Interview Record" with a Psych Tech (PT-A) dated November 15, 2014 at 7:15 a.m., indicated that he saw Resident 1 walking multiple times without her walker, and he repeatedly redirected and prompted the resident to go back and get her walker. The resident would respond okay and continue to walk. There was no documentation that PT-A provided Resident 1 with her walker in accordance with her plan of care. The ERI report from the facility dated November 20, 2014, indicated that on November 15, 2014, at about 6 a.m., Resident 1 was walking in the hallway without her walker, lost her balance and fell on her buttocks. She was assessed with pain in her ankle. During an interview with the DON on December 5, 2014, at 7:20 pm, when asked about the investigation for the incident, she was unable to provide any information. When asked if she thought the fall could have been prevented, she wasn't sure. She said that Resident 1 was on therapy for endurance prior to the fall, and she was "improving". She said Resident 1 used her FWW and goes everywhere. She forgets her walker and staff are to remind her and look for it. The DON could not say where the resident fell, whether anyone saw her fall, or who her direct care staff was on that morning. She agreed that there had not been a thorough investigation into the resident's fall, even though they knew what had happened.On December 5, 2014, at 7:30 p.m., PT-B was presented as someone who was working at the time of the incident. In an interview with PT-B at the same time, he stated he was at the opposite end of the hall at the time of Resident 1's fall incident. He said he didn't see Resident 1 fall, but he heard the commotion, and turned and saw her on the floor. He said he couldn't remember if she had her walker. A review of the "Interview Record" from PT-B regarding the incident indicated that he saw Resident 1 walking without her walker and immediately redirected her. The resident responded okay. There was no indication that PT-B provided Resident 1 with her walker as indicated in her plan of care.On January 8, 2015, at 6:45 a.m., an interview with the 11 p.m. to 7 a.m. shift certified nursing assistant (CNA 1), assigned to Resident 1 when the incident occurred was conducted. CNA 1 stated that Resident 1 always got up to go to the morning coffee time on the patio at 6:30 a.m. That was where she was headed when she fell. When asked why Resident 1 fell, she said that her walker was left in her room, and the resident got out of balance and fell. She stated that Resident 1 always forgot her walker and everyone knew the walker, and "everyone knew to take it to her." She stated she was in Room 17 with another resident when the incident occurred. Resident 1 fell right before she got to the patio door exit. CNA 1 said that Resident 1 does not go to the patio to coffee hour any more, and has breakfast in bed. When asked why, she said because she needed help to go there. When asked if she thought this fall could have been prevented, she said "yes."On January 8, 2015, during an interview at 9 a.m. with the 7 a.m. to 3 p.m. receptionist, she stated that the reception desk is supposed to be covered 24 hours 7 days a week. During lunch and breaks, they are not to leave until someone relieves them. She said she had been at the facility since July 2014, and knew Resident 1 was to have her walker; she said everyone knew she was to have her walker. She said if she saw Resident 1 come out of her room without her walker, she would call the CNA right away to bring the walker, but she was not at work when the incident occurred. When asked who was on duty, she stated that person had already left for the day. When asked about the receptionist/door monitor duties, she said that they are to ensure residents do not go out the door, which is at the bottom of the stairs. She provided a job description for the "Resident Door Monitor" that indicated the above information. In addition, the job duties of the door monitor included to re-direct any resident for their safety and well-being.On January 8, 2015, at 9:15 a.m., during an interview and record review with the Rehab Director, he stated that Resident 1 requires a wheel chair, and is supposed to start walking with full weight bearing using a CAM (controlled ankle motion) walker (boot to walk with). She was evaluated on January 7, 2015, and was totally dependent at that time, requiring total assist to stand. He said they don't keep the CAM walker in the resident's room because she may try to get up and use it without help, so they keep it in the Rehab room. He stated her safety awareness is very poor, and she is a very, very high risk for falls, is compulsive, and has a very low attention span.On January 8, 2015, at 9:45 a.m., Resident 1 was observed still waiting to get out of bed. CNA 2 was present and she said that Resident 1 now uses a wheel chair, but can't "drive it", indicating that she can't propel herself where she wants to go. At 10:15 a.m., on January 8, 2015, an interview regarding the incident area and layout of the facility was conducted with the DON. Resident 1's room was to the left of the stairway entrance to the facility, and the door monitor. Her room was at the corner, and the hallway continues with a right turn and goes to an exit that is not used by residents. At approximately 6 a.m., Resident 1 left her room without her walker. She turned right out of her room, and walked by the receptionist/door monitor, which is the only way to go to the patio, and any staff that were in the hallways. She continued by the administrative offices that are staffed in the early morning. She walked around the corner and down the hallway passing the East nursing station, where PT-B was passing medications, turned the corner and walked toward the patio. There was no evidence provided to indicate that staff either escorted her back to her room to get her walker, or ensured that she had supervision while they went to get her walker to provide to her, in accordance with her plan of care and IDT recommendations. The DON was informed that as a result of staff not providing Resident 1 with her FWW assistive device, she lost her balance, fell and fractured her ankle.Therefore, the facility staff failed to ensure Resident 1 was provided with and used her walker (assistive device to stabilize a person when walking). Resident 1 walked by several staff who saw her without her walker, but did not provide it to her in accordance with her plan of care. This deficient practice resulted in an avoidable fall and fracture to Resident 1's right ankle, and four days of hospitalization. This violation presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result to Resident 1. |
| 920000027 |
VERDUGO VALLEY SKILLED NURSING & WELLNESS CENTRE |
920011285 |
A |
18-Mar-15 |
6SLP11 |
10503 |
F157 ?483.10(b)(11) Notify of Changes A facility must immediately inform the resident; consult with the resident's physician; and if known, notify the resident's legal representative or an interested family member when there is an accident involving the resident which results in injury and has the potential for requiring physician intervention; a significant change in the resident's physical, mental, or psychosocial status (i.e., a deterioration in health, mental, or psychosocial status in either life threatening conditions or clinical complications); a need to alter treatment significantly (i.e., a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or a decision to transfer or discharge the resident from the facility as specified in ?483.12(a). The facility must also promptly notify the resident and, if known, the resident's legal representative or interested family member when there is a change in room or roommate assignment as specified in ?483.15(e)(2); or a change in resident rights under Federal or State law or regulations as specified in paragraph (b)(1) of this section. The facility must record and periodically update the address and phone number of the resident's legal representative or interested family member. F309?483.25 Provide Care and Services Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. The facility failed to ensure that a resident received prompt medical evaluation and treatment, including pain management, after she was found on the floor, screaming and yelling. Resident 1?s physician was not notified immediately after she fell on the floor on November 29, 2012. The staff also failed to notify the resident's court-appointed responsible party, Conservator 2 (C2), that Resident 1 sustained a fractured left knee from the fall. The fall resulted in severe pain from a fracture to Resident 1?s left knee, and injury to her right thumb and hand, with a delay of 36 hours from the time of the fall until she was transferred to the GACH for further treatment.During an unannounced complaint investigation that was initiated on December 10, 2012, a review of the admission information indicated Resident 1 was readmitted to the facility on October 19, 2012, with diagnoses that included difficulty walking, muscle weakness, diabetes mellitus (high blood sugar), and high blood pressure. The admission information listed Conservator 1 (C1) as the resident's responsible party upon readmission. However, the Authorization to Detain and Treat Conservatee form in the resident's chart indicated C2 as the court-appointed responsible party on May 2, 2012. The Fall Risk Assessment, dated October 19, 2012, indicated the resident was a high risk for falls. There was a physician?s order dated October 19, 2012, for Tylenol 325 milligrams 2 tabs orally every 4 hours as needed for mild pain.The current Minimum Data Set (MDS - a standardized comprehensive assessment of the resident's problems and conditions) dated November 14, 2013, indicated that Resident 1 had clear speech, could be understood and was able to understand. Resident 1 required one-person physical assistance for transferring from her bed to her wheelchair, and for walking, she had no pain, and was not on any scheduled pain medication regimen.There was a care plan for the problem of risk for falls due to previous episodes of vertigo or dizziness dated November 19, 2012. The interventions included to instruct the resident to ask for assistance if feeling dizzy or weak and discourage the resident from changing position abruptly. There was another care plan developed on the same date for pain management with a goal that the resident will maintain a pain level of 3 or less. One of the interventions included to administer prescribed medication and provide comfort measures. The Licensed Personnel Progress Notes (LPPN) indicated the following: * On November 29, 2012, at 9:10 p.m., Licensed Vocational Nurse 1 (LVN 1) heard the resident yelling and screaming. The nurse went inside the room and saw the resident on the floor. She was yelling and cursing, and wanted to be put back in her wheelchair. LVN 1 checked the resident's body and discovered her left knee was slightly swollen. LVN 1 notified Registered Nurse 1 (RN 1) who instructed her to put ice on the resident's left knee. The resident was offered pain medication but she refused. (There was no documentation of notification to the resident's physician or C2).* On November 30, 2012, at 6 a.m., Resident 1's left knee was slightly swollen, and she was unable to stand up due to a painful left knee. She complained of a pain level of 6/10 (based on a pain scale of 0 to 10, with 1 being the least pain and 10 being the worst pain level) to her right hand. Tylenol was given for the pain. (There was no documentation of notification to the resident's physician or C2).A review of the medication administration record for November 2012 revealed there was no documented evidence that Tylenol was given for the resident?s pain. The LPPN continued as follows: * On November 30, 2012, at 11 a.m., Resident 1 was examined by her doctor who wrote new orders.A review of the physician's order, dated November 30, 2012, indicated X-rays were ordered for the right thumb and hand, and left knee, and the nurses were to monitor the same. The LPPN continued: * On November 30, 2012, at 3 p.m., Resident 1 complained of pain in her right thumb, hand, and left knee. Her pain level was 8/10. At 9:45 p.m., the resident's right thumb, hand and left knee were slightly swollen. There was no documentation in the LPPN that Resident 1 was medicated for her pain. And, a review of the November 2012 medication administration record indicated there was no medication given for Resident 1?s pain.The LPPN continued as follows: * On November 30, 2012, at 10 p.m., the nurse faxed and called Resident 1?s X-ray results to the doctor's office, which revealed a left knee fracture. The doctor gave new orders to send the resident to the general acute care hospital (GACH) on December 1, 2012, in the morning for further evaluation of her left knee. * On December 1, 2012, at 7 a.m., Resident 1 was kept in the wheelchair because she was unable to walk due to a painful left knee of 6/10. At 10:30 a.m., the resident was picked up by ambulance and transported to the GACH for evaluation. The LPPN did not indicate that Resident 1 was given any medication to control her pain. During an observation on December 10, 2012, at 4:25 p.m., Resident 1 was very groggy, and when interviewed she stated she didn?t remember anything about her injury, where she fell, or how it happened.She said she just knows that she broke her knee.A review of the Routine Administration Record for November 2012, indicated Resident 1 was not given pain medication. The Pain Assessment Record for November 29 and 30, 2012, indicated Resident 1 had no pain on all three shifts, which was contradictory to the LPPN that indicated she had pain ranging from 6/10 to 8/10 through December 1, 2012. There was no documentation in the medication administration records that Resident 1 was given pain medication to control her pain, from the time she started to complain of pain on November 29, 2012, until she was transferred to the GACH on December 1, 2012. Resident 1 was transferred to the GACH for treatment 36 hours after she was found on the floor, screaming. According to the medication records, she was not provided pain medication to control her pain during this time.During an interview on January 22, 2013, at 3:12 p.m., Licensed Vocational Nurse 1 (LVN 1) was asked why she did not notify the resident's physician and C2 right away after the resident was found on the floor screaming and yelling. LVN 1 said she did contact the resident's physician and C2 right away, but was unable to provide documented evidence of the contacts. She said she had been too busy to make the documentation entry in the record. LVN 1 was not able to explain why it took 36 hours for the resident to be transferred to the GACH for evaluation.During an interview on January 23, 2013, at 9:20 a.m., C2 said he was not informed by the facility that Resident 1 had fractured her left knee. During a telephone interview with LVN 2 on May 14, 2013, he stated the licensed nurse who documented that she gave Tylenol to the resident on November 30, 2012, at 6 a.m., no longer worked at the facility.A review of the facilities policy Change of Condition Notification dated January 1, 2012, indicated the facility will promptly notify the resident's attending physician and the legal representative if the resident endures a significant change in their condition caused by an accident. "Change of Condition" related to attending physician notification is defined as when any sudden and marked adverse change in the resident's condition which is manifested by signs and symptoms different than usual denote a new problem complication or permanent change in status and require a medical assessment, coordination and consultation with the attending physician and a change in the treatment plan. The policy also indicated the licensed nurse will document the time and method by which the attending physician was contacted and the time the responsible party was contacted. The facility failed to ensure that a resident received prompt medical evaluation and treatment, including pain management, after she was found on the floor, screaming and yelling. Resident 1?s physician was not notified immediately after she fell on the floor on November 29, 2012. The staff also failed to notify the resident's court-appointed responsible party, Conservator 2 (C2), that Resident 1 sustained a fractured left knee from the fall. The fall resulted in severe pain from a fracture to Resident 1?s left knee, and injury to her right thumb and hand, with a delay of 36 hours from the time of the fall until she was transferred to the GACH for further treatment.The violation presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result to Resident 1. |
| 970000103 |
Virgil Rehabilitation and Skilled Nursing Center |
920011654 |
A |
05-Aug-15 |
EQ8F11 |
14022 |
42 CFR ?483.10(b)(11)(i) Notification of Changes A facility must immediately inform the resident; consult with the resident's physician; and if known, notify the resident's legal representative or an interested family member when there is-- (A) An accident involving the resident which results in injury and has the potential for requiring physician intervention;(B) A significant change in the resident's physical, mental, or psychosocial status (i.e., a deterioration in health, mental, or psychosocial status in either life threatening conditions or clinical complications);(C) A need to alter treatment significantly (i.e., a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or (D) A decision to transfer or discharge the resident from the facility as specified in ?483.12(a). 42 CFR ?483.25 Provide Care/Services for Highest Well Being Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. The nursing staff failed to notify the physician when a resident had a change in condition with the potential need to alter treatment. Resident A had episodes of vomiting and had five large loose stools, with severe abdominal pain during two shifts (16 hours). She became lethargic, required resuscitation (CPR), and died at the facility. On April 1, 2013, at 2 pm, an unannounced visit was made to the facility to investigate a complaint (CA00348306) regarding a resident?s death. A review of the medical record revealed Resident A was admitted to the facility on February 8, 2013, at about 7 pm, with the diagnoses of chronic kidney disease, chronic ischemic heart disease (partial blockage of blood flow to the heart), cardiopulmonary disease (COPD ? a chronic lung disease that makes it hard to breathe) hypertension (high blood pressure) and diabetes mellitus (high blood sugar).The Nursing Admission Assessment dated February 8, 2013, indicated Resident A was alert and oriented, had chronic pain daily to the right hip, the abdomen was soft and non-tender, and she was incontinent of bowel and bladder only at night according to the resident. A review of Resident A?s Physician's Admission Orders dated February 8, 2013, revealed an order for Docusate Sodium 100 milligram (mg) capsule per mouth twice a day for constipation, Lactulose [10 gram per 15 milliliter (ml) solution] 30 cubic centimeter (cc) twice a day for constipation (Lactulose is a synthetic sugar used to treat constipation and may cause diarrhea, stomach pain or vomiting), Dilaudid 2 mg tablet per mouth every six hours as needed for severe pain, and Tylenol 325 mg two tablet (650 mg) per mouth every four hours as needed, assess and note pain level before and after medication.The certified nursing assistant (CNA) documentation on the ADL (Activities of Daily Living) Data Report under BM (Bowel Movement), indicated that on February 10, 2013, day shift (7 a.m. to 3 p.m.), Resident A had 2 small loose stools. On February 11, 2013, day shift, the resident had 5 large loose stools.A review of the ?Progress Notes? documented by licensed nurses revealed the following: On February 9, 2013, day shift (7 a.m. to 3 p.m.), Resident A was alert and oriented times 3 (to person, place and time), not in acute distress, the abdomen was soft and non-tender. At 2:18 p.m., the resident complained of right hip pain, with pain meds given as ordered with partial relief.On February 10, 2013, night shift (February 9 at 11 p.m. to February 10 at 7 a.m.), Resident A slept good and denied pain or discomfort.On February 10, 2013, day shift, Resident A complained of right hip pain, with pain meds given as ordered with partial relief.On February 10, 2013, evening shift (3 p.m. to 11 p.m.), Resident A denied bladder discomfort, the abdomen was soft and non-tender. At 10 p.m., the physician was called regarding an episode of vomitus, and a new order for Compazine 10 milligrams (to control vomiting) every 4 hours as needed was received.On February 11, 2013, night shift (February 10 from 11 p.m. to February 11 at 7 a.m.), Resident A still had on and off vomiting. Compazine one tab was given but not effective. The resident vomited five times during the shift and had abdominal pain of 8/10. The physician was called but did not want the resident to be transferred, instead ordered to give intravenous (IV) hydration for five days, (started) also for antibiotic IV times five days, and to get a urine analysis. The resident was no longer vomiting as per endorsement (when signed off to the next shift).On February 11, 2013, day shift, Resident A complained of right hip pain, with pain meds given as ordered with partial relief.On February 11, 2013 at 3 p.m., Resident A was in bed with oxygen on at 3 liters per minute (L/min) via nasal cannula (through tubes in the nose) for shortness of breath (SOB). The head of the bed was up to facilitate easy breathing, and the resident was alert and verbally responsive. On February 11, 2013, at 4:28 pm, the physician ordered to discontinue IV antibiotic Levaquin and change to Bactrim twice a day for 10 days for urinary tract infection. Inform the physician regarding result of the UA (urine analysis ? test for infection) C&S (culture & sensitivity, to test for the best antibiotic for treatment) when obtained. On February 11, 2013, evening shift (charted on February 12, 2013, at 2:33 a.m.), at 5 p.m., Resident A ate dinner and medications were administered as ordered. No complaints were noted at this time. At approximately 7 p.m. to 7:20 p.m., the CNA saw the resident up in a wheelchair in the front of the lobby; the CNA asked the resident if she needed assistance/help, the resident stated she was ok and didn't need help at this time. The notes indicated the charge nurse and supervisor approached the resident in the lobby (no time given), and noticed the resident was lethargic, were trying to arouse her but she didn?t reply; put the resident back to her room still in the wheelchair. After a while, the resident vomited large amount of coffee-ground to tea-colored emesis (vomit); checked the resident but she was unresponsive. At 7:25 p.m., Code Blue (medical emergency) was called. The resident was put to bed. Suctioning was done and obtained secretions. Oxygen was given at 15 L/min via rebreather (allows for rebreathing of some of the exhaled air) mask. Assessed and checked vital signs. Radial (wrist) and carotid (neck) pulses noted upon palpation (feel), but no breathing or chest rising noted. Chest compressions were started with 2 assist. These interventions were done while 911 was called. At 7:30 p.m., paramedics arrived and took over, but after assessments and interventions were done, the resident was pronounced dead at 7:35 p.m. A review of the documentation from the ?Licensed Nurses Progress Notes? dated February 11, 2013, indicated at approximately 7:10 p.m., Resident A was put back to her room and was assessed to have an oxygen saturation (a measure of how much oxygen the blood is carrying as a percentage of the maximum it could carry) level of 74%. Oxygen was given at 15 liters per minute via rebreather mask. Radial and carotid pulse was noted upon palpation (feel); the resident suddenly vomited a large amount of coffee-ground to tea-colored vomitus approximately 300-400 cc (cubic centimeter).There was no documentation in the ?Progress Notes? dated February 11, 2013, of the resident's episodes of loose stools as documented on the ADL/BM sheet, or that the resident?s abdominal pain was assessed by a licensed nurse. There was no documented evidence the physician was notified that the resident had five large loose stools and ?severe? abdominal pain on February 11, 2013.The Nursing Daily Skilled Summary form dated February 11, 2013, charted at 7:30 a.m., indicated the resident had five episodes of vomiting transparent liquid with complaint of abdominal pain. At 5 a.m., the physician was notified and he ordered IV hydration for five days, and a urine analysis with culture and sensitivity.A review of the Medication Administration Record dated February 10, 2013, indicated Resident A was administered Dilaudid (narcotic opioid) two mg tablet at 9:12 a.m., for right hip pain of 7/10 (on a pain scale of 0 to 10 where 0 is no pain, 7-8 is severe pain, and 10 is the worst pain), effective to 0/10. On February 11, 2013, at 2:12 a.m. and 8:32 a.m., the Pain Management Flow Sheet indicated the resident was medicated for right hip pain. Resident A was also administered two tablets of Vicodin (narcotic opioid) ES 7.5-750 mg on February 11, 2013 at 12:36 p.m. for ?right abdominal pain? of 7/10 with partial relief after 30 minutes to a pain level of 4/10. (Common side effects of opioids are constipation, drowsiness and nausea and vomiting). A review of the Patient Care Plan dated February 11, 2013, indicated a problem for alteration in bowel movement. One of the approaches was ?special attention? and report to the physician if Resident A had signs or symptoms of impaction such as fever, abdominal pain, distention (bloated abdomen), lethargy or nausea/vomiting. On April 1, 2013, at 2 p.m., during an interview with CNA 1, who worked the day shift on February 11, 2013, she stated that Resident A was alert and complaining of ?severe? stomach pain. CNA 1 stated she changed the resident?s diaper five times, and was notified by the previous shift that the resident vomited during the night shift (11 p.m. to 7 a.m.). CNA 1 stated she informed Licensed Vocational Nurse 1 (LVN 1) that Resident A was in ?severe? pain and suggested to send her to the hospital. In another interview with CNA 1 on March 4, 2014, at 3:45 p.m., she stated that when she came in on February 11, 2013, at 7 a.m., Resident A was full of "poop" and her diaper was soaked.The resident pooped again after an hour and complained that she had ?severe? pain in the stomach. CNA 1 stated she informed LVN 1 before she left for the day that Resident 1 "pooped" 5 times with watery stool and had severe pain in the stomach.On April 1, 2013 at 3:20 p.m., during an interview, LVN 1 stated that Resident A was receiving lactulose (helps soften stools) routinely and complained of pain to the right hip. LVN 1 said that on February 11, 2013, he did not medicate the resident for diarrhea, and that he palpated (felt) the resident?s abdomen which was not hard. LVN 1 could not provide documented evidence in the nurses? notes that indicated an assessment of the resident?s abdomen was done. On March 3, 2014, at 3 p.m., during a concurrent review of the clinical record and interview with LVN 2, she stated that bowel movements (BMs) are monitored every shift and Resident A had two small loose BMs on February 10, 2013, and five large loose BMs on February 11, 2013.LVN 2 stated that if a resident has loose BM, the nursing staff are supposed to call and report it to the physician. LVN 2 could not provide documented evidence that the physician was notified that Resident A had several loose stools over two shifts.At 3:45 p.m., the Registered Nurse (RN 1) confirmed the record did not have documentation in the Progress Notes regarding Resident A?s episodes of diarrhea or loose stools on February 10 and 11, 2013.On March 5, 2014, at 4 p.m., LVN 3 stated in an interview that Resident A vomited on her shift. She stated Resident A complained of abdominal pain and she notified RN 2 (not available for interview). LVN 3 did not know if RN 2 notified the physician of the resident having loose BMs. On March 6, 2014, at 3:20 p.m., in a second interview with LVN 1, he stated that Resident A's main problem was pain from the back radiating to the front which was resolved with pain medication. LVN 1 stated the resident vomited five times on the previous shift (February 10, 2013, 11 p.m. to 7 a.m.) with no BM. The resident had two large BMs on his shift, and the first stool was formed. LVN 1 was asked if he checked the ADL Data Report and he stated ?yes.? However, when he was informed the ADL Data Report indicated the resident had five large loose stools on February 11, 2013, he stated that he thought the resident only had two large stools. LVN 1 stated that he did not call the physician on his shift on February 11, 2013.On March 13, 2014, at 3 p.m., in an interview with Physician 1, he stated the facility staff called him to report Resident A?s vomiting, but he was not aware Resident A had severe abdominal pain and loose stools. He said Resident A had been complaining of having constipation and was on lactulose. Physician 1 stated that if he had been informed of the resident's loose stools and severe abdominal pain, he would have ordered the staff to transfer Resident A to the hospital right away. On March 14, 2014, at 9:55 a.m., in an interview, CNA 2 stated Resident A was in the room assigned to her but she did not take care of her during the February 2013 incident. CNA 2 stated she helped CNA 1 change Resident A's diaper four or five times because the resident had diarrhea, and that the resident had a lot of watery stool the first time her diaper was changed. Therefore, based on the above information, the nursing staff failed to notify the physician when a resident had a change in condition with the potential need to alter treatment. Resident A had episodes of vomiting and had five large loose stools, with severe abdominal pain during over two shifts (16 hours). She became lethargic, required resuscitation, and died at the facility. This violation presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result to Resident A. |
| 920000027 |
VERDUGO VALLEY SKILLED NURSING & WELLNESS CENTRE |
920011675 |
A |
19-Aug-15 |
I09Z11 |
19618 |
42 CFR 483.20(k)(3) Comprehensive Care Plans (3) The services provided or arranged by the facility must-- (i) Meet professional standards of quality 42 CFR 483.25 Quality of Care Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. The facility failed to provide care and services in accordance with the plan of care, failed to follow professional standards of practice by not ensuring staff appropriately responded to an emergency according to its policy and procedures for a life-threatening medical emergency in a timely and effective manner; and failed to maintain updated staff records including information that would reflect the Basic Life Support (BLS - a level of medical care which is used for victims of life-threatening medical situations until they can be given full medical care at a hospital) certification status for the staff, for 1 of two sampled residents (Resident 1). In addition, the facility failed to ensure emergency equipment, which included walkie-talkies, was available for use, and failed to maintain current staff records with updated information including current Basic Life Support certification status for the staff. According to the 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation (CPR - techniques including chest compressions designed to pump the heart to get blood circulating and deliver oxygen to the brain to stimulate the heart to start working) and Emergency Cardiovascular Care (ECC - emergency medical procedures in which basic life support efforts are taken) healthcare providers are encouraged to tailor rescue actions to the most likely cause of arrest. The AHA recommends for immediate recognition and activation of the emergency response system once the healthcare provider identifies the adult victim who is unresponsive with no breathing or no normal breathing (i.e., only gasping). The healthcare provider briefly checks for no breathing or no normal breathing when the provider checks responsiveness. The provider then activates the emergency response system. The healthcare provider should not spend more than 10 seconds checking for a pulse, and if a pulse is not definitely felt within 10 seconds, should begin CPR and use the automated external defibrillator (AED - portable device used to identify and treat via electrical therapy an irregular heart rhythm) when available (Highlights of the 2010 American Heart Association (AHA) Guidelines for CPR and ECC, Pages 1, 2, 5).On May 26, 2015, the Department received and initiated an Entity Reported Incident that indicated Resident 1 had died during an emergency response rescue attempt on May 25, 2015. On June 3, 2015, at 6:10 p.m., during an interview regarding the death of Resident 1, Licensed Psychiatric Technician 1 (LPT 1) stated the following: 1a. LPT 1 stated Resident 1 had been having labored breathing on May 25, 2015. She administered a breathing treatment to the resident; he did not improve and still had labored breathing. She did not use her walkie-talkie (two way radio transmitter) to call Registered Nurse Supervisor 2 (RNS 2) because she failed to re-charge the battery that day. Instead she left Resident 1 to page RNS 2 on the telephone at the nurse's station. She waited at the nurse's station until RNS 2 returned her call, at which time she requested his assistance because of Resident 1's change in condition, and then returned to Resident 1's room. Certified Nursing Assistant 1 (CNA 1) was also in the room, and was not directed by LPT 1 to assist in this situation or to inform RNS 2. Not having the walkie-talkie available to immediately call RNS 2 for assistance, and not directing CNA 1 to act accordingly, caused a delay in life-saving emergency response for Resident 1. 1b. LPT 1 stated when she returned to Resident 1's bedside, he still had labored breathing and he was still receiving the breathing treatment. She called out his name several times but the resident did not respond. When asked why she did not start CPR efforts herself when the resident became non-responsive, she stated she called the resident's name "several times", but she was scared. She didn't know why she did not start CPR efforts herself as a first responder (the first person to arrive at and assist at the scene of an emergency) or before RNS 2 arrived. Certified Nursing Assistant 1 (CNA 1) was also present and did not act as a first responder. The staffs' delay in commencing CPR procedures immediately as first responders when Resident 1 became unresponsive, delayed life-saving emergency care.2. During an interview on June 2, 2015, at 1:20 p.m., the DSD was asked for a list of staff members that included the status of their CPR cards. The DSD provided a list that was not current or updated. During a review of a list of the nursing staff CPR re-certifications, there were 50 out of 85 CPR cards that were expired and had missing dates. The DSD stated her files were not current, should have been updated, and she had a stack of staff records that had not been reviewed. The facility's failure to ensure staff were current on CPR and emergency response procedures resulted in a delay in Resident 1's life-saving measures.According to the Admission Record, Resident 1 was a 67 year-old male, admitted to the facility on March 30, 2015, from a general acute care hospital (GACH). He had diagnoses which included chronic airway obstruction (COPD - a recurring condition that restricts normal breathing), and high blood pressure. A review of the full Minimum Data Set (MDS) a comprehensive assessment and care screening tool dated April 6, 2015, indicated Resident 1 was able to express ideas and wants, had clear speech and was able to understand others. According to the MDS, the resident's memory was moderately impaired but had the ability to recall after cues were given. The MDS indicated Resident 1 was on a mechanically altered diet and did not exhibit signs and symptoms of a swallowing disorder. According to the History and Physical (H&P) dated, April 28, 2015, Resident 1 did not have the capacity to understand and make decisions.Resident 1 had the following physician's orders: 1. Administer oxygen at two liters per minute by way of nasal cannula (a tube that delivers oxygen through the nose) as needed for COPD, dated March 30, 2015; 2. Administer Ipratropium Albuterol (a drug that relaxes and opens up the muscles around the airway for easier breathing) 0.5 milligrams (mg)- 3 mg solution nebulizer inhaler (a handheld device used to administer medication inhaled into the lungs) four times a day as needed for shortness of breath, wheezing or COPD dated March 30, 2015; and 3. Physician Orders for Life-Sustaining Treatment [(POLST)- a physician order that outlines a plan of care reflecting a resident's wishes concerning care at life's end] dated April 1, 2015, indicated Resident 1 wanted an attempt of cardiopulmonary resuscitation (CPR) and full treatment for prolonging life by all medically effective means. Resident 1 had a care plan developed on March 30, 2015, for respiratory problems, with interventions that included: assess as an indication of respiratory distress as shortness of breath (SOB), wheezing, coughing and notify the doctor immediately. Elevate the head of the bed as indicated for SOB to help with breathing. Give oxygen inhalation as indicated, and give breathing treatment as ordered. According to the facility's investigation report dated May 26, 2015, on May 25, 2015, at 6:04 p.m., Resident 1 received a breathing treatment in bed, became unresponsive and stopped breathing. A code blue was called and CPR was initiated. After arriving at the facility, the paramedics reported Resident 1's condition to the GACH's physician (MD 1) via telephone. At 6:29 p.m., Resident 1 was declared "expired" by MD 1. A review of the nurses' notes dated May 25, 2015, at 6:04 p.m., indicated while on a breathing treatment, Resident 1 became unresponsive and stopped breathing. The charge nurse was immediately called; code blue and 911 was called. CPR initiated via chest compressions until the paramedics arrived. At 6:11 p.m., the paramedics arrived and took over CPR on Resident 1. At 6:15 p.m., the paramedics reported the condition of Resident 1 to the physician (MD 1) via telephone. At 6:29 p.m., Resident 1 was declared expired by MD 1. During interviews with LPT 1 on May 27, 2015, at 3:20 p.m., and June 3, 2015, at 6:20 p.m., she stated that on May 25, 2015, at 5:50 p.m., Resident 1 was eating dinner sitting up on the side of the bed when she noticed he had labored breathing. Her assessment indicated that he was breathing hard and each time the resident inhaled his shoulders would rise. LPT 1 gave Resident 1 a nebulizer (a device used to deliver inhaled medications by producing a spray mist) respiratory treatment at 6:00 p.m. She stated she had never observed the resident in this condition and had never had to offer the resident a breathing treatment before. LPT 1 left Resident 1's bedside to go to North-East nursing station to overhead page RNS 2. She said RNS 2 was on the other side of the facility at the South-West station, and requested that he call her back. LPT 1 stated she waited at the nursing station phone for RNS 2 to call her back. When RNS 2 returned LPT 1's call, she asked him to come and check on Resident 1 who was having labored breathing. LPT 1 stated on her return to Resident 1's bedside, he still had labored breathing and was still receiving the breathing treatment. She called out the resident's name several times but the resident did not respond. LPT 1 stated she noticed Resident 1 was not breathing, his chest was not rising, his eyes were closed, and he had no body movements. LPT 1 stated she was walking out of the room to call a code blue when RNS 2 was at the door of the room, and they both walked back to Resident 1's bedside. LPT 1 stated RNS 2 saw the resident's condition, lowered the head of his bed, started chest compressions on Resident 1, and told her to call a code blue. LPT 1 stated she did not use her walkie-talkie to call RNS 2 because she failed to recharge the battery that day.When LPT 1 was asked why she did not start CPR efforts herself when Resident 1 became non-responsive, she stated she called the resident's name "several times", and stated she was scared. She stated she didn't know why she did not start CPR as a first responder before RNS 2 arrived. LPT 1 stated she had never provided CPR to anyone before and had never called a code blue before. She stated she was waiting for RNS 2 to get there.During an interview on June 2, 2015 at 3:20 p.m., regarding the use of the walkie-talkies, the DON stated they are used by front desk personnel, activities staff, RN Supervisors, housekeeping and maintenance staff, and the LPTs for emergencies. She stated this is a way to communicate instead of continuously overhead paging staff and in case of emergencies. During telephone and face-to-face interviews with RNS 2 on June 1, 2015, at 1:30 p.m. and June 2, 2015, at 3:40 p.m., he stated that on May 25, 2015, at around 6:02 p.m., he was paged to Resident 1's room by LPT 1 because the resident was having a hard time breathing. RNS 2 stated that LPT 1 met him at the door and they both walked towards the resident's bedside together. He stated the resident was lying on his bed with the head of the bed elevated approximately 30 to 40 degrees as it should be because he had been receiving a breathing treatment.RNS 2 stated when he reached Resident 1 he noticed the resident had his eyes open gazing upward. He could tell the resident was not breathing because his chest was not moving up and down. RNS 2 then lowered the bed and walked over to the resident's right side and repeatedly told LPT 1 to call a code blue. He started chest compressions and when the emergency ?crash? cart arrived, LPT 1 provided oxygen to Resident 1 with the Ambu bag (a hand held device commonly used to provide manual air to persons not breathing or not breathing adequately). During interviews on June 3, 2015, at 3:30 p.m. and 10:15 p.m., the Certified Nursing Assistant (CNA 1) stated Resident 1 was eating dinner on May 25, 2015, just before 6 p.m., when he leaned forward and started breathing hard but did not appear to be choking. CNA 1 stated LPT 1 was at the Nurse's station and overheard her ask the resident if he was okay. LPT 1 entered the room and administered a breathing treatment. While Resident 1 was receiving a breathing treatment, LPT 1 went to look for RNS 2 and met him at the door of the room. CNA 1 stated RNS 2 and LPT 1 both returned to the resident's bedside together, where Resident 1 was sitting up on the side of the bed. CNA 1 demonstrated how the resident was sitting at the edge of the bed with his shoulders hunched over and his arms dangling between his legs. CNA 1 stated RNS 2 laid Resident 1 down on the bed and started CPR. According to CNA 1, she took it upon herself to bring in the emergency ?crash? cart, because it appeared to be an emergency. CNA 1 stated RNS 2 initiated chest compressions and LPT 1 used the Ambu bag. CNA 1 stated she left the room because she had to finish distributing the rest of the dinner trays. During an interview on May 28, 2015, at 2:45 p.m., LPT 2 was asked to explain the CPR process if he was alone in the room with a resident who stopped breathing. LPT 2 stated, "I would use the walkie-talkie to call a code blue, make sure the resident is upright in the bed and breathing." During an interview on May 28, 2015, at 3:00 p.m., LVN 2 was asked to explain the CPR process if she was alone in the room with a resident who stopped breathing. LVN 2 stated, "I would check the pulse first, if no pulse I will call for assistance by pressing the call light so someone can help me to double check if the resident is really not breathing. I would also check the chart to see if the resident is a no code or have an advance directive, after that I would start CPR." LVN 2 was asked if the facility had a way to identify residents that are no codes and/or full codes. LVN 2 stated the facility does not have a list, but it is on the resident's chart. During interviews on June 2, 2015, at 2:20 p.m., and at 6:05 p.m., the DSD stated that the facility used an outside resource for CPR re-certification for the staff. When asked for the instructor's qualifications, lesson plan and a tracking system for CPR renewals, the DSD stated she did not have the CPR instructor's qualifications or lesson plans.During a review of a list of the nursing staff CPR re-certifications, there were 50 out of 85 CPR cards that were expired and had missing dates. When asked for the original staff credential checklist the DSD stated that she could not find it. The DSD was asked how does she ensure that all staff credentials and re-certifications are updated and how does she compare the old list to the new list. The DSD stated she does not have a current tracking system. According to the AHA, the quality of the rescuer education and frequency of retraining are critical factors in improving the effectiveness of resuscitation. (Highlights of the 2010 American Heart Association (AHA) Guidelines for CPR and ECC, Page 26).A review of the facility's policy titled, "Medical Emergencies - Code Blue" dated January 1, 2012, indicated the facility will provide an appropriate level of response to the resident during medical emergencies. A medical emergency is defined as any of the following conditions requiring immediate medical intervention and the initiation of the "Code Blue" procedure, which included respiratory or cardiac arrest, and severe respiratory distress. First Responder - The first of facility personnel to arrive and find a resident with any of the above conditions will: identify whether there is cardiopulmonary or respiratory arrest by shaking the person and calling out their name a minimum of three times. Respond to resident immediately and send available staff to call a Code Blue. Commence one person CPR, according to current practice; if alone, do resuscitation for one (1) minute before leaving the resident to call for help. The first responder should not leave the victim to call for help unless absolutely necessary according to the situation. Subsequent Responder(s) - Activate the emergency response system - call 911. Direct all needed personnel to the Code Blue site. Send a Staff member to the entrance door to wait where the ambulance is expected to arrive. The first RN to respond will lead the code unless responsibility is transferred to another licensed staff member (RN or MD). One person CPR will be maintained until there is a second responder available to begin two people CPR. CPR will continue until the paramedics arrive and assume responsibility.The policy indicated any available nursing staff (including CNAs) will complete the tasks as given in the first responder and subsequent responder sections of this procedure. Other staff (social workers, security, housekeepers, etc.) will be available to assist in placing phone calls and/or keeping residents away from the area.In the absence of an attending physician, it will be the responsibility of the first licensed staff member to respond to the code to lead, and coordinate the resuscitation efforts until paramedics arrive. Using the Code Blue Cart Checklist from the emergency cart, the nurse will assure that the following tasks have been completed and/or assigned: a. CPR has been initiated. b. 911 has been called. c. Code Blue or Stat has been paged overhead. d. Emergency Cart is on the scene. e. Staff has been assigned to direct the ambulance crew to the unit. f. Attending MD and/or MD on-call has been notified. g. Director of Nursing/Nurse Manager has been notified. h. Notify resident's family. i. Document the event in the resident record. j. Charting of time and condition of the resident at the time of discovery, CPR initiated, when Code Blue called, when physician and family notified, and when nursing staff responded. k. Complete an incident report, if indicated. l.Restock disposable items. m. Sign Emergency Checklist signifying cart readiness. n. Return emergency cart to the designated area. All documentation will be maintained in the resident's medical record. Therefore, the facility failed to provide care and services in accordance with the plan of care, failed to follow professional standards of practice by not ensuring staff appropriately responded to an emergency according to its policy and procedures for a life-threatening medical emergency in a timely and effective manner; and failed to maintain updated staff records including information that would reflect the Basic Life Support (BLS) certification status for the staff, for 1 of two sampled residents (Resident 1). In addition, the facility failed to ensure emergency equipment, which included walkie-talkies, was available for use, and failed to maintain current staff records with updated information including current Basic Life Support certification status for the staff. The above violation presented an imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would and did occur to Resident 1. |
| 920000027 |
VERDUGO VALLEY SKILLED NURSING & WELLNESS CENTRE |
920011785 |
B |
16-Oct-15 |
3ND711 |
10055 |
F323 CFR 42 483.25(h) ACCIDENTS The facility must ensure that ? ?483.25(h)(2) Each resident receives adequate supervision and assistance devices to prevent accidents. The facility failed to ensure that the resident environment remains as free of fire hazards as is possible for one Resident (1) and for the other residents, visitors and staff in the facility by failing to: 1. Ensure all of Resident 1's smoking materials were secured and stored by the staff as indicated in the facility's smoking policy and procedure in order to provide a safe environment;2. Ensure Resident 1 was assisted to and from the smoking area and supervised for unsafe smoking behavior at all times when smoking, as indicated in his care plan, to minimize the chance of accidental fires; and3. Ensure that staff members did not reset the fire alarm panel before the fire department cleared the facility of fire danger, in accordance with the facility's Fire Safety Plan, "Code Red Response", and its Fire Alarm Instructions policy, after a fire was extinguished in Resident 1's bathroom trash can.As a result, there was a fire that started in Resident 1's bathroom trash can, that placed Resident 1, other residents, staff, and visitors at risk for serious injury, burns or smoke inhalation. The facility placed all residents, visitors, and staff at risk for fire danger when the fire alarm was "silenced" by Licensed Psychiatric Technician 1 (LPT 1).On July 10, 2015, at 3 pm, a complaint investigation was conducted by the Department; the skilled nursing facility (SNF) census was 127.According to the admission record, Resident 1 was admitted to the SNF on April 15, 2015, with diagnoses that included psychosis (radical changes in personality, impaired functioning, and a distorted or nonexistent sense of reality), anxiety (an emotion characterized by an unpleasant state of inner turmoil, often accompanied by nervous behavior, such as pacing back and forth), and mood disorder. A review of Resident 1's undated History and Physical indicated he did not have the capacity to understand and make decisions due to psychosis.The Resident Care Plan for Smoking dated April 15, 2015, indicated Resident 1 was at risk for smoking related injury due to impaired cognition skills for decision making, impaired vision, disease impacting ability to safely smoke due to psychosis, and schizophrenia. The goal was the resident will smoke safely in accordance with facility policy daily for 90 days. The approaches included to supervise Resident 1 per facility policy while smoking, assist resident to and from designated smoking area, store smoking related materials per facility policy, and observe resident for unsafe smoking behavior. The Minimum Data Set (MDS) [a standardized comprehensive assessment of the resident's problems and conditions] dated May 11, 2015, indicated Resident 1 needed limited assistance to extensive assistance from staff for most care needs, with impairment on both sides of the upper extremities (arms/hands), and used a walker.A review of Resident 1's Multidisciplinary Progress record from July 1, 2015, to July 10, 2015, with the Director of Nursing (DON) indicated there was no documentation from the licensed staff regarding a fire incident involving Resident 1 that took place in the facility on July 7, 2015.A review of the Licensed Nurse Record forms with the DON, from July 6, 2015, to July 10, 2015, indicated Resident 1 was "monitored for safety" and would have "frequent visual checks for safety." There was no indication of what was being monitored, or how the monitoring would be done to ensure Resident 1's care plan was followed to ensure his safety.A review of the Interview Record report dated July 8, 2015, conducted by the director of nurses (DON) with Certified Nursing Assistant 3 (CNA 3), indicated CNA 3 was assigned in the patio to give cigarettes on July 7, 2015, at 8:30 p.m. Resident 1, who resides in Room 24, came to smoke and after smoking, the resident went back to his room, according to the report.According to the Glendale Fire Department's (GFD) Report dated July 7, 2015, at 9:50 pm, they responded to a reported fire alarm at the facility. On arrival there was no audible alarm noted. Upon entry into the facility, they found a staff member seated at the front desk. The Fire Captain (FC) asked if the fire alarm had been activated to which the staff member replied "yes". Another staff member walked up and stated that the alarm had been caused by somebody smoking. The FC then asked if the staff members had reset the alarm to which the staff member stated that the staff members were attempting to reset the system. While the FC attempted to assist with resetting the alarm, other FD personnel went to check the room where the activated detector was located (Room 24). The FD personnel reported the activation was not the result of smoking, but was a trash can fire that had been extinguished with water.When the FC went to Room 24 to investigate, he encountered light smoke coming from the bathroom, which was also in the bedroom and the hallway door. The bathroom floor was completely wet with water, as were the remnants of burnt paper in the bathroom trash can. The FC asked who had extinguished the fire, and he was told staff members had.The GFD Report indicated Resident 1 was lying on top of his bed in his room. When the FC asked Resident 1 what had happened, he said he did not know.A staff member told the FC that Resident 1 had been smoking. The FC attempted to question the resident further, asked if he had been smoking or had started a fire, but his responses were very unclear and nonsensical. The FC spoke to the person in charge, Registered Nurse 1 (RN 1), who informed the FC that residents only smoked in a designated area. The FC asked her how Resident 1 was able to bring smoking materials into his room to which RN 1 could not give him an explanation. The FC was told by RN 1 that a staff member had silenced the alarm. The FC explained that when there is an actual fire the facility is to wait for the FD and should not silence or reset the alarm. On July 10, 2015, at 3:47 p.m., during an interview with the Administrator, he stated the incident happened on July 7, 2015, at 10:30 p.m. in Room 24, located at the back of the facility close to the smoking patio. When the smoke detector alarmed, it sent a signal to the fire department and they responded. He said Licensed Psychiatric Technician 1 (LPT 1) reset the fire alarm.On July 13, 2015, at 1:35 p.m., during a smoking observation on the patio, there were 25 residents present, with and five staff supervising, including the Activities Director (AD). There was one staff distributing and lighting residents' cigarettes with a lighter. One resident (Resident 2) was smoking two lit cigarettes at the same time. The cigarette in his right hand had burnt down to the filter, and was going to burn his fingers until intervention by the Evaluator. At that time the AD was asked about cigarette extenders (holders for safety). She stated that the facility did use extenders, and that Resident 2 would benefit from one. She stated Resident 2 always wanted to smoke two cigarettes at the same time. When the residents went inside the facility after their smoking break, no one was checking or observing them to ensure they didn't have hidden smoking materials or lit cigarettes. On July 15, 2015, at 9:20 a.m., during a telephone interview with the Fire Captain, he stated there was an actual fire in the facility on July 7, 2015. He stated the staff should not reset the alarm while there was an actual fire not cleared by the FD.On August 17, 2015, at 4:45 p.m., a telephone interview was conducted with Licensed Vocational Nurse 1 (LVN 1) regarding smoking safety. When asked how staff supervise and ensure residents smoke only in designated areas, and don't have cigarettes or smoking materials, it was stated staff members check residents' belongings including whatever they have in the room, only if there is suspicion.On August 17, 2015, at 5 p.m., during a telephone interview CNA 3 stated she supervised the residents only in the smoking patio. She stated she does not check the residents for any cigarettes or any smoking materials before they return to their rooms.There was no evidence that Resident 1's smoking paraphernalia was secured and stored by the staff as indicated in the facility smoking policy and procedure in order to provide a safe environment. There was no evidence Resident 1 was supervised for unsafe smoking behavior on an ongoing basis to ensure the resident smoked in the designated smoking area only to minimize the chance of accidental fires.On July 10, 2015, at 3:47 p.m., the facility's undated Fire Alarm Instructions policy was reviewed with Administrator. The policy indicated when there is an actual fire, staff members are not to silence the fire alarm.The administrator stated Licensed Psychiatric Technician 1 (LPT 1) reset the fire alarm. A review of the facility's policy and procedure dated May 1, 2014, entitled "Smoking by Residents", indicated it is the policy of the facility to accommodate residents who desire to smoke by taking reasonable precautions, providing a safe environment for them, and protecting the non-smoking residents. Residents who require assistance and or monitoring for smoking safety are not allowed to smoke unaccompanied, per the policy.A review of another undated facility policy titled "Smoking Policy and Procedure", indicated all smoking materials (cigarettes, cigars, lighters, etc,) shall be secured and maintained by the facility staff. No resident will possess smoking materials, and smoking shall be permitted only in designated areas during smoking time. The latest scheduled smoking hour time indicated was 8:30 p.m. to 9:30 p.m. The above violation had a direct relationship to the health, safety and security of all residents. |
| 920000027 |
VERDUGO VALLEY SKILLED NURSING & WELLNESS CENTRE |
920011832 |
AA |
29-Feb-16 |
52BA11 |
22545 |
F 309 ?483.25 Quality of Care Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. F328 ?483.25(k) Special Needs The facility must ensure that residents receive proper treatment and care for the following special services; (6) Standard: Respiratory Care F279 ? 483.20(k) (1) Comprehensive Care plans. The facility must develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident?s medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The care plan must describe the following: (i)The services that are to be furnished to attain or maintain the resident?s highest practicable physical, mental, and psychosocial well-being as required under ?483.25; and (ii) Any services that would otherwise be required under ? 483.25 but are not provided due to the resident?s exercise of rights under ?483.10, including the right to refuse treatment under ? 483.10 (b) (4). F157 ?483.10(b) (11) Notification of Changes. (i) A facility must immediately inform: consult with the resident?s physician; and if known, notify the resident?s legal representative or an interested family member when there is? (B) A significant change in the resident?s physical, mental, or psychosocial status (i.e., a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); F224 ?483.13(c) Staff Treatment of Residents The facility must develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. ?Neglect? means failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness (42 CFR 488.301).F385 ?483.40 Physician Visits A physician must personally approve in writing a recommendation that an individual be admitted to the facility. Each resident must remain under the care of a physician. (a) Physician supervision. The facility must ensure that? (1) The medical care of each resident is supervised by a physician; and (2) Another physician supervises the medical care of residents when their attending physician is unavailable. (b) Physician visits. The physician must? (1) Review the resident's total program of care, including medications and treatments, at each visit required by paragraph (c) of this section; (2) Write, sign, and date progress notes at each visit; and (3) Sign and date all orders with the exception of influenza and pneumococcal polysaccharide vaccines, which may be administered per physician-approved facility policy after an assessment for contraindications. (c) Frequency of physician visits. (1) The resident must be seen by a physician at least once every 30 days for the first 90 days after admission, and at least once every 60 days thereafter. (2) A physician visit is considered timely if it occurs not later than 10 days after the date the visit was required. (3) Except as provided in paragraphs (c)(4) and (f) of this section, all required physician visits must be made by the physician personally. The Department received a complaint on September 5, 2014, alleging a resident (Resident 1), was transferred to a general acute care hospital (GACH) via 911 paramedics on August 24, 2014 from a skilled nursing facility (SNF). The complaint indicated Resident 1 became unresponsive, lethargic (sleepiness or deep unresponsiveness and inactivity), and had labored breathing (airway obstruction; breathlessness; difficulty breathing). According to the complaint, Resident 1?s family member (FM) stated the resident?s condition had been declining, especially his respiratory condition, for a while. The FM had requested the facility to have Resident 1 seen by a lung specialist (pulmonologist); however, there was no documentation that the Resident was ever seen by a pulmonologist. The FM was also informed that Resident 1 had not been seen by a physician for months, and the facility told the FM that he needed to choose a physician to see the resident. Resident 1 expired on August 30, 2014 in the GACH. The facility failed to provide Resident 1 with the necessary care and services to attain or maintain the highest practicable physical, mental, psychosocial well-being, in accordance with comprehensive assessment and plan of care; to ensure that Resident 1 received proper treatment and care for respiratory problems; to develop a comprehensive care plan for services to attain or maintain the resident?s highest practicable physical well-being; to immediately inform and consult with the resident?s physician when there was a change in the resident?s physical health status; to ensure that each resident remains under the continuing care of a physician and the medical care of each resident is supervised by a physician; and to develop and implement written policies and procedures that prohibited mistreatment, neglect, and abuse of residents, including but not limited to: Failure to ensure Resident 1, who had a history of respiratory problems, was assessed for signs and symptoms of respiratory distress daily, as indicated in the resident?s plan of care. Failure to notify a physician immediately, as stipulated in Resident 1?s plan of care, when the resident exhibited respiratory signs and symptoms. Failure to ensure Resident 1 had a primary care physician for supervision and management of the resident?s care and services. Failure to ensure physician?s orders were obtained before the staff provided care and services to Resident 1. Failure to call 911 paramedics promptly when Resident 1 had a significant change of condition, as ordered by the physician, and as stipulated in the facility?s policy and procedures, regarding emergency situations. These deficient practices resulted in a delay in a medical assessment, care, and treatment for Resident 1, who was transported to a GACH. According to the GACH records, the resident was diagnosed with sepsis (infection that is potentially life-threatening), had an extensive right lobe pneumonia (infection of the lung), requiring intravenous ([IV] into the vein) antibiotics and fluids. The resident was in acute respiratory failure, requiring an oral intubation (insertion of a tube into the trachea [a large membranous tube, extending from the larynx to the bronchial tubes and conveying air to and from the lungs (the windpipe) for purposes of airway maintenance and lung ventilation) and was placed on a ventilator (a breathing machine designed to mechanically move breathable air into and out of the lungs), due to the resident exhibiting respiratory failure. Resident 1 was admitted to the intensive care unit (ICU) and expired six days later (August 30, 2014), after being placed on hospice care (end of life care) the day prior. The GACH listed Resident 1?s cause of death as being acute respiratory failure. A review of a Resident 1?s Minimum Data Set (MDS), an assessment and care screening tool, dated June 9, 2014, indicated Resident 1's cognition was intact, but was non-ambulatory and was totally dependent in most of all his care needs, except eating, where he only required limited assistance and set-up. A review of an unsigned physician's order, dated April 8, 2014, indicated to administer oxygen at 2 liters per minute (PM) via nasal cannula ([N/C] tube in the nose) as needed to keep the resident?s oxygen saturation greater than 92 percent (%). A review of unsigned recapped-orders (orders previously written and carried forward) physician?s orders for the month of August 2014, indicated to administer oxygen to Resident 1 at 2 to 4 liters PM via N/C "continuously" for chronic obstructive pulmonary disease ([COPD] a chronic lung disease). A review of Resident 1?s Admission Face Sheet, indicated the resident was a 58 year-old male, who was initially admitted to the facility on June 3, 2013, and last readmitted on April 8, 2014. Resident 1?s diagnoses included pneumonia (an infection of the lungs caused by fungi, bacteria, or viruses), chronic airway obstruction ([COPD] persistent or recurring condition impedes normal breathing), asthma (common chronic inflammatory disease of the airways), and a history of extensive burns over 90 percent (%) of his body that occurred in 1990. A further review of Resident 1?s clinical records indicated there was no documented evidence the resident was physically seen by a physician from June 4, 2014 through August 11, 2014. There were no documented physician?s progress notes in Resident 1?s chart from June 4, 2014 through August 11, 2014. On October 2, 2015, at 11:20 a.m., during a review of Resident 1's clinical record and an interview with Licensed Vocational Nurse (LVN) 1, LVN1 stated that initial treatment orders were written by a treatment nurse or a charge nurse, and then communicated to the assigned physician. LVN 1 stated he had written treatment orders for Resident 1. LVN 1 stated he left a message for Physician 3, but did not remember talking to a physician. LVN 1 further stated since it?s a treatment, he would go ahead and do the treatment without talking to the physician. A review of the Physician and Telephone Orders with LVN 1 revealed three treatment orders for Resident 1 dated April 8, 2014, written by LVN 1 but not signed by a physician.A review of the facility?s policy, with a revised date of January 1, 2012, and titled, ?Physician Supervision of Resident Care and Alternative Visit Schedules,? stipulated each resident admitted to the facility must be under the continuing supervision of an attending physician. The policy further stipulated an attending physician would evaluate a resident as needed and at least every 30 days, unless there was an alternate schedule. Another facility?s policy, dated January 2004 and titled, ?Physician Documentation,? indicated part of the physician?s responsibilities included writing and/or giving orders and reviewing a resident?s total program of care. A review of a Resident 1?s care plan, titled, ?Respiratory,? dated April 8, 2014, and revised and updated, on July 20, 2014, indicated Resident 1 was at risk for respiratory distress due to his diagnoses of COPD and asthma with shortness of breath (SOB). The goal was to minimize the resident's signs and symptoms of respiratory distress on a daily basis. The staff?s approaches included assessing the resident for indications of respiratory distress such as SOB, wheezing (high-pitched whistling sound made when breathing), rhonchi (rattling lung sounds usually caused by secretions), and coughing, if present, and to notify the physician immediately. The staff?s approaches also included monitoring the sputum?s (mixture of saliva and mucus coughed up from the respiratory tract, typically as a result of infection or other disease) consistency, color, odor, and amount.However, a review of the Licensed Nurses Record forms, dated from April 8, 2014 to August 23, 2014, indicated there was no daily documentation of Resident 1?s respiratory assessment, as stipulated in the resident?s plan of care as follows: For nine of the 22 days for the month of April 2014 (post readmission). For 27 of the 31 days for the month of May 2014 For 22 of the 30 days for the month of June 2014 For 29 of the 31 days for the month of July 2014 For 13 of the 24 days for the month of August 2014, this included six days prior to Resident 1?s documented change in condition (COC) with respiratory problems. In addition, a review of the record revealed no documented nursing notes, from August 19 through August 24, 2014, to indicate the resident?s status prior to the resident?s COC on August 24, 2014. According to the nursing note dated August 24, 2014, Resident 1 had a change in condition (COC). A review of the COC document, an Interact Assessment Form ([SBAR] an inter-facility communication record), dated August 24, 2014, and timed at 6:20 a.m., indicated Resident 1 had an acute change in level of consciousness (LOC) and lung congestion (abnormal accumulation of fluid). Resident 1 was assessed and had labored breathing, was lethargic, verbally unresponsive, congested, had an increased heart rate, and a weak pulse. The resident?s vital signs were documented as blood pressure of 146/72 (normal reference range [NRR] is 120/80), pulse was 116 beats per minute (NRR is 60 to 100), respirations of 25 per minute (NRR is 16 to 20), and a temperature of 98.4 Fahrenheit [F] (NRR is 98.6). Resident 1's oxygen saturation level (referring to the percentage of oxygen-saturated hemoglobin ([transport oxygen]/ unsaturated + saturated] in the blood), while receiving oxygen at 2-4 liters per minute (PM) via N/C was 95-96%. According to the Medication Administration Record (MAR) for the month of August 2014, Resident 1's oxygen saturation levels generally were documented as 96-97%, while receiving 2-4 liters of oxygen PM via N/C. A review of a charge nurse?s narrative note, dated August 24, 2014, indicated at 6:20 a.m., the charge nurse reported to the registered nurse (RN) supervisor that Resident 1 had a change in LOC, had limited verbal response, was lethargic, but was able to state his name. According to the note, a breathing treatment was given to Resident 1 and both Physicians 1 and 2 were paged. At 6:30 a.m., on August 24, 2014, Physician 1 (the resident?s physician since June 3, 2014) called back and was informed of Resident 1's status. Physician 1 gave a verbal order to transfer Resident 1 to the GACH via 911 paramedics. According to the nurse?s narrative, at 7 a.m., on August 24, 2014, Resident 1 was picked up by the paramedics in ?fair condition,? was non-verbal, but was able to turn his head when his name was called. A review of the Physician and Telephone Orders form, dated August 24, 2014, timed at 6:30 a.m., indicated to transfer Resident 1 to the GACH for medical evaluation due to an acute (sudden) change in LOC and congestion. This order had a line drawn across it with ?error? written on it. Another Physician and Telephone Orders form with the same date and time, indicated to transfer Resident 1 to the GACH via 911 paramedics. On September 4, 2014, at 11:30 p.m., there was a clarification of Physician and Telephone Orders of transfer for August 24, 2014, indicating ?around? 7:35 a.m., to transfer Resident 1 to the GACH via 911 paramedics due to a change in level of consciousness (LOC) and congestion. A review of the charge nurse?s narrative note, dated August 24, 2014, indicated Resident 1 was picked up by 911 paramedics in ?fair condition at 7 a.m.? However, a review of the paramedics report indicated they were not dispatched until 7:40 a.m., on August 24, 2014, which was over an hour after the physician ordered the 911 transfer. According to the paramedics report, dated August 24, 2014, paramedics were dispatched to the SNF facility at 7:43 a.m., and arrived at 7:45 a.m. The paramedics? report indicated Resident 1 had SOB with ALOC (altered level of consciousness) since 6 a.m. that morning, almost two hours prior to the paramedics being dispatched. Resident 1?s heart rate was documented by the paramedics at 126 beats per minute (bpm), and had an elevated respiratory rate at 30, and the resident?s blood pressure was 128/76. According to the paramedics? report, Resident 1?s LOC was altered with a Glasgow Coma Score ([GCS] a neurological scale) of 9 (4=eye; 4=motor; 1=verbal). The resident was not verbally responsive. The paramedics documented rales (rattling in the chest caused by congestion) were heard after Resident 1 was moved to the gurney. A review of the facility's policy, with a revision date of January 1, 2012, and titled, "Change of Condition Notification,? stipulated that in an emergency situation the licensed nurse will do the following: "If the resident deteriorates, the symptoms are serious, and the most rapid intervention available by a physician would place the resident in great jeopardy, call 911 for transport to the hospital." The policy?s list of emergency situations included a resident experiencing shortness of breath. Resident 1 was documented as experiencing shortness of breath on August 24, 2014 at 6:20 a.m. A review of the GACH?s emergency room (ER) note, dated August 24, 2014, indicated at approximately 10 a.m., Resident 1's vital signs were: blood pressure was 135/100, heart rate was 128, respirations were 30 bpm, and the resident?s temperature was 97.5 F. The oxygen saturation was 94% while receiving oxygen. A review of the ER physician?s order, dated August 24, 2014, and timed at ?1730? (5:30 p.m.), indicated an order to intubate Resident 1 and place him on a ventilator, due to the resident?s increase in respiratory distress.The ER physician?s admission assessment, dated August 24, 2014, and timed at 2 p.m., indicated Resident 1 was admitted to the GACH with diagnoses that included acute respiratory failure , pneumonia with sepsis, COPD with pulmonary fibrosis [literally "scarring of the lungs"] a respiratory disease in which scars are formed in the lung tissues, leading to serious breathing problems), acute renal failure ([ARF] kidney failure), and multiple decubitus wounds (injuries to skin and underlying tissue resulting from prolonged pressure on the skin).A review of Resident 1?s GACH?s history and physical (H/P), dated August 24, 2014, indicated the resident was brought to the GACH due to an altered mental status and SOB while in the SNF. According to the H/P, Resident 1 had been coughing, was congested, and had SOB for several days while in the SNF, per the resident?s family member (FM). Resident 1 was examined in the ER and was in respiratory distress, with increase in his respiratory and heart rate since arrival, was septic ([infection] with bacteria in the blood), had an acute renal (kidney) failure, and his x-ray indicated the resident had a large right-sided pneumonia (lung infection). A review of the GACH physician?s order, dated August 30, 2014, indicated Resident 1 was put on hospice care and expired the same day. A review of Department Justice (DOJ) Bureau of Medical Fraud & Elder Abuse Unit?s Report of Investigation dated July 8, 2015, which was shared with the Department of Public Health, indicated Investigator 1 had conducted interviews with Resident 1?s documented Physician (Physician 3) on June 18, 2015. Investigator 1 asked Physician 3 if he was Resident 1?s primary care physician (PCP). Physician 3 indicated that he had never been Resident 1?s physician, nor was he associated with the facility, because he has never been to the facility and should have not been listed as the PCP for Resident 1. On September 28, 2015, at 4 p.m., during a telephone interview, Physician 3 stated Resident 1 was not his patient. Physician 3 stated he had never cared for Resident 1 or been to the facility or corresponded with anyone at the facility regarding Resident 1. On November 5, 2015, at 1:50 p.m., during a telephone interview, Physician 1 (who was the facility?s Medical Director) stated when he was informed about Resident 1's request to change physicians; he visited the resident the next day, on June 3, 2014. Physician 1 stated he was not aware that Resident 1 did not have a PCP and was not being seen and followed by a physician, until the facility?s staff informed him in June 2014. He stated the facility only called him once, on August 24, 2014, regarding Resident 1's change of condition. Physician 1 stated he ordered for the resident to be transferred to the GACH on August 24, 2014.A review of Resident 1?s death certificate, indicated the resident expired on August 30, 2014, at 3:08 p.m., and the primary cause of death was bronchopneumonia (inflammation of the lungs, arising in the bronchi or bronchioles [passageways by which air passes through the nose or mouth to the alveoli of the lungs]).A review of an autopsy report, dated September 16, 2014, indicated Resident 1?s primary cause of death was bronchopneumonia. The autopsy concluded with the medical examiner-coroner?s opinion that after a review of the case circumstances, the resident?s medical records, and a complete autopsy, Resident 1?s ?cause of death is attributed to complications of bronchopneumonia.? The facility failed to provide Resident 1 with the necessary care and services to attain or maintain the highest practicable physical, mental, psychosocial well-being, in accordance with comprehensive assessment and plan of care; to ensure that Resident 1 received proper treatment and care for respiratory problems; to develop a comprehensive care plan for services to attain or maintain the resident?s highest practicable physical well-being; to immediately inform and consult with the resident?s physician when there was a change in the resident?s physical health status; to ensure that each resident remains under the continuing care of a physician and the medical care of each resident is supervised by a physician; and to develop and implement written policies and procedures that prohibited mistreatment, neglect, and abuse of residents, including but not limited to: Failure to ensure Resident 1, who had a history of respiratory problems, was assessed for signs and symptoms of respiratory distress daily, as indicated in the resident?s plan of care. Failure to notify a physician immediately, as stipulated in Resident 1?s plan of care, when the resident exhibited respiratory signs and symptoms. Failure to ensure Resident 1 had a primary care physician for supervision and management of the resident?s care and services. Failure to ensure physician?s orders were obtained before the staff provided care and services to Resident 1. Failure to call 911 paramedics promptly when Resident 1 had a significant change of condition, as ordered by the physician, and as stipulated in the facility?s policy and procedures, regarding emergency situations. The above violations either jointly, separately, or in any combination presented either an imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result and was a direct proximate cause of death of Resident 1. |
| 920000031 |
VERDUGO VISTA HEALTHCARE CENTER |
920011984 |
A |
29-Jan-16 |
E38S11 |
8655 |
483.25 Quality of Care Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. 483.25 (c) Pressure Sores Based on the comprehensive assessment of a resident, the facility must ensure that? (1) A resident who enters the facility without pressure sores does not develop pressure sores unless the individual?s clinical condition demonstrates that they were unavoidable; and (2) A resident having pressure sores receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing. On 1/4/16, at 1:30 p.m., an unannounced visit was made to the facility to investigate a complaint related to Resident 1 developing pressure sores (injury to the skin or tissue over a bony area) and the family was not notified. Based on interview, and record review, the facility failed to ensure Resident 1, who entered the facility without a pressure sore and was identified as high risk for developing pressure sores, was provided with the necessary treatment and services for pressure sore prevention and to promote healing of pressure sores by:(1) Failing to promptly assess the development of pressure sore to the sacral (large, triangular bone at the base of the spine) and the coccyx area (tail bone). (2) Failing to implement the plan of care developed for the resident?s risk of skin breakdown. As a result, Resident 1 developed an unstageable pressure sore (full tissue loss in which the base of the ulcer is covered by slough - yellow, tan, gray or brown, and/or black eschar, in the wound bed) to the sacrum and a Stage III pressure sore (full tissue loss wherein subcutaneous fat may be visible, but bone tendon or muscle are not exposed) to the coccyx.A review of the Admission Face Sheet indicated Resident 1 was admitted to the facility, on 6/29/15, at 6:30 p.m., with glioblastoma multiforme (aggressive cancer of the brain), diabetes mellitus (high blood sugar), seizure (uncontrolled electrical activity in the brain resulting in an uncontrolled shaking of the body) and chronic obstructive pulmonary disease (lung disease that makes it hard to breathe). According to the initial Minimum Data Set (MDS - standardized assessment and care planning tool), dated 7/6/15, indicated Resident 1 was alert with periods of confusion, was able to make her needs known to staff, and staff understood her, was incontinent of bowel and bladder functions (unable to restrain natural discharges or evacuations), was dependent on staff for all activities of daily living (ADLs) including, bed mobility, transfers, and personal hygiene, had no pressure sores and was identified as not being at risk for developing pressure sores.A review of the initial nursing admission assessment dated 6/29/15, indicated Resident 1 had no pressure sores upon admission, but there was redness to the right and left groin area.The "Braden Scale - For Predicting Pressure Sore Risk" form indicated a total score of 20, which indicated Resident 1 was a high risk for development of pressure sores.A review of the Fragile Skin and the Pressure Sore Risk Care Plans dated 7/8/15 indicated Resident 1 had fragile skin and was at risk for developing pressure sores (in contrast to the MDS). The care plans interventions included informing the physician and responsible party for any abnormal changes, monitoring the skin during care for skin tears, bruising, swelling, redness, irritation and breakdown, and performing weekly skin checks.A review of the Weekly Pressure Ulcer Record, dated 7/21/15, documented by Licensed Nurse 5 indicated the resident had scattered peri-anal (around the anus) pressure sore Stage II (skin open). There was no description of the pressure sore including, color, size, depth, number of sites, and presence of drainage, odor or pain.The facility's Ulcer Risk Guidelines and Treatment Protocols, dated 12/2005, defines Stage II Pressure Sore as partial thickness loss of dermis presenting as a shallow, open ulcer with a red-pink wound bed, without slough. It may present as an intact of open-ruptured serum filled blister. This stage should not be used to describe skin tears or excoriations.According to the discharge orders, on 7/25/15 (approximately one month after admission) at 11:17 a.m., Resident 1 was transferred to a general acute care hospital (GACH) with treatment orders for peri-anal redness and peri-anal scattered pressure sore, Stage II. There was no description of the Stage II scattered pressure sore in the medical record. The Resident Transfer form indicated Resident 1 had no pressure sores and had clear skin. A review of the GACH's Pressure Ulcer Assessment, conducted by Registered Nurse 3, on 7/25/15, at 4:14 p.m., indicated Resident 1 presented with unstageable pressure sores to the sacrum (bilatera), and multiple skin tears in the labia majora (rounded fold of skin part of the external female genitalea) and both groin areas. The Pressure Ulcer Assessment, conducted by Registered Nurse 4, on 7/25/15, at 7:10 p.m., indicated unstageable pressure sores to the sacrum, a Stage III pressure sore to the coccyx area, and skin tears to the peri-areas.A review of the Skin/Wound Document Photograph, dated 7/25/15, by identified the sacrum pressure sore as unstageable. The Stage III coccyx pressure sore, measured 10 centimeters (cm) in length by 5 cm in width, was reddish in color, and sanguineous drainage.The facility?s policy and procedure titled, "Pressure Ulcer Treatment Policy," dated 3/2000, indicated the facility staff must notify the family or responsible party and must document notification.The facility's policy and procedure titled, "Skin Care Management," dated 12/1/05, indicated a significant change of status in skin breaks required documentation in the licensed progress notes and on the Weekly Pressure Sore Record. The policy indicated documentation was to include size, stage, location, odor, and pain, initiation of care plan, and notification of the interdisciplinary wound team. The licensed nurse would document the status of all pressure sores to include the dressings, surrounding skin condition, presence of possible complications, and pain using the "Daily Monitoring Pressure Ulcer Record."The policy indicated the licensed nurse would communicate all identified pressure sores to the resident's family or responsible party and would document family notifications in the patient's medical record and the care plan. Residents with newly identified or known pressure sores would be assessed by the Interdisciplinary Team Members. During an interview with Family Member 1, on 1/4/16, at 10 a.m., she stated the facility staff did not notify the family. She stated the family was aware that due to Resident 1's incontinence, she had redness to the peri-anal areas, but they were not aware of any skin breakdown such as pressure sores.On 1/4/16, at 3 p.m., Resident 1?s clinical record was reviewed with the director of nursing (DON). The DON stated the nurses did not inform her Resident 1 developed pressure sores and did not implement the Skin Care Management policy for Resident 1. The DON stated the care plan could not be implemented because the treatment nurses missed identifying and assessing the pressure sores to the sacral and coccyx areas. The DON could not find documentation the nurses notified Resident 1?s responsible party of the skin breakdown identified on 7/21/15.The facility failed to ensure Resident 1, who entered the facility without a pressure sore and was identified as high risk for developing pressure sores, was provided with the necessary treatment and services for pressure sore prevention and to promote healing of pressure sores by:(1) Failing to promptly assess the development of pressure sore to the sacral (large, triangular bone at the base of the spine) and the coccyx area (tail bone). (2) Failing to implement the plan of care developed for the resident?s risk of skin breakdown. As a result, Resident 1 developed an unstageable pressure sore (full tissue loss in which the base of the ulcer is covered by slough - yellow, tan, gray or brown, and/or black eschar, in the wound bed) to the sacrum and a Stage III pressure sore to the coccyx. The above violation presented either an imminent danger that death or serious harm would result or substantial probability that death or serious physical harm would result to Resident 1. |
| 920000031 |
VERDUGO VISTA HEALTHCARE CENTER |
920011985 |
A |
29-Jan-16 |
E38S11 |
9259 |
483.25 Quality of Care Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care.On 1/4/16, at 2 p.m., an unannounced visit was made to the facility to investigate a complaint regarding Resident 1?s pain and not receiving the ordered pain medications. Based on interview, and record review, the facility failed to ensure that the resident received and was provided with the necessary care and services to control and reduce her generalized pain in accordance with the plan of care by:1. Not assessing Resident 1?s pain level 2. Not re-evaluating the effectiveness of the pain medication, and 3. Not administering pain medication as ordered by the physician in a timely manner As a result, Resident 1 was suffering in severe pain, shaking, crying, and moaning from 7/23/15 to 7/25/15. A review of the Admission Face Sheet indicated Resident 1 was admitted to the facility on 6/29/15, at 6:30 p.m., with glioblastoma multiforme (aggressive brain cancer), diabetes mellitus (abnormal blood sugar levels), seizure (uncontrolled electrical activity in the brain resulting in an uncontrolled shaking of the body), and chronic obstructive pulmonary disease (lung disease that makes it hard to breathe). The Minimum Data Set (MDS ? a comprehensive assessment and care planning tool) dated 7/6/15, indicated Resident 1 was alert with periods of confusion, was able to make her needs known to staff and staff understood her, and was dependent on staff for her activities of daily living (ADLs) including bed mobility, transfers, dressing, and personal hygiene.A review of the Pain Care Plan, dated 7/8/15, developed for Resident 1?s pain related to cancer, included in the interventions assessing level of pain using the pain rating scale 0-10 (zero indicating no pain and 10 the worst possible pain); staff to administer pain medications as ordered by the physician; and to consult the physician if the current measures fail to provide adequate pain relief.A review of the Situation/Background/Assessment or Data Collection/Recommendation (SBAR - a tool used to facilitate prompt and appropriate communication among health care professionals), dated 7/23/15, indicated Resident 1 was in severe, generalized pain with pain level rated 10 out of 10 (the worst possible pain). At 6 p.m., the Resident 1 was shaking, crying, and in great pain, mostly on her back and abdomen. The physician was notified and ordered at 6 p.m. Norco (a narcotic pain medication) 5/325 milligrams (mg) by mouth every four hours as needed for moderate to severe pain. Norco was given at 6 p.m. At 6:15 p.m., the SBAR narrative note indicated the resident?s son reported the pain medication given was not effective and did not take the pain away. At 6:30 p.m., the physician ordered another dose of Norco 5/325 mg which was administered to Resident 1. At 9 p.m., the SBAR note indicated Resident 1 was in terrible pain, shaking and crying again. The physician was notified and ordered Norco for moderate pain and Dilaudid (a narcotic pain medication) 1 mg intravenous (IV- administered into a vein) every 4 hours as needed for severe pain.A review of the Infusion Medication Administration Record, dated 7/23/15, at 9 p.m., indicated Dilaudid was administered to Resident 1, but there was no documentation to determine the Dilaudid was effective.A review of the Doctor's Progress Notes, dated 7/24/15, indicated Resident 1 complained of severe back pain.According to the Nurse's Notes dated 7/24/15, at 4 p.m., Resident 1 was seen and examined by the physician with new orders for Roxanol 0.5 ml (a narcotic pain medication) by mouth every two hours as needed for pain. However, a review of the Infusion Medication Administration Record, dated 7/24/15, indicated the Dilaudid 1 mg IV for severe pain was given at 5:10 p.m. and 9:10 p.m. (not the Roxanol). There was no pain assessment found to indicate if Dilaudid was effective in relieving Resident 1's severe pain or an assessment of the rating of the pain.On 1/4/16, at 2:30 p.m. during an interview, the Director of Nursing (DON) stated the facility staff was giving Resident 1 Dilaudid instead of Roxanol, because the pharmacy had not made the delivery. The DON further indicated the staff should have notified the physician the Roxanol was not available, should have notified the pharmacy the facility did not have Roxanol in the house supply, and should have made arrangements for the Roxanol to be delivered STAT (immediately). The DON stated she could not explain why the medication was not given until 7/25/15, at 2 a.m., when the staff received the Roxanol on 7/25/15, at 1:08 a.m.A review of the Pain Management Flow Sheet, dated 7/25/15, indicated Resident 1 was not administered the Roxanol by mouth which was ordered on 7/24/15, at 4 p.m., until 7/25/15, at 2 a.m., 10 hours after the physician ordered it. In addition, according to the weekly Pressure Ulcer Record dated 7/21/15, Resident 1 developed scattered peri-anal (around the anus) pressure sore Stage II (break in the skin which is usually painful). However, there was no documented evidence the nursing staff addressed the pain Resident 1's manifested in relation to the new developed pressure sores.Resident 1 was transferred to a general acute care hospital (GACH) on 7/25/15 due to seizures. According to the GACH's Pressure Ulcer assessment, on admission the resident was identified as having an unstageable pressure sore to the sacrum (large, triagular bone at the base of the spine) and multiple skin tears to the labia majora (rounded fold of skin part of the external female genitalea) and both groins.On 1/4/16, at 5 p.m., during an interview, Family Members 2 and 3 stated the resident was in severe pain and the Dilaudid given on 7/24/15, at 5:10 p.m. and 9:10 p.m. was not effective. Family member 2 stated Resident 1 was crying and moaning and the nursing staff told them all they could do was to give the Dilaudid because the Roxanol had not arrived. During an interview with Pharmacist 1, on 1/11/16, at 2:50 p.m., she stated all pain medications were treated as STAT (immediately). Pharmacist 1 stated the medication should be delivered and administered within 4 hours.A review of the Omnicare - Facility's Pharmacy Services and Procedures Manual, "Receipt of STAT/Emergency Deliveries," dated 12/1/07, indicated the facility should immediately notify the pharmacy when facility received from a physician a medication order which may require a stat/emergency delivery. If a necessary medication was not contained within the facility's stat/emergency supply, and the facility determined that a stat/emergency delivery was necessary, the facility should arrange either an earlier scheduled delivery, delivery by contract courier, or for the medication to be dispensed and delivered by a third party pharmacy, to ensure timely receipt.A review of the facility's policy and procedure titled, "Pain Assessment," dated 3/2000, indicated the facility staff would target the site of pain, pain experience was very subjective, pain was whatever the resident says it is. The policy indicated a full assessment of pain includes: origin, location, severity, alleviating, exacerbating factors, current treatment, and response to treatment. Assessment included observing indicators of pain including moaning, crying, and other vocalizations, wincing or frowning, and other facial expressions, body posture such as guarding or protecting an area of the body or lying very still or decreases in usual activities.The policy indicated facility staff was to document the pain assessment results on the Resident Data Set. A review of the facility's policy and procedure titled, "Pain Management Flow Sheet," indicated staff should record the follow-up observations (pain after interventions) one-hour post intervention.During an interview with Family Member 1, on 1/6/16, at 3 p.m., she stated Resident 1 was in severe pain and that was why the physician told her he would order something stronger, Roxanol. Family member 1 stated she, Family Members 2 and 3 kept asking when the Roxanol was coming and why the resident had not received the Roxanol. Family Member 1 stated staff continued to tell them that the medication had not arrived and they did not have any in house supply of Roxanol in the facility. The facility failed to ensure that the resident received and was provided with the necessary care and services to control and reduce her generalized pain in accordance with the plan of care by:1. Not assessing Resident 1?s pain level 2. Not re-evaluating the effectiveness of the pain medication, and 3. Not administering pain medication as ordered by the physician in a timely manner As a result, Resident 1 was suffering in severe pain, shaking, crying, and moaning from 7/23/15 to 7/25/15. The above violation presented either an imminent danger that death or serious harm would result or substantial probability that death or serious physical harm would result to Resident 1. |
| 920000031 |
VERDUGO VISTA HEALTHCARE CENTER |
920012029 |
A |
20-Apr-16 |
0DJO11 |
7349 |
F323 CFR 42 ?483.25 (h)(1)(2) The facility must ensure that ? (1) The resident environment remains as free from accident hazards as is possible; and (2) Each resident receives adequate supervision and assistance devices to prevent accidents. F456 42 CFR ?483.70 (c) Space and EquipmentThe facility must -- (2) Maintain all essential mechanical, electrical, and patient care equipment in safe operating condition. The facility failed to provide adequate supervision to a resident and ensure equipment was maintained in safe operating condition to prevent accidents by failing to, including but not limited to: 1. Ensure at least two persons assisted during the Hoyer-lift transfer (a mechanical assistive hydraulic lift/hoist device used to transfer residents) of Resident 1 from her wheelchair to the bed, in accordance with the assessment and facility policy; and 2. Maintain the Hoyer lift in safe condition in accordance with the manufacturer?s guidelines, and remove it from use when it was not working properly. As a result of these failures, Resident 1 fell from the Hoyer lift, and hit her head sustaining a head laceration that required two staples. She also suffered intractable (severe, constant pain that is not curable by any known means) back pain and required three days of hospitalization for treatment and pain control. On April 19, 2012, the Department received an Entity Reported Incident (ERI) report indicating on April 18, 2012, Resident 1 fell from a Hoyer lift and sustained a head laceration. A review of the Admission Record revealed Resident 1 was initially admitted to the facility on August 19, 2011, with the diagnoses of Lumbago (lower back pain), and psychosis (mental disorder). The Patient Data Collection sheet dated August 20, 2011, indicated Resident 1 required 2 persons assist for transfers. The care plan dated August 31, 2011, indicated Resident 1 had a problem with self-care and needed assistance with her care due to a cerebral vascular accident (stroke) and dementia. One of the interventions indicated the use of a mechanical lift (Hoyer Lift) for transfers. Another care plan on the same date indicated Resident 1 was a high risk for falls, based on the fall risk assessment score of 15 (9 and above high risk). The interventions included to observe fall precautions, safety, and observe safe transfers. The care plan dated September 1, 2011, indicated Resident 1 had impaired communication and sometimes made herself understood; her decision-making was severely impaired, and she had short and long term memory loss. The Nurse?s Notes dated April 18, 2012, at 12:00 noon, indicated a Certified Nursing Assistant (CNA) called the attention of the licensed staff that Resident 1 fell from a Hoyer lift and was on the floor. Resident 1 was checked and noted to have bleeding coming from the back of her head. Pressure was applied to control the bleeding. The physician was called and an order was received to transport the resident to the hospital for evaluation. According to the Emergency Room Notes, on April 18, 2012, Resident 1 was brought in for intractable back pain, which occurred after a fall, and also suffered a 2 centimeter head laceration which required 2 staples. The resident was admitted to the GACH following a fall from a Hoyer lift, and was discharged and returned to the facility on April 21, 2012. In an interview with CNA 1 on June 28, 2012, at 11:00 am, she stated she was the only one working with Resident 1 at the time of incident. CNA 1 placed Resident 1 in the sling with four hooks, got the control and pushed to lift the resident a little bit and the Hoyer lift went up all the way and tilted the resident. One hook got loose and the resident fell. CNA 1 stated she did not ask for help, and stated all CNAs were using the Hoyer lift by themselves. CNA 1 stated she should have been working with another person in order to prevent the incident. CNA 1 stated there was no indication the Hoyer lift was not working properly, and she did not see a note on the lift indicating it was defective.In an interview with the maintenance supervisor on June 28, 2012 at 12:15 pm, he stated CNA 4 told him the Hoyer lift was not working properly. When asked if he could provide documentation that he attempted to have the Hoyer lift repaired prior to Resident 1?s incident on April 18, 2012, he could not provide any information. There was no documented evidence provided to show preventive maintenance had been done on the Hoyer lift. The date of service from the company to replace the controls on the machine was on April 24, 2012, after the incident.A review of the Operation instruction for the Hoyer lift under Maintenance Safety Instruction Checklist indicated slings and hardware are to be inspected/adjusted monthly. There was no documented evidence provided by the facility that this had been done. On June 28, 2012, at 12:35 pm., during an interview, the licensed vocational nurse (LVN 2) stated CNA 1 was lifting Resident 1 using the Hoyer lift and the sling became unhooked. LVN 2 saw Resident 1 on the floor and bleeding at the back of the head. Resident 1 was crying because of the head injury.In an interview dated June 28, 2012, at 1:00 pm, CNA 4 stated the Hoyer lift had not been working properly all the time. The control button would sometimes cause the sling to go up and down all the way, but not all the time. CNA 4 stated he had reported the problem to the maintenance supervisor. In an interview with the Director of Rehab on June 28, 2012, at 2:30 pm, she stated the Hoyer Lift required two persons to operate properly. She stated the hydraulic lift would tilt if only one person used it to transfer a resident. A review of the policy and procedure on Resident Transfer: Mechanical Lift dated August 15, 2002, indicated the manufacturer?s instruction and recommendation should always be followed, including the number of staff needed for safe transfers. Mechanical lifts require at least a 2-person assist. The investigation report dated April 26, 2012, indicated CNA 1 was placed on suspension for five days, and returned to work after receiving training on all types of transfers.The facility failed to provide adequate supervision and ensure equipment was maintained in safe operating condition to prevent accidents by failing to, including but not limited to: 1. Ensure at least two persons assisted during the Hoyer-lift transfer (a mechanical assistive hydraulic lift/hoist device used to transfer residents) of Resident 1 from her wheelchair to the bed, in accordance with the assessment and facility policy; and 2. Maintain the Hoyer lift in accordance with the manufacturer?s guidelines, and remove it from use when it was not working properly. As a result of these failures, Resident 1 fell from the Hoyer lift, and hit her head sustaining a head laceration that required two staples. She also suffered intractable (severe, constant pain that is not curable by any known means) back pain and required three days of hospitalization for treatment and pain control. The above violation presented imminent danger of death or serious harm or a substantial probability of death or serious physical harm to Resident 1, and any resident who required the use of the Hoyer lift for transfers. |
| 920000076 |
VALLEY MANOR |
920012557 |
A |
28-Oct-16 |
C3F611 |
14017 |
CFR 483.25 Quality of Care Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. 483.25 (h) Accident Hazards/Supervision/Devices The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. On 1/8/16, at 8:20 a.m., an unannounced visit was made to the facility to investigate an entity reported incident regarding Resident 1 sustaining a fall at the facility resulting in a hip fracture. Based on observation, interview, and record review, the facility failed to provide its residents with the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, and failed to ensure that the resident environment remains as free of accident hazards as is possible and that each resident receives adequate supervision and assistance devices to prevent falls and injuries, including: 1. Failure to ensure Resident 1, who was assessed as high fall risk due to impaired vision, poor safety awareness, and confusion, received adequate supervision, and assistance devices to prevent falls and injuries, in an environment as free of accident hazards as is possible, including: a. Failure to ensure proper functioning of Resident 1?s bed alarm to promptly notify staff of unassisted transfers to prevent falls and minimize injuries. b. Failure to evaluate the order to apply two side rails of the bed raised up which posed an increased risk for injury from fall if the resident would climb over the rails to get out of bed. 2. Failure to routinely monitor bed alarms to ensure the alarms were properly functioning to prevent falls for Residents 2, 3, and 4, who were assessed as high risk for fall and had bed alarms as a fall prevention intervention. 3. Failure to evaluate effectiveness of interventions in order to develop new and more effective interventions to prevent falls and minimize injuries. 4. Failure to develop comprehensive policies and procedures for fall prevention including the maintenance and use of bed alarms. As a result, on 12/23/15, Resident 1 sustained a fall resulting in a left hip fracture that required hospitalization and surgery. Resident 1 died at the general acute care hospital (GACH) on 1/10/16. In addition, Residents 2, 3, and 4 had an increased potential to sustain further falls with injuries. a. A review of the Admission Face Sheet indicated Resident 1 was admitted to the facility on 6/22/00, with the diagnoses including osteoporosis (thinning bones), visual loss, and anxiety (nervousness). A care plan dated 1/21/15 indicated Resident 1 was at risk for fall due to impaired vision, poor safety awareness, and psychosis (severe mental disorder in which thoughts and emotions are so impaired that contact is lost with external reality). The interventions included monitoring the resident's whereabouts/location with visual check at least every two hours and assisting the resident with re-orientation to room/facility with frequent verbal cueing. A physician?s order dated 7/7/15 indicated the use of one side rail up for mobility. A review of the Fall Risk Assessment dated 10/15/15, indicated Resident 1 was disoriented, required the use of assistive devices (wheelchair, walker), had a balance problem, and was at high risk for falls. A review of the Minimum Data Set (MDS - standardized assessment and care planning tool) dated 12/22/15, indicated Resident 1 was disoriented, was unable to make daily decisions, required extensive assistance and one person physical assistance with activities of daily living (ADLs) such as transfers, toilet use, and personal hygiene. The MDS indicated the resident had history of falls since admission with no evidence of injury. A review of the licensed personnel progress notes dated 11/29/15, at 5:50 p.m., indicated Resident 1 was found on the floor, by the bed and was lying on the left side. The physician when notified ordered x-rays to the left upper and lower extremities and no fractures were found. On 12/1/15, physical therapy was ordered three times a week for three weeks due to weakness and gait difficulty. On 12/4/14, the physician ordered the use of a bed alarm (provides an early warning to caregivers when a resident is about to get up from bed) while in bed for safety and prevention of falls. A review of the licensed personnel progress note dated 12/10/15, at 10:53 a.m., indicated Resident 1 was found on the floor at the bedside and was placed back in bed with the bed alarm. The resident was assessed as sustaining no injury. There was no documentation to indicate if the bed alarm went off and staff heard it. On the same day of the fall 12/10/15, the physician ordered two side rails up while in bed for safety and for fall prevention. There was no documentation by an interdisciplinary team evaluating the effectiveness of the bed alarm, if the bed alarm was properly functioning, and what was prompting the resident to get out of the bed. There was no documentation addressing the new order to use the two side rails up (a restraining device), how the side rail up would be beneficial or become an accident hazard if the resident would attempt to climb over the rails in order to get out of the bed. A review of the licensed personnel progress notes dated 12/23/15, at 3:20 p.m., indicated Resident 1 was found on the floor by his bed, lying on his left side, complaining of pain to the left hip. The progress note did not address if the bed alarm went off and was heard by staff or if the side rails of the bed were still up. The physician was notified and the resident was transferred to a GACH for evaluation. Further record review disclosed no documentation to indicate Resident 1's whereabouts/location was monitored with visual check at least every two hours, or if he was assisted with re-orientation to his room and the facility with frequent verbal cueing, as indicated in the plan of care. There was no documentation why the bed alarm was not heard prior to finding the resident on the floor. A review of the x-ray report from the GACH dated 12/24/15, at 1:51 a.m., indicated Resident 1 had a left hip fracture. The operative report, dated 12/26/15, indicated Resident 1 was taken to the operating room to have an open reduction and internal fixation (ORIF) of the intertrochanteric (hip joint) fracture of the left hip (realigns the bone fracture into the normal position, internal fixation refers to the steel rods, screws, or plates used to keep the bone fracture stable in order to heal the right way and to help prevent infection). Resident 1 expired at the GACH on 1/10/16. According to the GACH Report of Death, the resident had sustained a fall and a fractured hip at the nursing home. On 1/8/16, during an interview, certified nursing assistant 1 (CNA 1) stated that on 12/23/15, at 1:05 p.m., he took Resident 1 to the restroom, placed the resident back to bed with the bed alarm and both side rails up. CNA 1 stated the bed alarm was on, but he did not hear the alarm sound when the resident fell. According to the official Certificate of Death, signed on 1/16/16 by the Deputy Coroner, the immediate cause of death was blunt force trauma caused by a ground level fall sustained his place of residency. The manner of death was accident. b. A review of the Admission Face Sheet indicated Resident 2 was admitted to the facility on 12/11/14, with diagnoses which included anxiety and reduced mobility. A review of the MDS dated 6/18/15, indicated Resident 2 was alert and oriented, was unable to walk, and required extensive assistance with one person assist in all ADLs. A review of Resident 2's Fall Risk Assessment dated 9/9/15 indicated the resident was disoriented, had fallen in the past three months and was unable to walk and used a wheelchair. The fall assessment indicated Resident 2 was a high risk for falls. A review of Resident 2's care plan dated 7/16/15 indicated the resident was at risk for fall due to unsteady gait, poor balance control, and poor safety awareness and had fallen on 7/6 and 7/8/15. An updated care plan for fall dated 12/10/15, indicated in the interventions to apply a magnetic alarm on Resident 1's wheelchair and a bed alarm for safety and prevention of falls. The care plan intervention indicated to monitor the effectiveness of the use of the alarm. During a tour with the Registered Nurse (RN 1) on 1/8/16, at 10:40 a.m., Resident 2 was not in the bed at the time. The bed alarm pad was tested and the alarm did not sound. RN 1 stated the alarm was not functioning properly as it should be. The pad was supposed to alarm when the resident was not lying on it to alert staff the resident was out of bed. c. A review of the Admission Face Sheet indicated Resident 3 was initially admitted to the facility on 10/1/14 and re-admitted on 10/17/14, with diagnoses including delirium (a state of mental confusion that develops quickly and usually fluctuates in intensity), tremors, psychosis, and acute respiratory failure. A review of the MDS dated 10/9/15 indicated Resident 3 was alert, oriented and required extensive assistance and one person assist with ADLs. A review of Resident 3's Fall Risk Assessment, dated 10/1/14, 1/7/15, 4/7/15, and 10/8/15 indicated the resident scored at high risk for falls. A review of Resident 3's care plan for Fall, updated on 7/15/15, indicated the resident was at high risk for fall due to seizure (convulsions) disorder, refusing assistance with transfer left shoulder dislocation, and a history of fall prior to admission. The care plan interventions included assisting the resident with all transfers and walking, keeping call light within reach and answering promptly, applying a bed alarm in bed and a magnetic alarm on the resident's wheelchair for fall prevention. On 1/8/16, at 10:45 a.m., Resident 3, alert and oriented, was observed sitting up in bed with a bed alarm in place. The alarm did not sound when the resident stood up. RN 1 tested the alarm and stated that the bed alarm was not working. 4. According to the Admission Face Sheet, Resident 4 was admitted to the facility, on 6/23/13, with diagnoses which included paranoid schizophrenia (the patients have false beliefs that a person or persons are plotting against them or members of their family). A review of the MDS dated 10/7/15, indicated Resident 4 was alert and oriented, required limited assistance and one person assist with ADLs. The Fall Risk Assessment dated 12/9/15 indicated the resident was at high risk for falls. A review of Resident 4's care plan for Falls dated 12/17/14, updated on 12/9/15 indicated the resident was at high risk for fall due to unsteady gait, poor balance, history of stroke and history of hip fracture. The care plan indicated the resident had a history of falls on 10/20, 11/13, and 12/13/15. Interventions included applying a magnetic alarm on the resident's wheelchair and bed. On 1/8/16, at 11 a.m., Resident 4 was observed lying down, asleep in bed. The cord to the bed alarm was not connected to the alarm box. At that time, restorative nursing assistant 1 (RNA 1) stated the alarm was not connected because the pad was in the wrong position. RNA 1 stated the alarm should be connected at all times. During an interview with the Director of Nurses (DON) on 1/8/16, at 1:10 p.m., she stated the facility did not have a policy and procedures for bed alarms. The DON was unable to provide a policy for fall assessment and prevention and stated the facility did not have one. the facility failed to provide its residents with the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, and failed to ensure that the resident environment remains as free of accident hazards as is possible and that each resident receives adequate supervision and assistance devices to prevent falls and injuries, including: 1. Failure to ensure Resident 1, who was assessed as high fall risk due to impaired vision, poor safety awareness, and confusion, received adequate supervision, and assistance devices to prevent falls and injuries, in an environment as free of accident hazards as is possible, including: a. Failure to ensure proper functioning of Resident 1?s bed alarm to promptly notify staff of unassisted transfers to prevent falls and minimize injuries. b. Failure to evaluate the order to apply two side rails of the bed raised up which posed an increased risk for injury from fall if the resident would climb over the rails to get out of bed. 2. Failure to routinely monitor bed alarms to ensure the alarms were properly functioning to prevent falls for Residents 2, 3, and 4, who were assessed as high risk for fall and had bed alarms as a fall prevention intervention. 3. Failure to evaluate effectiveness of interventions in order to develop new and more effective interventions to prevent falls and minimize injuries. 4. Failure to develop comprehensive policies and procedures for fall prevention including the maintenance and use of bed alarms. As a result, on 12/23/15, Resident 1 sustained a fall resulting in a left hip fracture that required hospitalization and surgery. Resident 1 died at the general acute care hospital (GACH) on 1/10/16. In addition, Residents 2, 3, and 4 had an increased potential to sustain further falls with injuries. The above violations presented either an imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result. |
| 920000076 |
VALLEY MANOR |
920012571 |
A |
10-Nov-16 |
BD6E11 |
10143 |
F323 CFR 42 483.25(h) ACCIDENTS The facility must ensure that ? (1) The resident environment remains as free of accident hazards as is possible; and (2) Each resident receives adequate supervision and assistance devices to prevent accidents. The facility staff failed to provide supervision and/or a lap-buddy (a cushion that fits snugly into a wheelchair to remind the resident to ask for help before attempting to get up unassisted, for the prevention of falls), to Resident 1's wheelchair to prevent a fall with injury. Resident 1 fell from his wheelchair landing face down on the floor. As a result of the fall, Resident 1 sustained a comminuted fracture (the bone involved is broken into several pieces), to the maxillary sinus walls (bone cavity on both sides of the nose), nasal septal fractures, (the bone that divides the nostrils) associated intraspinous hemorrhage (bleeding from the structures of the face that included the nose and the sinuses behind both cheek bones) and a laceration (deep cut) to the forehead. In addition, Resident 1's face and head trauma placed him at risk for serious complications. Resident 1 required transfer to the general acute care hospital (GACH), where he was hospitalized for seven days for treatment and evaluation, and was discharged back to the skilled nursing facility (SNF) on August 3, 2015. On August 14, 2015, the Department of Public Health received a complaint (CA00454958) alleging Resident 1 fell from his wheelchair to the floor and sustained injuries to the forehead. An unannounced investigation was initiated on August 28, 2015. A review of the admission record, indicated Resident 1, a 78 year-old male, originally admitted to the SNF on July 6, 2010, with diagnoses that included cerebral vascular accident [CVA- sudden death of brain cells due to bleeding and/or lack of oxygen], multi infarct dementia (a series of strokes due to interrupt blood flow to the brain], osteoporosis (brittle and fragile bones), aphasia (loss of speech due to brain damage), generalized weakness and diabetes mellitus (a disease in which the individual's blood sugar is elevated; in diabetic patients wound healing is delayed and wound infection is one of the associated complications). A review of the Minimum Data Set [MDS- a comprehensive assessment and screening tool] dated June 10, 2015, indicated Resident 1's cognitive status and daily decision making skills were severely impaired, was totally dependent and required "Two+ persons physical assist" for bathing and transfers, and "One person physical assist" for bed mobility. The MDS indicated Resident 1 was at risk for falls. A review of Resident 1's "Physical Therapy Evaluation" dated July 11, 2010, indicated initial treatment was because of the resident's CVA (stroke) and fall history, and Resident 1 required fall precautions. Resident 1 required "Max 2" person assist from a sit to a stand position, and "Max 2" person assist for transfers from the bed to the wheelchair; and required "Max" assist from a lying to a sitting position and for rolling/bed mobility. The evaluation indicated Resident 1 did not ambulate (walk) during the evaluation. A review of Resident 1's physician's orders dated July 9, 2010, indicated to apply a lap buddy while in the wheelchair and release every two hours for comfort and circulation. A review of Resident 1's "Fall Risk Evaluation" dated May 6, 2015, indicated he was at high risk for falls. The "Fall Risk Evaluation" dated July 28, 2015, indicated Resident 1 continued to be at high risk for falls. A review of Resident 1's care plan initiated on February 15, 2015, and reviewed on May 6, 2015, by nursing staff, titled "Fall" indicated Resident 1 was at risk for falls due to impaired vision, weakness, lack of safety awareness, and tended to bend forward when he coughed. The goal of the care plan was to prevent injuries from a fall. The interventions included to apply restraints, but did not include the type of restraint to be used, the duration and circumstances under which it is to be used. Resident 1's nursing care plan for assistance with transfers initiated on May 25, 2015, indicated transfers required a two-person assist. A review of the SNF?s Investigation Report dated July 29, 2015, indicated on July 28, 2015, Certified Nursing Assistant 1 (CNA 1) transferred Resident 1 unassisted from bed to a wheelchair and left to reach for the footrests (wheelchair parts) which were located under the roommate?s bed. During this time, Resident 1 fell out of the wheelchair onto the floor, face down. CNA 1 was not able to catch the resident and prevent the fall. The report did not indicate why CNA 1 did not apply the lap-buddy as ordered by the physician before he left Resident 1 unattended to search for the wheelchair foot rests. A review of CNA 1's statement dated July 28, 2015, regarding the incident, did not indicate that he had placed a lap buddy as ordered by the physician after the resident was seated in the wheelchair. (A lap buddy can also be considered a restraint). On May 3, 2016, at 1:55 p.m., during an interview, Resident 1?s roommate (Resident 2), stated on the date of the incident, he had observed CNA 1 assisting Resident 1 into the wheelchair and he did not see a lap-buddy applied to the wheelchair or to the resident. Resident 2 stated he saw Resident 1 fall and land on the floor with his face down, and CNA 1 was not able to get Resident 1 off the floor by himself. Resident 2 stated Resident 1 had to go to the hospital because he had bad cuts and was bleeding on his face. During an interview on May 3, 2016, at 3:40 p.m., Registered Nurse 1 (RN 1) stated he was the nurse on duty who provided first aid to Resident 1?s face lacerations when the resident fell from the wheelchair. Resident 1's care plans were reviewed with RN 1, who stated the care plan initiated on May 27, 2014, revised May 6, 2015, indicated transfers required two-person physical assist. RN 1 stated the care plan titled, "Visual Functioning" initiated and reviewed the same dates, had an intervention to apply a restraint as needed while up in the wheelchair for prevention of falls and for safety. RN 1 stated he did not recall seeing a lap-buddy, as ordered by the physician, when he entered the room to provide first aid to Resident 1?s injuries. On June 6, 2016, at 9:45 a.m., during an interview CNA 1 stated on the date of the incident he entered Resident 1's room and completed his care. CNA 1 then pulled the wheelchair by the bedside and transferred Resident 1 from his bed to the wheelchair unassisted. CNA 1 briefly turned his body to reach the foot rests located under the roommate?s bed. During that time, Resident 1 fell out of the wheelchair onto the floor, face down. CNA 1 was not able to catch the resident and prevent the fall. Following the fall, CNA 1 called out for help and Licensed Vocational Nurse 1(LVN 1) and RN 1 came to assist him. The three of them transferred Resident 1 back to bed after RN 1 assessed for injuries. CNA 1 stated Resident 1 was bleeding from the forehead and RN 1 provided first aide. Emergency services via 911 were called, and Resident 1 was transferred to a GACH. During the same interview on June 6, 2016, at 9:45 a.m., CNA 1 stated he had taken care of Resident 1 for a long time and did not recall if Resident 1 was on the list of two-person physical assistance. CNA 1 denied having any knowledge of the physician's order to provide a lap-buddy to Resident 1, or that Resident 1 required two-persons physical assist for transfers. CNA 1 stated he always transferred Resident 1 by himself. A review of the facility's policy and procedure dated January 2004, titled, "Restraint Assessments: Physical and Chemical" indicated the facility should use a physical restraint for ensuring the safety and well-being of the resident or of others. The physician's order should include the type of restraint to be used, the duration and circumstances under which it is to be used. According to the licensed nurse's note, dated July 28, 2015, at 8:40 a.m., RN 1 provided first aid to stop the bleeding. Resident 1 was transferred back to bed with the assistance of four nursing staff. The physician was notified and an order to transfer the resident to the GACH was obtained. Emergency services (911), was called and Resident 1 was transferred to GACH at 9:15 a.m. for further evaluation and treatment of his injuries sustained in the fall. A review of the GACH physician's consult dated July 29, 2015, indicated Resident 1 was admitted for observation and the forehead laceration was sutured in the emergency room on July 28, 2015. A review of the CT-scan (Computerized Tomography a diagnostic tool] results obtained from the GACH dated July 29, 2015, indicated Resident 1 had a comminuted fracture (the bone involved is broken into several pieces), to the maxillary sinus walls (bone cavity on both sides of the nose), nasal septal fractures, (the bone that divides the nostrils) associated intraspinous hemorrhage (bleeding from the structures of the face that included the nose and the sinuses behind both cheek bones) and a laceration (deep cut) to the forehead. The facility staff failed to provide supervision and/or a lap-buddy (a cushion that fits snugly into a wheelchair to remind the resident to ask for help before attempting to get up unassisted, for the prevention of falls), to Resident 1's wheelchair to prevent a fall with injury. Resident 1 fell from his wheelchair landing face down on the floor. As a result of the fall, Resident 1 sustained a comminuted fracture to the maxillary sinus walls, nasal septal fractures, associated intraspinous hemorrhage, and a laceration to the forehead. In addition, Resident 1's face and head trauma placed him at risk for serious complications. The above violations jointly, separately or in any combination, presented either an imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result to Resident 1. |
| 920000057 |
VALLEY PALMS CARE CENTER |
920012900 |
A |
2-Feb-17 |
G5G411 |
25117 |
F309
42 CFR? 483.25 QUALITY OF CARE
Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care.
F329
42 CFR? 483.25 (l) UNECESSARY DRUGS
Each resident?s drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used--
(1) In excessive dose (including duplicate drug therapy); or
(2) For excessive duration; or
(3) Without adequate monitoring; or
(4) Without adequate indications for its use; or
(5) In the presence of adverse consequences which indicate the dose should be reduced or discontinued; or
(6) Any combinations of the reasons stated in paragraphs (l) (1) through (5) of this section.
F157
42 CFR? 483.10 (b)(11) NOTIFICATION OF CHANGES
(i) A facility must immediately inform the resident; consult with the resident?s physician; and notify, consistent with his or her authority, the resident representative(s) when there is-
(B) A significant change in the resident?s physical, mental, or psychosocial status (that is, deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications).
The facility failed to provide necessary care and services to adequately manage and control blood glucose levels for Resident 16 by failing to:
1. Ensure Resident 16 received insulin (a hormone made by the pancreas that keeps blood sugar levels from getting too high or too low) dosage as ordered by the physician.
2. Ensure the licensed nursing staff followed the physician's order to notify the physician when Resident 16?s blood glucose levels were at a reportable range as set and directed by the physician.
As a result, Resident 16 had uncontrolled high blood glucose levels, and on December 10, 2016, was transferred to the general acute care hospital (GACH), and received multiple doses of insulin by injection to lower his blood glucose levels of 900 mg/dl.
Uncontrolled blood sugar levels present a high risk for severe complications such as diabetic ketoacidosis (the body begins to break down fat for energy, and if left untreated, can lead to a diabetic coma and be life-threatening); and/or hyperglycemic hyperosmolar syndrome [blood glucose levels greater than 600 mg/dL where the body can't use either glucose or fat for energy causing increased urination. Left untreated, this can lead to life-threatening dehydration (loss of fluids exceeds intake of fluids) and a coma].
According to the admission record, Resident 16 was a 67 year-old male admitted to the facility on XXXXXXX, 2013, with diagnoses that included diabetes mellitus (uncontrolled blood sugar levels), hypertension (high blood pressure), and anemia (a condition in which your blood has a lower than normal number of red blood cells).
A review of Resident 16's History and Physical report completed by the resident's physician, dated May 26, 2016, indicated the resident was competent and able to give informed consent regarding his medical/physical treatment relating to existing and continuing medical condition.
A review of Resident 16's Minimum Data Set [MDS- a comprehensive assessment and screening tool], dated September 23, 2016, indicated the resident understood and was able to make himself understood. Resident 16 required supervision and set up with eating and moving between locations in his room and the adjacent corridor on the same floor and if in a wheelchair, self-sufficiency once in the chair. The MDS indicated the resident was receiving insulin injections.
On December 9, 2016, at 4:15 p.m., during observation, Resident 16 was in bed, awake, and oriented to person and place. At this time, Resident 16 stated that his blood sugar was high most of the time. He also stated that he drank juices and had access to the facility vending machine. He stated he received his meals 30 minutes to one hour after he received his insulin injection. Resident 16 stated that no staff members had ever discussed with him the type of diet necessary to effectively manage his blood sugar.
Resident 16 had a care plan initiated on June 29, 2015, for diabetes mellitus manifested by uncontrolled blood sugar and noncompliance with therapeutic diet. The care plan goals were for the resident to have no signs and symptoms of hypoglycemia (low blood sugar) and hyperglycemia (high blood sugar), to be compliant with the therapeutic diet, and maintain blood sugar levels between 70 to 110 mg/dl daily for 3 months. The care plan interventions included to monitor for thirst, excessive appetite and urinating; for change in level of consciousness or mood; for excessive perspirations, and to report to physician promptly; to provide diet as ordered, encourage adherence to diet and report to the physician if non-compliant; and to administer medication as ordered and monitor effect of medication.
A review of Resident 16's physician orders indicated the following:
1. Call the physician for glucose greater than 300 mg/dl or less than 80 mg/dl two times a day related to type 2 diabetes without complications, dated July 7, 2013.
2. Victoza solution pen-injector (medication injection used to control blood sugar levels in adults) 18 mg per 3 milliliter (ml), inject 1.2 mg subcutaneously one time a day related to diabetes, dated July 22, 2015.
3. Lantus solution (insulin to treat diabetes) inject 60 units subcutaneously one time a day related to diabetes, dated June 30, 2016.
4. Novolog solution (insulin used to treat diabetes) inject 22 units subcutaneously before meals related to diabetes, administer 5 to 15 minutes before meals or with meals, dated August 1, 2016.
(According to the American Diabetic Association, Novolog is a rapid acting insulin that starts to lower blood glucose within 5 to 10 minutes after injection).
5. Novolog solution, inject subcutaneously before meals and at bedtime as per sliding scale (refers to the progressive increase in pre-meal or nighttime insulin doses and is based on a finger-stick blood sugar test level done at set intervals). Glucose (mg/dl) zero to 60 = 0 unit give orange juice oral if alert/responsive and call physician; glucose 61 to 130 mg/dl = 0 unit, glucose 131 to 160 mg/dl = 2 units, glucose 161 to 200 mg/dl = 3 units, glucose 201 to 250 mg/dl = 4 units, glucose 251 to 300 mg/dl = 6 units, glucose 301 to 350 mg/dl = 8 units, glucose 351 to 400 mg/dl = 10 units, and if greater than 401 mg/dl call the physician. Accucheck (finger-stick test) before meals and at bedtime, dated October 1, 2015.
A review of Resident 16's Medication Administration Record (MAR) documents for the month of September 2016, October 2016, November 2016, and December 2016, indicated the resident did not receive insulin in the dose ordered by the physician as follows:
1. On September 25, 2016, at 9 p.m., the blood glucose (BS) level was 132 mg/dl with no Novolog administered. The resident did not receive 2 units of Novolog as indicated in the physician order.
2. On October 14, 2016, at 6:30 a.m., the BS level was 168 mg/dl with 2 units of Novolog administered. The resident did not receive 3 units of Novolog as indicated in the physician order.
3. On October 17, 2016, at 6:30 a.m., the BS level was 253 mg/dl with 4 units of Novolog administered. The resident did not receive 6 units of Novolog as indicated in the physician order.
4. On October 21, 2016, at 4:30 p.m., the BS level was 72 mg/dl. The resident received 22 units of Novolog before his meal. There was no documented evidence that the licensed nursing staff notified the physician for the resident?s BS level of less than 80 mg/dl as indicated in the physician order.
5. On October 24, 2016, at 6:30 a.m., the BS level was 300 mg/dl with 13 units of Novolog administered. According to the physician order, the resident should have received 6 units of Novolog.
6. On October 25, 2016, at 4:30 p.m., the BS level was 206 mg/dl with 10 units of Novolog administered. According to the physician order, Resident 16 should have received 4 units of Novolog.
7. On November 27, and 30, 2016 at 6:30 a.m., the BS levels were 370 mg/dl and 415 mg/dl, respectively. The resident received 10 units of Novolog for both dates, and there was no documented evidence the licensed nursing staff notified the physician, as indicated in the physician orders. The routine order indicated to call the physician for BS above 300 mg/dl, and the sliding scale order indicated to call the physician for BS above 401 mg/dl, and did not indicate to administer Novolog.
8. On December 2, 2016, at 6:30 a.m., the BS level was 135 mg/dl. The resident did not receive 2 units of insulin as indicated in the physician order.
9. On December 4, 2016, at 6:30 a.m., the BS level was 173 mg/dl with 2 units of Novolog administered. The resident did not receive 3 units of Novolog as indicated in the physician order.
10. On December 6, 2016, at 11:30 a.m., the BS level was 396 mg/dl with 8 units of Novolog administered. The resident did not receive 10 units of Novolog as indicated in the physician order.
11. On December 7, 2016, at 11:30 a.m., the BS level was 390 mg/dl with 8 units of Novolog administered. The resident did not receive 10 units of Novolog as indicated in the physician order.
12. On December 8, 2016, at 6:30 a.m., the BS levels were 78 mg/dl. The resident received 22 units of Novolog before his meal. There was no documented evidence the licensed nursing staff notified the physician for the resident?s BS level of less than 80 mg/dl as indicated in the physician order.
On December 13, 2016, at 11:41 a.m., during an interview, the director of staff development (DSD) stated on October 21, 2016, and December 8, 2016, Resident 16's blood glucose levels were less than 80 mg/dl. The DSD stated the licensed nursing staff should have notified the physician and clarified the order before administering 22 units of Novolog since there were no parameters set for blood glucose levels less than 80 mg/dl, for Novolog 22 units before meals.
On December 15, 2016, at 11:32 a.m., during an interview, Licensed Vocational Nurse 4 (LVN 4) stated she was the licensed nurse who administered 13 units of Novolog to Resident 16 on October 24, 2016, at 6:30 a.m. LVN 4 stated she should have administered 6 units of Novolog as ordered by the physician.
A review of Resident 16?s MAR and nurses? notes for the month of September 2016, October 2016, November 2016, and December 2016, indicated the licensed nursing staff did not call the physician when Resident 16?s BS was greater than 300 mg/dl, or less than 80 mg/dl as indicated in the physician order as follows:
1. On September 4, 2016, at 6:30 a.m., Resident 16?s BS level was
319 mg/dl. On September 12, 17, 18, and 20, 2016, at 4:30 p.m., the BS levels were 348 mg/dl, 375 mg/dl, 318 mg/dl, and 306 mg/dl, respectively. There was no documented evidence that the licensed nursing staff notified the physician for blood glucose levels above 300 mg/dl as indicated in the physician order.
2. On October 21, 2016, at 4:30 p.m., Resident 16?s BS level was 72 mg/dl. The resident received 22 units of Novolog before his meal. There was no documented evidence that the licensed nursing staff notified the physician for a BS level less than 80 mg/dl as indicated in the physician order.
3. On October 2, 2016, and October 27, 2016, at 6:30 a.m., Resident 16?s BS levels were 434 mg/dl and 480 mg/dl, respectively. The resident received 10 units of Novolog. There was no documented evidence that the licensed nursing staff notified the physician. The physician order for sliding scale indicated to call the physician for blood glucose level above 401 mg/dl; the order did not indicate to administer Novolog.
4. On October 1, 2016, October 20, 2016 and October 21, 2016 at 6:30 a.m., Resident 16?s BS levels indicated 400 mg/dl, 390 mg/dl, and 390 mg/dl, respectively. On October 14, 15, 20, 24, 26, and 28, 2016, at 4:30 p.m., the BS levels indicated 325 mg/dl, 355 mg/dl, 389 mg/dl, 346 mg/dl, 436 mg/dl, and 312 mg/dl, respectively. There was no documented evidence that the licensed nursing staff notified the physician for Resident 16?s BS levels above 300 mg/dl as indicated in the physician order.
5. On November 17, 18, 27, 2016, at 6:30 a.m., Resident 16?s BS levels were 400 mg/dl, 400 mg/dl, and 370 mg/dl, respectively. On November 4, 12, 16, 18, 19, 21 and 30, 2016, at 4:30 p.m., the BS levels were 64 mg/dl, 349 mg/dl, 359 mg/dl, 398 mg/dl, 386 mg/dl, 316 mg/dl, and 308 mg/dl, respectively. There was no documented evidence the licensed nursing staff notified the physician for Resident 16?s BS levels above 300 mg/dl, and/or levels less than 80 mg/dl, as indicated in the physician order.
On December 16, 2016, at 11:32 a.m., during an interview, LVN 4 stated she did not think she notified Resident 16's primary physician on November 27, 2016, when the resident?s BS level was 370 mg/dl because most insulin orders indicated to notify the physician if the blood glucose was above 400.
6. On November 24, 2016, at 6:30 a.m., Resident 16?s BS level was 78 mg/dl. The resident received 22 units of Novolog before his meal. There was no documented evidence that the licensed nursing staff notified the physician for the BS level less than 80 mg/dl as indicated in the physician order.
7. On December 9, 2016 at 6:30 a.m., the blood glucose level indicated 388. On December 4, 2016 and December 9, 2016 at 4:30 p.m., the blood glucose levels indicated 354 and 382 respectively. The licensed nursing staff did not notify the physician for blood glucose levels above 300 mg/dl per physician order.
8. On December 8, 2016, at 6:30 a.m., Resident 16?s BS level was 78 mg/dl. The resident received 22 units of Novolog before his meal. There was no documented evidence that the licensed nursing staff notified the physician for the resident?s BS level less than 80 mg/dl as indicated in the physician order.
On December 13, 2016, at 11:22 a.m., during an interview, Registered Nurse 1 (RN 1) stated that she reviewed Resident 16's MAR for the month of September 2016, October 2016, November 2016, and December 2016. RN 1 stated she could not find any documented evidence that the licensed nursing staff notified the physician when the resident?s BS levels were above 300 mg/dl, and/or less than 80 mg/dl.
On December 13, 2016 at 11:41 a.m., during an interview, the Director of Staff Development (DSD) stated that on October 21, 2016, and December 8, 2016, Resident 16's BS levels were less than 80 mg/dl. The DSD stated the licensed nursing staff should have notified the physician and clarified the order before administering 22 units of Novolog since there were no parameters given for blood glucose levels less than 80 mg/dl.
A review of Resident 16's laboratory test results dated November 7, 2016, indicated he had a hemoglobin A1C (a test that measures a person's average blood glucose level over the past 2 to 3 months) result of 7.8 percent (normal reference range is less than 5.7 percent, diabetes above 6.5 percent).
On December 13, 2016, at 12:40 p.m., during an interview, Certified Nursing Assistant 1 (CNA 1) stated that Resident 16 frequently bought soda (drink that is generally high in sugar content) from the vending machine. CNA 1 also stated that she had reported this to the licensed staff each time she witnessed the resident drinking soda.
On December 16, 2016, at 9:45 a.m., during an interview, RN 2 stated Resident 16 usually purchased cookies and "coke" from the vending machine. RN 2 stated the resident usually woke up around 4:30 a.m., and asked for his blood glucose level to be checked. If the resident?s blood glucose level was high (300 to 400), RN 2 stated she would administer insulin right away, around 4:30 a.m., and notify the upcoming shift to call and notify the physician.
During a review of Resident 16?s medical record with RN 2, she was unable to provide documented evidence of Resident 16's eating habits and morning routine. RN 2 was also unable to provide documented evidence that the licensed nursing staff were monitoring the resident for thirst, excessive appetite, voiding, change in level of consciousness or mood, and excessive perspirations, as indicated in his care plan.
On December 16, 2016, at 11:32 a.m., during an interview and review of Resident 16's medical record, LVN 4 stated that the resident?s blood glucose level would sometimes be high in the morning because he had already eaten snacks before she could check his blood glucose at 6:30 a.m. LVN 4 stated that she did not document if the resident had already eaten prior to checking his blood glucose level. LVN 4 was unable to provide documented evidence of Resident 16's eating habits prior to checking his BS levels. LVN 4 was also unable to provide documented evidence that the licensed nursing staff were monitoring for thirst, excessive appetite, voiding, change in level of consciousness or mood, and excessive perspirations, as indicated in the resident?s care plan.
A review of the Nurses Notes from April 2016 to December 9, 2016, indicated the licensed nursing staff were not monitoring Resident 16's nonadherence to his therapeutic diet. There was no documentation that licensed nursing staff had educated or attempted to educate Resident 16 regarding the risks associated with noncompliance to his diet with foods and drinks obtained from the vending machine.
A review of Resident 16's nutritional screening and data collection forms dated April 24, 2015, and March 31, 2016, did not address the resident's ability to buy food and drinks from the facility vending machine.
A review of Resident 16's Nutrition Progress Note dated September 17, 2016, indicated the resident had gained seven pounds in one month. The progress note also indicated that it was uncertain why the weight gain had taken place and that the weight gain was not desirable given his overweight status with a body mass index [BMI- a measure used to evaluate body weight relative to a person's height] of 28.1 (BMI of 25 - 29.9 is classified as overweight).
According to the American Diabetes Association, having diabetes and being overweight increases the risk for complications. Losing just a few pounds through exercise and making the right food choices can help with diabetes control and can reduce the risk for other health problems.
A review of the registered dietitian notes from March 2016 to September 2016, did not indicate that the dietitian met with Resident 16 to develop a weight management plan with small, measurable, attainable and realistic objectives. For example, there was no collaborative effort to incorporate cookies or sugary drinks into the resident's diet in order to motivate him to adopt healthier eating habits.
There was no documented evidence that the interdisciplinary team [IDT-involving two or more disciplines or fields of study] assessed contributing factors to Resident 16's non-compliance to the plan of care regarding diabetes management. There was no documented evidence that the IDT had met with the resident to address the vending machine and discuss potential adverse consequences of not following a therapeutic diet. There was no documented evidence that concerted efforts were made to identify the causes or triggering factors contributing to the resident?s need to purchase food and drinks from the vending machine.
A review of Resident 16's change of condition (COC) form dated December 9, 2016, indicated the resident's BS level was checked at 11:34 a.m., and the blood glucose meter indicated "high". The COC form indicated the physician was notified of the resident being anxious from hunger, thirst, and perspiration (sweating). The form indicated the resident stated he drank a bottle of green tea that he bought from the facility vending machine.
A review of Resident 16's physician order dated December 9, 2016, and timed 1:30 p.m., indicated to continue previous order of insulin and monitor for hypoglycemia and hyperglycemia.
On December 9, 2016, at 4:22 p.m., during an interview, LVN 3 stated Resident 16 did not follow diet recommendations. Resident 16 had his own money and could buy food and drinks from the facility vending machine. LVN 3 stated that the resident told her that he drank the whole can of a particular iced tea (high sugar content) obtained from the facility's vending machine, before she checked the resident's BS level at 11:34 a.m.
A review of Nurses Notes dated December 10, 2016, at 7:30 a.m., indicated Resident 16's BS level was checked and the blood glucose meter registered "Hi". The Nurse's Notes did not indicate that the resident's primary physician was notified of the elevated blood sugar after it was identified as high at 7:30 a.m., as indicated in the care plan and the physician order. Instead, the resident was fed breakfast. After breakfast, his BS level was rechecked and it still registered "Hi". The resident's primary physician was not called until 8:15 a.m. to address the resident?s elevated blood sugar.
According to the Nursing Notes dated December 10, 2016, at 9:20 a.m., Resident 16's primary physician was notified of the resident?s elevated blood sugar level. The Notes indicated that Resident 16 was non-compliant with his diet and would go to the facility vending machine to get food and drinks.
A review of Resident 16's physician orders dated December 10, 2016, and timed 9:20 a.m., indicated to transfer the resident to the general acute care hospital (GACH) emergency room for evaluation and management of poorly controlled blood sugar levels.
A review of the GACH emergency (ER) admission summary dated December 10, 2016, indicated Resident 16 was admitted for hyperglycemia with significant elevated blood glucose of 906 mg/dl. While in the ER, the resident received two liters bolus (given fast) of normal saline, 10 units of insulin human regular (short acting type of insulin) through intravenous route, and 20 units of Novolog subcutaneously, with minimal improvement of the resident's blood glucose level.
A review of Resident 16's urine analysis results, performed at the GACH, dated December 10, 2016, indicated a glucose level greater than 1000 in the urine (normal reference is negative) and urine ketones (substances that are made when the body breaks down fat for energy) of 15 (normal reference is negative).
A review of the GACH History and physical dated December 11, 2016, indicated that Resident 16 was admitted for severe hyperglycemia out of control. The initial blood sugar level was 906 mg/dl (normal less than 140 mg/dl). The resident received two liters of normal saline and multiple dosages of insulin to lower the high blood sugar.
The resident had not returned to the facility from the GACH at the time of exit conference on December 19, 2016.
A review of the facility revised policy dated December 11, 2011, titled "Obtaining a Fingerstick Glucose Level" indicated that the person performing the procedure should record the date and time the procedure was performed and the blood sugar level. Follow facility policies and procedures for appropriate nursing interventions regarding blood sugar results (if resident is on sliding scale coverage, and/or physician intervention is needed to adjust insulin or oral medication dosages. Report results promptly to the supervisor and attending physician.
A review of the revised facility policy dated April 2013, titled "Diabetes-Clinical Protocol" indicated the physician will order desired parameters for monitoring and reporting information related to diabetes or blood sugar management. The staff will incorporate such parameters into the medication administration record and care plan.
The facility failed to provide necessary care and services to adequately manage and control blood glucose levels for Resident 16 by failing to:
1. Ensure Resident 16 received insulin (a hormone made by the pancreas that keeps blood sugar levels from getting too high or too low) dosage as ordered by the physician.
2. Ensure the licensed nursing staff followed the physician's order to notify the physician when Resident 16?s blood glucose levels were at a reportable range as set and directed by the physician.
As a result, Resident 16 did not receive the recommended insulin dose in order to adequately control his blood sugar levels. Resident 16 had uncontrolled high blood glucose levels (over 900 milligrams per deciliter (mg/dl), was transferred to the general acute care hospital (GACH), and received multiple doses of insulin by injection to lower his blood glucose levels.
This violation presented either an imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result to Resident 16. |
| 940000030 |
VILLA SERENA HEALTHCARE CENTER |
940008722 |
B |
25-Jan-12 |
NPQJ11 |
10696 |
F-323 483.25 (h) Free of Accident Hazards/Supervision/Devices The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. An unannounced visit was made to the facility for a recertification survey conducted from 9/14/11 to 9/21/11.Based on observation, interview and record review, the facility failed to ensure Resident 11, who had history of a fall and was assessed as having a decline in ambulation status and bladder continence, received adequate supervision and assistance devices to prevent accidents by failing to: 1. Develop interventions addressing the resident?s functional decline, including supervision, assistive devices, toileting program and referral to specialized rehabilitative services for safe walking and to prevent further falls. 2. Ensure the resident was instructions on the use of a front wheel walker (FWW). 3. Monitor and encourage the use of the FWW during ambulation as ordered by the physician. Resident 11 fell on the floor while walking unassisted, unsupervised and without the use of the FWW, and sustained laceration to the right eyebrow that required transferring the resident to an acute care hospital emergency room for the application of five sutures (stitches). On 9/19/11, at 8 a.m., Resident 11 was observed sitting on the side of his bed with his eyes closed. The resident did not respond to an attempted interview. Observation of the resident's room revealed the resident did not have a walker, cane or other assistive device available to use when walking and transferring. It was also noted the room had no bathroom. The closest restroom was located across the hallway next to the room in front of the resident's room.On 9/19/11, a review of the clinical record revealed the resident was admitted to the facility on 5/15/08, with diagnoses that included dementia (a progressive condition marked by the development of multiple cognitive deficits), edema (an abnormal excess accumulation of serous fluid in connective tissue) and psychotic (loss of contact with reality) disorder.A review of the resident's Minimum Data Set (MDS - standardized assessment and care planning tool) dated 1/5/11, indicated the resident had a problem with long and short-term memory, was moderately impaired with daily decision-making, had unclear speech, was independent with transfers, ambulation and toilet use and was continent of bowel and bladder function.According to the nurses' notes, the resident sustained a fall on 1/25/11, at 1:30 p.m., while attempting to take his meal tray to the nurses? station. The resident was found on the floor by the nurses' station and he was unable to recall what happened. The resident was noted with redness and swelling at the left elbow and the left knee. The physician ordered x-rays of the right and left knees and the left elbow and the result dated 1/26/11, indicated no fractures. According to Follow-up Investigation report, the recommendation/intervention included to have physical therapy evaluate the resident's gait and ambulation status. There was no plan of care developed after the resident's fall to address interventions to prevent further falls. According to the Social Service Assessment dated 4/5/11, the resident showed a decline in ambulation and had bladder continence. The resident leaned forward, walked very slow and needed more assistance with activities of daily living (ADLs). The social services note also documented nursing had decided not to provide the resident with a bladder training because of the resident's fall risk.According to an interdisciplinary team note documented in the Nursing Assessment form dated 4/7/11, the resident's quarterly MDS was not completed due to a possible significant change in the status of the resident. The resident had declined in continence and ambulation status. The note further indicated they will continue to observe and consider a significant change of status assessment.Although the resident was identified with a decline in his ambulation abilities, there were no interventions implemented or a plan addressing actual and potential for falls, need of supervision, assistive devices and/or physical assistance with ambulation. There was also no referral for physical therapy to evaluate the resident's physical deterioration. According to a nurse's note dated 4/10/11, at 9:36 a.m., the resident was found on the floor, calling for help. The resident was noted with a cut on the right eyebrow. The physician was notified and ordered to transfer the resident to an emergency room.A Post-Fall Assessment form dated 4/10/11, indicated the laceration measured 3.5 centimeters (cm) in length by 0.5 in width. A Follow-up Investigation report dated 4/10/11, indicated the resident was trying to go the bathroom and was found by the bed side. Another nurse's note dated 4/10/11, at 2:01 p.m., indicated the resident returned from the acute hospital with five stiches on the right eyebrow and a treatment order was obtained. A (head) computerized tomography (CT - radiological study) scan was negative. According to the Emergency department visit report from the acute care hospital dated 4/10/11, the resident has a head injury with a simple laceration of the scalp. A nurse's note dated 4/11/11, at 10 a.m., documented the resident was observed continuing to use the toilet as desired; however, daily incontinence was also noted. The documentation did not indicate the resident was receiving supervision and assistive devices to prevent falls.On 4/11/11, at 11:30 a.m., a physician's order was obtained for the use of a front wheel walker. However, there was no documentation the physical therapist was involved in assessing and evaluating the type of walker or other assistive device the resident would benefit from. There was no training on the use of the walker and no fitting of the height of the walker based on the resident's height. A care plan dated 4/13/11, addressed the resident's problem of being a risk for fall and injury due to poor safety awareness, history of falls, the use of psychoactive medications and decline in cognitive status due to the disease process of dementia. The interventions included to encourage the use of a front wheel walker when walking and keep close observation to minimize potential for falls.A plan of care dated 4/13/11, developed for the resident's problem of requiring extensive assistance with walking in the corridor, had approaches to keep the front wheel walker always available and to encourage its use. A significant change of condition MDS assessment dated 4/14/11, indicated the resident had long and short-term memory problems, was independent with bed mobility, transfers, and walking in the room, but needed extensive assistance with a one person physical assist to walk in the corridor. The assessment further documented the resident's walking was not steady and he needed a walker as a mobility device. The resident was always continent of bowel and frequently incontinent of urine.An interdisciplinary team note documented in the Nursing Assessment form dated 4/15/11, the resident had a significant change in status assessment and declined in ambulation and bladder continence. The resident had an actual fall on 4/10/11, possibly related to a decline in the gait. The resident's was slow with the tendency to lean forward. The last physical therapy evaluation was dated 1/25/11. Although the interdisciplinary team addressed the last physical therapy evaluation was done on 1/25/11 (after the fall without injury), there was no documented rationale related to the lack of referral to physical therapy when the resident was identified having a decline in ambulation and when the resident sustained a fall with injury on 4/10/11.On 5/12/11, an order was obtained for the resident to walk with a front wheel walker daily as tolerated with a restorative nursing assistant (RNA). There was no documented evidence there was input from the physical therapist for the RNA exercise program.Another nurse's note dated 9/14/11, at 8:45 a.m., documented the resident was found lying face down in the hallway near the railing by Room 12 (the room across from the resident's room and next to the restroom). The resident sustained a skin tear along his right forearm and redness on his right cheek and both knees. The physician was informed and x-rays were ordered. The x-ray results were negative for fractures. According to the Initial Investigation Report dated 9/6/11, the resident stated he was trying to go to the bathroom and fell. The report documented the resident did not use the walker and would be encouraged to use the walker at all times.Observation on 9/19/11, 9/20/11, and 9/21/11, at various times from 7:30 p.m. to 2 p.m., revealed the resident did not have a front wheel walker at his bedside.On 9/20/11, at 8:30 a.m., during an interview, the Director of Nursing confirmed there was no plan of care developed to reduce the resident's risk for fall after the first fall on 1/25/11. The Director of Nursing could not explain why there was no input obtained from physical therapy to promote a safe ambulation and why there was no toileting program to ensure supervision and assistance to prevent falls. The Director of Nursing did not explain why there was no front wheel walker in the resident's room. The Director of Nursing further stated the facility had no policy and procedure to monitor, prevent and reduce the number of falls in the facility.The facility failed to ensure Resident 11, who had history of a fall and was assessed as having a decline in ambulation status and bladder continence, received adequate supervision and assistance devices to prevent accidents by failing to: 1. Develop interventions addressing the resident?s functional decline, including supervision, assistive devices, toileting program and referral to specialized rehabilitative services for safe walking and to prevent further falls. 2. Ensure the resident was instructed on the use of a front wheel walker (FWW). 3. Monitor and encourage the use of the FWW during ambulation as ordered by the physician. Resident 11 fell on the floor while walking unassisted, unsupervised and without the use of the FWW, and sustained laceration to the right eyebrow that required transferring the resident to an acute care hospital emergency room for the application of five sutures (stitches). The above violation had a direct or immediate relationship to the health, safety or security of Resident 11. |
| 940000030 |
VILLA SERENA HEALTHCARE CENTER |
940008723 |
B |
25-Jan-12 |
NPQJ11 |
12586 |
F-325 ? CFR 483.25 (i) Maintains nutrition status unless avoidable Based on a resident's comprehensive assessment, the facility must ensure that a resident - (1) Maintains acceptable parameters of nutritional status, such as body weight and protein levels, unless the resident's clinical condition demonstrates that this is not possible; and (2) Receives a therapeutic diet when there is a nutritional problem. An unannounced visit was made to the facility for a recertification survey conducted from 9/14/11 to 9/21/11. Based on observation, interview, and record review, the facility failed to ensure Resident 1, who was dependent on a gastrostomy tube (GT- a tube placed through the skin and the stomach wall to provide nutrition and medications) for feeding, maintained acceptable parameters of nutritional status by failing to: 1. Document, monitor and refer to the attending physician any signs and symptoms of feeding formula intolerance. 2. Closely monitor the resident?s weight for prompt interventions 3. Obtain participation of the resident?s attending physician in assessing underlying medical conditions causing the progressive unplanned weight loss. Resident 1 lost 13.6 percent (%) of her total body weight within six months after her continuous feeding was changed to bolus feeding (a set amount of formula run down the feeding tube at specific times during the day). The resident sustained a severe unplanned weight loss totaling 17 pounds (lbs) in six months. On 9/14/11, at 2 p.m., Resident 1 was observed in bed, the skin was pale in color and was noted to be emaciated (very thin). The resident was non-verbal and had involuntary body movements.On 9/15/11, a clinical record review revealed the resident was admitted to the facility 9/9/05, with diagnoses that included severe mental retardation, Parkinson's disease (a progressive disorder of the nervous system that affects movement), dementia (loss of mental ability severe enough to interfere with normal activities of daily living), dysphagia (difficult swallowing), seizure disorder, anemia and GT feeding. The Minimum Data Set (MDS - standardized assessment and care planning tool) dated 7/28/11, indicated the resident was severely impaired for daily decision-making, needed total assistance with all activities of daily living (ADLs) and had a GT for feeding. The Nutritional Assessment form indicated on the date of admission, 9/9/05, the resident's height was 68 inches, the weight was 119 lbs and the ideal body weight ranged between 126 to 154 lbs. The Monthly Record of Vital Signs and Weight form for the year 2010 indicated the resident's weight ranged from 119 to 126 pounds.A review of the dietary progress notes dated 1/19/11, revealed the resident's weight was 119 lbs and was receiving TwoCal HN [High in calories (2 calorie per milliliter cal/ml) and high-nitrogen liquid formula] one can (eight ounces)every four hours bolus feeding. However, on 2/1/11, the resident's weight was 116 lbs (three lbs weight loss) and on 2/7/11, the enteral feeding was changed to TwoCal HN continuous feeding at 85 cubic centimeters (cc) per hour in 18 hours via enteral pump to provide 1530 cc and 3060 calories per day. The resident's weight increased to 120 lbs by 3/1/11 and to 125 lbs by 4/1/11. According to the dietary progress notes dated 3/25/11, the Registered Dietitian (RD) documented the resident's Albumin (the major plasma protein) level was within normal levels (between 3.4 to 4.8 grams per deciliters - G/dl). The resident's estimated needs were 1909 to 2227 calories per day, 76 to 95 grams of protein per day and 1636 cc of fluids per day. The RD documented the feeding ordered met the resident's estimated needs.During the last six months from 4/1/11 to 9/2/11, according to the monthly weight record, the resident's sustained a 15 lbs weight loss as follows: On 4/1/11= the resident's weight was 125 lbs. On 5/2/11= the resident's weight was 125 lbs. On 6/1/11= the resident's weight was 123 lbs. On 7/1/11= the resident's weight was 119 lbs. On 8/1/11= the resident's weight was 110 lbs. On 9/2/11= the resident's weight was 110 lbs. A plan of care developed on 4/19/11, for the resident's problem of altered nutrition and GT, included in the goals that the resident will be able to tolerate feeding and will receive adequate calorie and nutritional requirement daily. The approaches included to observe for tolerance to the feeding like presence of diarrhea, nausea and vomiting. According to a dietary progress note dated 4/22/11, the RD documented the resident was tolerating the continuous GT and the feeding met the resident's estimated needs. The RD further documented the laboratory test dated 3/9/11, indicated the resident's hemoglobin (protein in the red blood cells) and hematocrit (the percentage of the volume of whole blood that is made up of red blood cells) were within normal levels.According to a nurse's note dated 5/18/11, the physician was called regarding the resident pulling the GT and the physician ordered to change the continuous feeding to TwoCal HN one can, every four hours to deliver 2850 calories/1400 cc per day. However, further review of the nursing notes and the interdisciplinary noted prior to 5/18/11, did not indicate the resident had episodes of pulling the tubing. There was no plan of care addressing the resident's behavior of pulling the tubing. There was no documentation the RD was notified of the new order. The RD documented in the dietary progress notes dated 5/27/11, the resident was pulling out the GT, was placed on bolus feeding and the nutritional needs were met with the current order. On 6/24/11, the RD documented in the dietary progress notes the resident had a weight loss of two pounds and the laboratory tests results dated 6/8/11, indicated the hemoglobin and hematocrit were below the normal levels. Hemoglobin was 10.6 with a reference range from 11.5 to 15.0 G/d and the hematocrit was 32.7 with a reference range from 34.0 to 44.0 percent (%). There was no Albumin level obtained. The RD further indicated the resident will be monitored for change of weight, adjust or change the GT feeding. A plan of care developed on 7/15/11, due to the resident's problem of having a GT feeding, had a goal for the resident to be well nourished and hydrated daily. The approaches included to give the formula as ordered, observe for feeding intolerance, nausea, vomiting and diarrhea and adjust calories as needed for weight gain. On 7/22/11, the RD documented the resident was tolerating well the formula and the formula exceeded the resident's nutritional estimated needs per day. The RD documented that if the resident had further weight loss, the GT formula would be increased the following month. The RD did not recommend monitoring the resident's weight more frequently than monthly when the resident by 7/1/11, had already lost six pounds of body weight.By 8/1/11, the resident had lost a total of 15 lbs since the change of feeding formula on 5/18/11, from continuous feeding via pump to bolus feeding. There was no documented evidence nursing staff weighed the resident more frequently than monthly to closely monitor weight fluctuation. On 8/11/11, the RD documented in the dietary progress notes she was informed by the interdisciplinary team the resident was not tolerating the GT. The RD recommended to change the formula to Carnation VHC (very high calorie liquid nutrition) one can (250 cc) five times a day, to provide 2813 calories/1250 cc per day. However, a review of the nursing notes and interdisciplinary team notes prior to 8/11/11, revealed no documentation of intolerance to the GT feeding formula. The nursing documentation did not indicate the resident had diarrhea, nausea, vomiting, abdominal distention or any other symptom suggesting feeding intolerance.A Decubitus Report form dated 8/14/11, indicated the resident had developed a Stage II pressure sore to the left lower buttock (ischial area) with a size of 2.3 centimeter (cm) by 1.5 cm. A treatment with Calmoseptine (over the counter moisture barrier) was started. A review of a laboratory report dated 8/19/11, revealed the resident's pre-albumin level was 9.7 milligrams (mg) per deciliters with a reference range from 18-45 mg/dl. Pre-Albumin is a protein produced in the liver, it has a short half-life (two days), which makes it a good indicator of nutritional status (Lippincott William & Wilkins, Diagnostic Tests Made Incredibly Easy! 2nd edition, 2009, Page 46).Another, dietary progress note dated 8/26/11, revealed the resident was tolerating the GT feeding well with no problems. A laboratory blood test report dated 9/19/11, indicated an abnormal hemoglobin level of 10.1 G/dl and an abnormal hematocrit level of 31.1%.The resident sustained a significant unplanned and unexplained weight loss and was having abnormal laboratory test results even though the feeding formula ordered met the resident's nutritional need. However, there was no documented evidence the interdisciplinary team investigated possible causal factors for the weight loss including accurate administration of the feeding formula. There was no intake and output monitoring, calorie count, or other interventions to ensure adequate intake and tolerance. There was no documented communication with the physician related to the unplanned progressive weight loss for further assessment to identify underlying medical conditions causing the continuous weight loss.On 9/19/11, at 10:30 a.m., upon the Evaluator's request, the resident's weight was obtained and was 108 lbs The resident had a weight loss of two pounds since 9/2/11 and a total of 17 pounds in six months. During an interview on 9/19/11, at 11 a.m., with Dietary Supervisor, she stated the reason the resident was changed from continuous GT feeding was because the resident would turn over the feeding pole (the stand where the feeding and the enteral pump are hung) every day. She further stated the reason the resident's feeding formula was changed from the HN formula to VHC formula was because the resident could not tolerate the HN formula and would have diarrhea several times a day. However, there was no documented evidence in the clinical record to confirm Dietary Supervisor's statement. By the last day of the survey, 9/21/11, two attempts to interview the RD failed.On 9/20/11, at 7:45 a.m., during an interview, Licensed Vocational Nurse 1 (LVN 1) stated the resident did not receive continuous feeding because she kept on pulling the tubing causing the GT pole to fall. On 9/20/11, at 10 a.m., during an interview, the Director of Nursing was unable to explain the lack of nursing documentation related to the resident's feeding intolerance and diarrhea episodes. The Director of Nursing could not provide documented evidence causal/risk factors for the resident's gradual weight loss were evaluated and analyzed and that the feeding intake was consistently monitored to ensure effectiveness of dietary interventions. The facility failed to ensure Resident 1, who was dependent on a gastrostomy tube (GT- a tube placed through the skin and the stomach wall to provide nutrition and medications) for feeding, maintained acceptable parameters of nutritional status by failing to: 1. Document, monitor and refer to the attending physician any signs and symptoms of feeding formula intolerance. 2. Closely monitor the resident?s weight for prompt interventions 3. Obtain participation of the resident?s attending physician in assessing underlying medical conditions causing the progressive unplanned weight loss. Resident 1 lost 13.6 percent (%) of her total body weight within six months after her continuous feeding was changed to bolus feeding (a set amount of formula run down the feeding tube at specific times during the day). The resident sustained a severe unplanned weight loss totaling 17 pounds (lbs) in six months. The above violation presented either an imminent danger that death or serious harm would result or substantial probability that death or serious harm would result to Resident 1. |
| 940000025 |
VIEW HEIGHTS CONVALESCENT HOSPITAL |
940009066 |
B |
02-Mar-12 |
C74K11 |
5557 |
CFR 483.25 (h) Accidents The facility must ensure that ? (1) The resident environment remains as free from hazards as is possible; and (2) Each resident receives adequate supervision and assistance devices to prevent accidents. On 2/2/12, an unannounced visit was made to the facility to conduct a standard recertification survey which was completed on 2/4/12. Based on observation, interview, and record review, the facility failed to ensure the resident environment remains as free form hazards as is possible by failing to: Provide safe hot water temperatures, below 120 degrees Fahrenheit (F). Hot water temperatures above 120 degree F were measured in two shower rooms, one tub room, and in the hand washing sinks in the bathrooms between Rooms 2-4, 5-7, 13-14, 17-18, 23-24 and 29-31 in the South Side of the facility. The North Side of the facility had temperatures above 120 degrees F between Rooms 38-39, 43-44, 47-49, 51-52 and 55-57. There were a total of 62 residents residing in the affected rooms and a total of 154 total residents in the facility. The unsafe hot water temperature placed the residents in both the North and South Sides of the facility at risk for burn, scalding, and tissue damage. On 2/2/12, between 7 p.m. and 8:30 p.m., during the general environmental inspection tour of the facility in the presence of Certified Nursing Assistant 3 (CNA 3) and Housekeeper 1, the temperature of the hot water delivered to plumbing fixtures used by the residents was measured in the North and South Sides of the facility. The unsafe hot water temperatures in the hand washing sinks in the South Side were as follows: Bathroom between Rooms 2 and 4- 128.6 degrees F Bathroom between Rooms 5 and 7- 133.2 degrees F Bathroom between Rooms 13 and 14 - 138.6 degrees F Bathroom between Rooms 17 and 18 - 128.6 degrees F Bathroom between Rooms 23 and 24 - 139.6 degrees F Bathroom between Rooms 29 and 31 - 142.0 degrees F Tub Room 1 - 131 degrees F Shower Room 1 - 126 degrees F Shower Room 2 - 130.5 degrees F The unsafe hot water temperatures in the hand washing sinks in the North Side were as follows:Bathroom between Rooms 38 and 39 - 146.1 degrees F Bathroom between Rooms 43 and 44 - 141.9 degrees F Bathroom between Rooms 47 and 49 - 142.4 degrees F Bathroom between Rooms 48 and 50 - 141.6 degrees F Bathroom between Rooms 51 and 52 - 139.9 degrees F Bathroom between Rooms 55 and 57 - 141.3 degrees FAccording to the U.S. Consumer Product Safety Commission (http://www.cpsc.gov/), most adults will suffer third-degree burns if exposed to 130 degrees F for 30 seconds. A temperature of 120 degrees F for five minutes of exposure could result in third-degree burns. The U.S. Consumer Product Safety Commission urges to all users to lower their water heaters to 120 degrees F to prevent scalding, injuries, and death in elderly. On the same day, 2/2/12, at 8:55 p.m., during an interview, the administrator stated the high temperatures could be related to the repair of the plumbing fixtures on the South Side of the facility. However, the administrator could not explain the high temperatures in the North Side of the facility. There were a total of 62 residents in the affected rooms.According to the Resident Census and Conditions of Residents (CMS-672 form) completed and submitted by the facility on 2/2/12, there were a total of 154 residents in the facility, 153 had documented psychiatric diagnosis, 154 residents had behavioral symptoms and received psychoactive medications. 147 residents were independently ambulatory.The facility's maintenance department policy and procedure on Water and Plumbing, dated 1/2011, indicated to check and record water temperature at the nursing station and other common areas such as laundry and kitchen daily. The policy required that hot water temperature be maintained at not less than 105 degrees F and not more than 120 degrees F for all hot water used by residents. On 2/3/12, at 11:20 a.m., during an interview, the administrator stated the maintenance staff kept a record of daily water temperature. The administrator further stated the facility did not have a hot water temperature alarm to alert the facility of unsafe hot water temperature in the facility.A review of the daily temperature log record indicated only the water temperature of the nurses? station?s sink was recorded daily. From 1/19/12 to 1/31/12, the temperature ranged from 130 to 148 degrees FThe maintenance supervisor could not provide documentation the hot water temperatures in the residents' room were monitored on a daily basis. The facility failed to ensure the resident environment remains as free form hazards as is possible by failing to: Provide safe hot water temperatures, below 120 degrees Fahrenheit (F). Hot water temperatures above 120 degree F were measured in two shower rooms, one tub room, and in the hand washing sinks in the bathrooms between Rooms 2-4, 5-7, 13-14, 17-18, 23-24 and 29-31 in the South Side of the facility. The North Side of the facility had temperatures above 120 degrees F between Rooms 38-39, 43-44, 47-49, 51-52 and 55-57. There were a total of 62 residents residing in the affected rooms and a total of 154 total residents in the facility. The unsafe hot water temperature placed the residents in both the North and South Sides of the facility at risk for burn, scalding, and tissue damage. The above violation had direct or immediate relationship to the health, safety, or security of the residents. |
| 940000025 |
VIEW HEIGHTS CONVALESCENT HOSPITAL |
940009093 |
A |
03-Apr-12 |
C74K11 |
8312 |
F309 483.25 Quality of Care Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. An unannounced visit was made to the facility for a recertification survey conducted from 2/2/12 to 2/4/12.Based on interview and record review, the facility failed to provide Resident 1 with the necessary care and services in accordance with the comprehensive assessment and plan of care by failing to: 1. Monitor the condition of the feet for injury, breakdown, signs and symptoms of infection, and pain. 2. Follow the physician?s order for monthly podiatry care for diabetic foot care. 3. Implement interventions for pain management when the resident developed pain to the right great toe. On 2/2/12, Resident 1's right great toe was red, swollen, had purulent (discharge of yellow-white fluid - pus) drainage and the resident complained of severe pain. The resident was not receiving treatment to the affected toe, the pain was not managed and the podiatrist had not evaluated the resident for over three months. On 2/2/12, the resident was diagnosed with a right great toe cellulitis (skin infection caused by bacteria) requiring oral antibiotic therapy.On 2/2/12, at 6 p.m., during the initial tour of the facility, in the presence of Registered Nurse 1 (RN 1), Resident 1 was observed in his room complaining of pain to his right foot. The resident was wearing closed shoes and socks. Upon interview, the resident stated he has had pain to the right great toe for approximately two months and had requested from the nurses to be seen by the podiatrist but nothing was done. The resident stated he did not know if the problem was an ingrown nail but he needed to be examined by a podiatrist. The resident removed his right shoe and sock exposing his right great toe (first toe) which was observed swollen, red in color, with yellow thick (pus) drainage. The resident stated the severity of the pain was 9 out of 10 (9/10 - pain scale range from zero to 10, where zero represents no pain and 10 is the worst pain possible). On 2/2/12, at the end of the tour, a review of the clinical record revealed Resident 1 was admitted to the facility on 1/22/09, and re-admitted on 7/15/10, with diagnoses that included Type 2 diabetes mellitus [adult onset diabetes, chronic disease in which there are high levels of sugar (glucose) in the blood. The body does not produce enough insulin or the cells ignore the insulin. Insulin is necessary for the body to be able to use glucose for energy.], schizoaffective disorder (a condition in which a person experiences a combination of schizophrenia symptoms - such as hallucinations or delusions - and of mood disorder symptoms, such as mania or depression) and obesity. The quarterly Minimum Data Set (MDS - standardized assessment and care planning tool) dated 1/20/12, indicated the resident was alert and oriented, had no memory problems, had clear speech, was able to communicate his needs and required supervision in eating, dressing, personal hygiene and walking. The resident medication regimen included three daily oral anti-diabetics (to lower blood sugar), subcutaneous insulin per sliding scale four times a day, seven psychotropic (mind altering) medications for behavior control and one anti-inflammatory medication (Nabumetone) twice daily for arthritis. A physician's order dated 7/15/10, indicated monthly podiatry care for diabetic foot care. Another physician's order dated 2/6/11, indicated Tylenol 500 milligrams (mg) two tablets orally every eight hours as needed (PRN) for pain.A plan of care dated 10/13/11, developed for the resident's problem of having a diagnosis of diabetes mellitus and being at risk for impaired skin integrity, had a goal for the resident not to have injuries or infections. The interventions included protecting the extremities from pressure or injury, check feet and toes every shower day, provide podiatry care as ordered, prevent injury to feet and ankles and monitor for signs and symptoms of infections.The clinical record lacked documentation of a monthly podiatry service for diabetic foot care. The last podiatry evaluation was dated 10/27/11. Further record review revealed no documented evidence the nursing staff had addressed the resident's right great toe condition. There was no evidence the attending physician and the podiatrist had been made aware of the right great toe condition. The licensed nursing notes, the weekly summary notes which included an assessment of the resident's skin condition and toenails, and the nursing assistant's Daily Body Check Report form, did not document the status of the resident's right great toe.A review of the medication administration record (MAR) for the month of 1/2012 and for 2/1/12 and 2/2/12, by 7 p.m., revealed the resident was not given Tylenol for pain.According to the nursing note dated 2/2/12, timed at 7:20 p.m., the resident was offered Tylenol for pain (rated 5/10) which the resident refused. At 7:35 p.m., the physician was notified and ordered the resident to be transferred to an acute hospital emergency room for evaluation of the right great toe. On 2/2/12, at 8:15 p.m., the resident was transferred via ambulance and on 2/3/12, at 1:10 a.m., the resident returned to the facility. The resident was diagnosed with cellulitis of the right great toe, oral antibiotic (Augmentin) therapy was ordered for seven days and to cleanse the right toe with normal saline and cover with dry dressing daily for seven days. On 2/2/12, at 7:40 p.m., an interview was conducted with Licensed Vocational Nurse 1 (LVN 1), who documented the resident refused the Tylenol for pain. LVN 1 explained the resident stated the Tylenol did not help with the pain but did not attempt to obtain an order for another pain medication. LVN 1 further stated she informed the physician the status of the toe and the physician ordered the transfer for further evaluation of the toe. On 2/3/12, at 3 p.m., during an interview, Certified Nursing Assistant 1 (CNA 1), stated that approximately two weeks ago (could not remember the date) she reported to RN 2 that the resident's right great toe was red. CNA 1 stated she did not document the redness but she had reported it to the supervisor. On 2/3/12, at 3:15 p.m., during an interview, RN 2 stated she did not remember if CNA 1 had reported to her the resident's redness on the toe. On 2/4/12, at 10:53 p.m., during an interview, CNA 2 stated she noticed on Sunday (1/29/12) the resident was limping when coming out from church service and complained his toe was hurting. CNA 2 stated the resident asked a staff member (could not recall who) to put him in the list for the podiatrist.?Diabetic foot problems, such as ulcerations, infections, and gangrene, are the most common cause of hospitalization among diabetic patients. Routine ulcer care, treatment of infection, amputation s, and hospitalizations cost billions of dollars every year and place a tremendous burden of the health care system.? Clinical Diabetes Journal - Volume 24, Number 2, April 2006, page 91. The facility failed to provide Resident 1 with the necessary care and services in accordance with the comprehensive assessment and plan of care by failing to: 1. Monitor the condition of the feet for injury, breakdown, signs and symptoms of infection, and pain. 2. Follow the physician?s order for monthly podiatry care for diabetic foot care. 3. Implement interventions for pain management when the resident developed pain to the right great toe. On 2/2/12, Resident 1's right great toe was red, swollen, had purulent drainage and the resident complained of severe pain. The resident was not receiving treatment to the affected toe, the pain was not managed and the podiatrist had not evaluated the resident for over three months. On 2/2/12, the resident was diagnosed with a right great toe cellulitis requiring oral antibiotic therapy.The above violation presented either an imminent danger that death or serious harm would result or substantial probability that death or serious physical harm would result to Resident 1. |
| 940000025 |
VIEW HEIGHTS CONVALESCENT HOSPITAL |
940009627 |
B |
28-Nov-12 |
Z7XL11 |
10323 |
? 72311. Nursing Service-General (a) Nursing service shall include, but not be limited to, the following: (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. ? 72315. Nursing Service-Patient Care (b) Each patient shall be treated as individual with dignity and respect and shall not be subjected to verbal or physical abuse of any kind. ?72523. Patient Care Policies and Procedures. (a) Written patient are policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. On 6/3/11 at 8:30 p.m., an unannounced visit was made to the facility to investigate an entity reported incident of patient to patient physical abuse. On 5/16/11 at 10 a.m., Patient 1 hit Patient 2 in the face resulting in Patient 2 sustaining a nasal fracture.Based on observation, interview and record review, the facility failed to implement Patients 1 and 2?s care plans according to the methods indicated, implement policies and procedures and ensure Patient 2 was not subjected to physical abuse of any kind by failing to: 1. Utilize safety measures to protect patients or others. 2. Provide frequent rounds and close observation to ensure patients? safety. 3. Monitor the patients? whereabouts and behavior every 15 minutes. On 5/16/11, at 10 a.m., Patients 1 and 2, who both had delusions and disorganized thought process, and Patient 1, who was also verbally and physically aggressive, were not monitored as per the plan of care and policy and procedure resulting in the patients getting into a physical altercation. Patient 2 spit on Patient 1 and in return, Patient 1 hit Patient 2 in the face resulting in a fractured nose that required evaluation at an acute care hospital.On 6/3/11, a review of Patient 1?s clinical record revealed he was a 46 year old male, admitted to the facility on 4/20/10, with diagnoses including paranoid schizophrenia (mental disorder with impaired thought process and persecutory delusions) and mild anemia. The Minimum Data Set (MDS ? standardized assessment and care planning tool) dated 1/21/11, indicated the patient had no memory problems, had delusions (misconceptions or beliefs that are firmly held contrary to reality) and required supervision with walking, dressing and personal hygiene.The physician?s orders dated 1/14/11, included the psychotropic (mind altering) medications, Abilify 10 milligrams (mg) orally twice a day for psychosis manifested by hearing voices and Haldol Dacanoate 25 mg intramuscular every month for psychosis. A plan of care dated 4/19/10, developed for the patient?s history of disorganized behavior, included in the approaches, frequent monitoring, reality orientation and close supervision. Another plan of care last dated 4/25/11, developed for the patient?s delusional ideations manifested by disorganized thought process and flight of ideas, included in the approaches to utilize safety measures to protect patients or others. According to the nursing notes on 5/16/11, at 10 a.m., staff members heard yelling, entered the room and found Patients 1 and 2 in the restroom hitting each other. The patients were separated. At 12 p.m., the PET (Psychiatric emergency team) team was called and at 3 p.m., Patient 1 was transferred to an acute hospital for psychiatric evaluation. The patient was readmitted back to the facility on 5/23/11.A review of Patient 2?s clinical record revealed he was a 53 year old male, admitted to the facility on 6/24/10, and readmitted on 11/2/10, with diagnoses including schizoaffective disorder bipolar type (a mental illness characterized by recurring episodes of mood disorder and psychosis) and obesity. According to the Resident Summary form dated 5/8/11, the patient was alert and oriented, able to communicate his needs and able to dress, walk and eat without staff assistance.The physician?s orders included the psychotropic medications Trileptal 600 mg orally twice a day for mood stabilization since admission and Haldol 10 mg twice a day for psychosis dated 11/24/10. A plan of care last dated 2/2/11, developed for the Patient 2?s delusional ideations manifested by disorganized thought process and flight of ideas, included in the approaches to utilize safety measures to protect patients or others. Another plan of care last dated 2/2/11, developed for the patient?s agitation manifested by becoming verbally and physically aggressive, included in the approaches to assess behavior frequently for signs of increased agitation and to redirect the agitation and potentially violent behaviors with physical outlets in area of low stimulation According to the nursing notes and the facility?s incident investigation, on 5/15/11, Patients 1 and 2 were found in the restroom (the patients lived in contiguous rooms that shared a restroom) hitting each other. Patient 2 was bleeding from the nares (nostrils - opening of the nose) and had a hematoma (collection of blood) on the forehead. Paramedics were called and at 10:30 a.m., Patient 2 was transferred to an emergency room where an x-ray indicated a comminuted (the bone is splintered or crushed) fracture involving the nasal bone. The patient returned to the facility on the same day at 7:30 p.m.According to the facility?s Resident Safety Monitoring policy and procedure dated 1/2010, the purpose of the policy was to establish guidelines for assuring the safety and well-being of patients at risk for unsafe behavior. Safety Checks were defined as monitoring the patient?s whereabouts and behavior every 15 minutes. Contact Line of Sight was defined as staff having visual observation of the patient and the patient?s behavior was constantly monitored. The procedure indicated direct care staff shall be assigned by the licensed nurse to do safety checks rounds every 15 minutes. The responsibility shall be rotated between direct care staff members. The rounds sheet is to be kept on a clip board and carried by the assigned staff member during unit rounds. The safety rounds will be documented by the person conducting the rounds. A direct care staff member shall be assigned a post by the charge nurse and must be in full view of patient?s rooms or other designated area in order to observe the patients for safety. The staff member may not leave his/her post until another staff member is present for relief. The policy did not specify the number of patients to be supervised by the direct care staff assigned to do safety rounds to ensure effective safety monitoring.According to the 5/16/11 South Station Daily Assignment for the 7 a.m. to 3 p.m. shift, Certified Nursing Assistant 1 (CNA 1) was assigned to monitor the section (South Back) where Patients 1 and 2 resided. The assignment sheet indicated CNA 1 had breaks from 8:50 a.m. to 9 a.m., 11:15 a.m. to 11:45 a.m., and 1:25 p.m. to 1:35 p.m. According to the South Back Rounds 7-3 Shift form, CNA 1 was assigned a total of 52 patients to monitor every 15 minutes, including Patients 1 and 2. The form included the patients? names and room numbers, the times of monitoring starting at 7 a.m. and ending at 3 p.m., with the time in increments of 15 minutes, the location of the patients at the monitored time, and the staff member?s initials every 15 minutes. CNA 1 initialed the form every 15 minutes even during his scheduled breaks. According to CNA 1?s time card, the lunch break was from 11:06 a.m. to 11:36 a.m., however, CNA 1 documented safety rounds were conducted at 11:15 a.m. and at 11:30 a.m. At 10 a.m., (the time of the incident), CNA 1 documented Patient 1 was in the courtyard and Patient 2 was in his room. On 6/6/11, at 9:27 a.m., Patient 1 was observed in his room, resting in bed. At the time of the observation, when interviewed regarding the incident, the patient stated Patient 2 instigated the fight by coming to his room three times and making threats to his roommate.On 6/6/11, at 9:42 a.m., when interviewed, Patient 2 stated he was in the restroom combing his hair when Patient 1 screamed he was going to kill him and started attacking him until staff came to help.On 6/7/11, at 11:59 a.m., when interviewed regarding the signing of the rounds sheet CNA 1 reported he was out on breaks and was not monitoring the patients at those times.CNA 1 explained he initials the times he missed when on breaks by walking around and making sure the patients were still in the facility.The facility?s policy and procedure on Abuse dated 2009, indicated the any kind of abuse and neglect will not be tolerated and the basic responsibility of every employee was to ensure the safety and well-being of the resident. The facility?s policy and procedure on Preventing Resident Abuse, dated 2009, indicated the abuse prevention program included assessing, care planning and monitoring residents with needs and behaviors that may lead to conflict or neglect; assessing residents with signs and symptoms of behavior problems and developing and implementing care plans to address behavioral issues; striving to maintain adequate staffing on all shifts to ensure the needs of each resident are met.Based on observation, interview, and record review, the facility failed to implement Patients 1 and 2?s care plans according to the methods indicated, implement policies and procedures and ensure Patient 2 was not subjected to physical abuse of any kind by failing to: 1. Utilize safety measures to protect patients or others. 2. Provide frequent rounds and close observation to ensure patients? safety. 3. Monitor the patients? whereabouts and behavior every 15 minutes. On 5/16/11 at 10 a.m., Patients 1 and 2, who both had delusions and disorganized thought process, and Patient 1, who was also verbally and physically aggressive, were not monitored as per the plan of care and policy and procedure resulting in the patients getting into a physical altercation. Patient 2 spit on Patient 1 and in return, Patient 1 hit Patient 2 in the face resulting in a fractured nose that required evaluation at an acute care hospital.The above violation had direct or immediate relationship to the health, safety or security of Patient 2. |
| 940000030 |
VILLA SERENA HEALTHCARE CENTER |
940009709 |
A |
11-Feb-13 |
L54Z11 |
11721 |
F-309 483.25 Quality of Care Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care.On 1/4/13, at 7:15 p.m., an unannounced visit was made to the facility to conduct a recertification survey. Based on observation, interview and record review, the facility failed to provide Resident 6 with the necessary care and services in accordance with the comprehensive assessment, plan of care and physician?s orders by failing to: 1. Ensure certified nursing assistants (CNAs) and licensed nurses monitored the characteristics of the bowel movements (color, consistency, degree of hardness and size) to identify constipation (abnormally delayed or infrequent passage of usually dry hardened stool) and prevent fecal impaction (an accumulation of hardened stools in the rectum or sigmoid colon that the individual is unable to move). 2. Ensure licensed nurses administered the ordered laxative medications (to loosen stools) when the resident did not have bowel movements for three or more days as stated in the plan of care.On 11/23/12, Resident 6 was transferred to a general acute care hospital (GACH) due to rectal bleeding where he was diagnosed and treated for fecal impaction. After readmission to the facility on 11/28/12, the nursing staff failed to monitor the resident for constipation and failed to administer the ordered laxatives when the resident did not have bowel movements for three or more days placing the resident at risk for further fecal impaction. On 1/6/13 at 9:45 a.m., Resident 6 was observed in bed, had a gastrostomy tube (GT ? a tube surgically inserted in the stomach through the abdominal wall for purposes of nutrition and medication administration) and an indwelling urinary catheter (tubing inserted into the bladder to allow drainage of urine) connected to a draining bag. The resident was unable to communicate to participate in an interview. A review of the clinical record indicated the resident was admitted to the facility on 9/30/08, with diagnoses that included failure to thrive (insufficient weight gain or inappropriate weight loss), severe fecal impaction, seizure (convulsions) disorder, and profound mental retardation. The resident was transferred to a GACH on 11/23/12 due to rectal bleeding and was readmitted on 11/28/12, after the resident was treated for severe fecal impaction.The Minimum Data Set (MDS -standardized assessment and care planning tool) dated 11/20/12, indicated the resident had memory problems, was severely impaired in cognitive skills for daily decision-making, had no speech, rarely/never understood or was understand, did not walk and required total assistance with transfer, dressing, eating, toilet use, personal hygiene, and bathing. The resident used a wheelchair as mobility device, was incontinent (unable to voluntarily control) of bowel and had an indwelling catheter for urinary drainage. The resident had a GT used to flush water and for medication administration and had a mechanical altered (blended, chopped, ground, or mashed) diet by mouth. A care plan dated 1/20/11, and last revised on 11/2012, developed for the resident's risk for constipation due to decreased mobility, had a goal for the resident to have bowel movements at least every three days. The approaches included to monitor and record bowel movements daily, and to assess and monitor sign and symptoms of constipation. Another plan of care dated 1/20/11, last revised on 11/2012, developed for the resident's risk for dehydration related to the use of Lasix (diuretic), use of GT for water flushing, oral nectar-thickened liquids (consistency of nectar), and dependent on staff for eating, had a goal for the resident to be free from signs and symptoms of dehydration. The approaches included to monitor the resident?s for signs and symptoms of dehydration. A care plan dated 2/28/12, and last revised on 11/2012, was developed for the resident's risk for constipation and risk for dehydration related to pureed diet (pudding consistency), GT, and use of diuretic, had a goal for the resident to be well nourished and hydrated, have good skin turgor and routine elimination. The approaches included to give diet as ordered, fluids per GT as ordered and monitor for dry, cracked lips, sunken eyes, dark colored urine, increased confusion, and decreased skin turgor.The physician's orders dated 9/30/08, included Docusate Sodium (stool softener) 25 cubic centimeters (cc) via GT/orally twice a day for constipation, milk of magnesia (MOM - to loosen the stool) at bedtime as needed if no bowel movements in three days, and to flush the GT with 330 cc of water every six hours. A physician's order dated 4/20/09, indicated pureed diet with nectar thick liquid. A physician's order dated 8/31/09, indicated digital disimpaction [manual removal of feces (stool) from the rectum] if no bowel movements for three days and as needed.According to the National Digestive Diseases Information Clearinghouse (NDDIC) website http://digestive.niddk.nih.gob/ddiseases/pubs/constipation_ez/, constipation occurs when stool passes through the large intestine too slowly. When stools stays in the large intestine too long, the intestine removes too much water, and the stool becomes hard and dry. One of the causes of constipation is not drinking enough liquids. Dehydration can cause constipation.According to PubMed Health, a service of the National Library of Medicine, National Institutes of Health, http://www.ncbi.nlm.nih.gov/pubmedhealth/, fecal impaction is a large lump of dry, hard stool that remains stuck in the rectum. It is most often seen in patients with long-term constipation. A review of the Nurse Assistant Notes form for the three shifts (morning, evening and night) from 11/1/12 to 11/23/12, revealed the bowel movement was recorded by number of times; however, the stools characteristics such as color, consistency, degree of hardness and size, were not recorded to determine if the resident was constipated. The pre-printed form for CNAs' documentation did not include description of the stool. On 1/6/13 at 10:35 a.m., a record review was conducted with Licensed Vocational Nurse 4 (LVN 4). The Nurse Assistant Notes from 11/1/12 to 11/23/12, indicated the number of times the resident had bowel movements; however, there was no monitoring of the size and consistency (hardness) of the bowel movement to determine if the resident had constipation which was confirmed by LVN 4 According to a nursing note dated 11/23/12, indicated the resident was noted with blood on the diaper, the physician was notified and the resident was transferred to a GACH for further evaluation. According to the GACH documentation dated 11/23/12, the resident arrived to the emergency room with rectal bleeding. On 11/26/12, a colonoscopy [a test that allows looking at the inner lining of the intestine with the use of a thin, flexible tube (scope)] procedure found solid stool up to the proximal splenic flexure [the sharp bend of the colon (large intestine) where the transverse colon joins the descending colon and it is located under the spleen] making further scope passage unsafe and without purpose. The recommendation was to do more preparation of the colon and to repeat the procedure. On 11/27/12, a repeat colonoscopy was done and the findings indicated the patient was further manually disimpacted (despite repeat preparation) revealing several non-bleeding stercoral ulcerations (ulcers of the colon due to pressure and irritation from retained fecal masses) in the rectum (final section of the large intestine, terminating at the anus). The resident returned to the facility on 11/28/12. The physician's orders upon readmission on 11/28/12, included Docusate Sodium (stool softener) 25 cubic centimeters (cc) via GT/orally twice a day for constipation, MOM 30 cc via GT/orally at bedtime if no bowel movement for three days and Dulcolax suppository at bedtime if the Milk of Magnesia was not effective.A care plan developed on 12/1/12, for the resident's risk for fecal impaction, included in the approaches to monitor and record bowel movements every shift and to give laxatives (promotes the expulsion of feces) as ordered. The CNA - ADL Tracking Form for the month of 12/2012, indicated the resident did not have bowel movement from 12/2/12 to 12/6/12 (five days) and from 12/23/12 to 12/26/12, (four days); however, there was no documented evidence the license nurses were made aware and no evidence laxatives were administered as ordered. In addition, the CNAs' documentation only included the number of bowel movements but not the characteristics of the stool.The pre-printed form for CNAs' documentation did not include description of the stool. According to a facility's undated policy and procedure on Maintenance of Regular Bowel Movement, the purpose of the policy is to ensure all residents are monitored for regular bowel movements. CNAs are to log the resident's bowel movement every shift. For any resident with no bowel movements for three days, CNAs are to report to licensed nurses for laxatives to be administered as ordered. The policy did not address monitoring the stool characteristics. Pursuant to Clinical Gerontological Nursing: A Guide to Advanced Practice/1999 Saunders Co./Joyce Takano Stone, Jean F. Wyman, Sally A. Salisbury. 2nd ed. Page 240, 241: Assessment of Constipation included a patient history, a physical examination and a bowel record. Bowel history and associated symptoms include characteristics of bowel function, frequency of defecation, stool consistency and color, straining, pain with defecation, sensation of incomplete evacuation. On 1/6/13 at 1 p.m., during an interview, LVN 1 stated she was not aware the resident did not have bowel movements for more than three days. LVN 1 stated she sometimes checks the CNAs records of residents' bowel movements. LVN 1 was unable to provide evidence the resident was administered laxative as ordered when there was no bowel movement for three days. On 1/6/13, at 1:30 p.m., the Director of Nursing (DON) was unable to explain the reason the licensed nurses did not monitor the resident's bowel movements characteristics and the CNAs' documentation. The DON confirmed the pre-printed form for the CNAs' documentation did not have a section to indicate stool characteristics but only the number of episodes. The facility failed to provide Resident 6 with the necessary care and services in accordance with the comprehensive assessment, plan of care and physician?s orders by failing to: 1. Ensure CNAs and licensed nurses monitored the characteristics of the bowel movements to identify constipation and prevent fecal impaction. 2. Ensure licensed nurses administered the ordered laxative medications when the resident did not have bowel movements for three or more days as stated in the plan of care.On 11/23/12, Resident 6 was transferred to a GACH due to rectal bleeding where he was diagnosed and treated for fecal impaction. After readmission to the facility on 11/28/12, the nursing staff failed to monitor the resident for constipation and failed to administer the ordered laxatives when the resident did not have bowel movements for three or more days placing the resident at risk for further fecal impaction. The above violation presented either an imminent danger that death or serious harm would result or substantial probability that death or serious physical harm would result to Resident 6. |
| 940000071 |
VILLA ELENA HEALTHCARE CENTER |
940010703 |
B |
06-May-14 |
E1U611 |
6070 |
Based on observation, interview and record review, the facility failed to ensure a resident had the right to be free from verbal and physical abuse by failing to:Ensure that Resident 1 was not verbally and physically abused by a certified nursing attendant (CNA 2). This failure caused the resident unnecessary emotional suffering. Findings: On 6/26/13 at 7 a.m., an unannounced visit was made to the facility to investigate an entity self-reported incident regarding resident's rights.A review of the facility's letter, which was faxed to the Department on 6/10/13, indicated that on 6/8/13 at 9:30 p.m., CNA 2, while providing care to Resident 1, who was yelling and cursing, covered her mouth (cupped hands), held her arms with his other hand and told the resident to be quite. CNA 1, who was in the room at the time of the incident intervened and told CNA 2 to stop, and if he needed to calm down, to leave the room. CNA 2 then proceeded to cover the residents mouth with a blanket and again CNA 1 told him to stop it. CNA 1 stayed with Resident 1 and tried to calm her down.Based on the above incident with Resident 1, CNA 2 was terminated and this incident was reported to the CNA board.On 6/26/13 at 8:45 a.m., during an interview, Resident 1 was observed dressed, and sitting in her wheelchair. Even though Resident 1 was not able to stay on the same subject and was not able to name the person, she remembered when she was sleeping 'he' came to her room and that scared her.On 6/26/13 at 7:45 a.m., in an interview the SSD stated he talked to Resident 1 and even though she could not give the name of the person, she stated "that mother f_ _ ker guy covered my face."On 6/26/13 at 8:30 a.m., in an interview, CNA 3 stated Resident 1 started to cry when she saw her. When she asked why she was crying the resident told her that "Cabron (a_ _ hole) guy put his hands on my mouth, grabbed both of my wrists and arms."On 6/26/13 at 9 a.m., during an interview, CNA 1 stated for some reason CNA 2 seemed to be mad (he had an angry face). At around 9:30 p.m., she and CNA 2 were making their rounds together in room 208, when CNA 2 without talking to the resident in bed A grabbed her blanket, pulled it off of the resident and proceeded to provide incontinent care. CNA 1 stated she saw CNA 2 do the same thing to Resident 1 which made the resident very mad, so the resident started to curse at CNA 2. At the same time, CNA 1 said she saw CNA 2 cover Resident 1's mouth with is hand while trying to hold her hands down. CNA 1 said she told CNA 2 to please stop and if he is tired, just go outside. However CNA 2 turned around and came to CNA 1's side of the bed, grabbed the sheet and put it on the residents' mouth pushed on her chest to keep her down and told Resident 1 to shut up a_ _hole. CNA 1 said she pushed CNA 2 out of the room and immediately went to her supervisor about what had happened.CNA 1 stated she was very upset and scared to report the incident because CNA 2 told her in the past he had a gun in his car.On 6/26/13 at 10:30 a.m., in an interview, CNA 2 stated when he went to change Resident 1, she was aggressive, so he unintentionally cupped her mouth because she kept cursing at him.A review of Resident 1's clinical records indicated the resident was re-admitted to the facility on 12/22/11, with diagnoses which included senile dementia (a loss of brain function that occurs with certain diseases which affects memory, thinking, language, judgment, and behavior). A review of the Minimum Data Assessment (MDS - a comprehensive assessment of each resident's functional capabilities which helps nursing home staff identify health problems), dated 5/22/13, indicated the resident had unclear speech, usually understood and or understands, had short and long term memory problems, moderately impaired with daily decision making, inattention, exhibits verbal behavioral symptoms directed toward others, requires limited assistance from staff for bed mobility, extensive assistance for toileting, and is always incontinent of bowel and bladder functions.The following care plans, dated 12/22/11, indicated Resident 1 has self-care deficits due to impaired cognition secondary due to dementia, has cognitive and communication deficit, and is confused secondary due to dementia. The approaches were to do reality orientation while giving care, do verbal reminders and cues that assist the resident in orientation, explain all procedures, and pleasantly interactions which reassure the resident when confused.On 6/26/13 at 9:50 a.m., in an interview, the Administrator said he was informed of the allegations the same night and suspended CNA 2. While speaking to Resident 1 he noticed she was very emotional when describing what happened to her, and after speaking to CNA 1, he terminated CNA 2 because he also admitted to covering the residents' mouth. The Administrator said he did not report the allegations to the law enforcement. A review of the letter sent by the Administrator indicated the Department had not been notified until Monday 6/10/13. The Administrator said he also failed to report the allegation to the state agency within 24 hours.A review of the facility's policy and procedure for abuse reporting and investigation, updated 3/94, indicated verbal abuse is defined as any use of oral, written or gestured language that includes disparaging and derogatory terms to residents, regardless of their age, ability to comprehend, or disability. A physical abuse is defined as hitting, slapping, pinching, or kicking, etc. It also includes controlling behavior through corporal punishment.The facility failed to ensure a resident had the right to be free from verbal and physical abuse by failing to ensure that Resident 1 was not verbally and physically abused by a certified nursing attendant (CNA 2). This failure caused the resident unnecessary emotional suffering. The above violation has direct or immediate relationship to the health, safety, or security of Resident 1. |
| 940000025 |
VIEW HEIGHTS CONVALESCENT HOSPITAL |
940010963 |
B |
27-Aug-14 |
None |
4646 |
1418.91. (a) A long-term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the department immediately, or within 24 hours. (b) A failure to comply with the requirements of this section shall be a class "B" violation.The Department received an entity reported incident (ERI) from the facility on June 13, 2013. The ERI indicated that on June 11, 2013, Residents A, B and C were assaulted by the housekeeper. According to facility?s documentation, the first allegation of sexual abuse occurred on June 10, 2013, which was three days (72 hours) after the first alleged sexual abuse incident was reported to the staff. On July 23, 2014, at 9 a.m., an unannounced complaint investigation was conducted to investigate the ERI. Based on interviews and record reviews, the facility failed: To report the alleged abuse to the Department within 24 hours, as mandated by the State. On July 23, 2014, at 9 a.m., a review of the facility document titled, ?Employee Statement? written by the program director indicated on June 10, 2013, at approximately 4 p.m., it was reported to her that Resident A expressed concerns about a male housekeeper personnel (Employee 1) being sexually inappropriate. The report indicated Employee 1 kept entering Resident A?s room, on numerous occasions, for no apparent reason, supposedly to clean when it was not necessary. The report also indicated Resident A told the program director, once when the resident was in the shower she clearly heard Employee 1 tell someone he wanted to see her private area and another time he entered her bedroom while she was ?using it.? According to the program director?s report, Resident A was informed there would be a follow-up investigation and the facility would provide safety for her. The program director?s report indicated the resident was moved back to the South Side Unit. The director of nursing (DON) was made aware of Resident A?s allegation and a discussion with human resources was conducted to discuss further training for the housekeeping personnel.On July 23, 2014 at approximately 10:30 a.m., an interview was conducted with the program director. She stated she could not remember the date Resident A informed her of the incident. She stated when she asked Resident A if Employee 1 touched her, Resident A stated, ?No.? The program director stated when she moved Resident A to another unit she thought it would alleviate the problem. When asked about Residents B and C?s allegations of sexual abuse, the program director presented hand written letters from Residents A, B, and C, dated June 13, 2013. All three letters indicated that Employee 1 made sexual advances towards all three residents. Resident B?s letter indicated that on several occasions Employee 1 touched her inappropriately. Interviews of all three residents were attempted but the program director stated all three residents had been discharged from the facility and were not available for interview. On July 23, 2014 at approximately 12:30 p.m., a review of the administrator?s letter to Employee 1, dated June 13, 2013, indicated Employee 1 was suspended on June 13, 2013, pending the results of the investigation. A review of another letter dated June 20, 2013, addressed to Employee 1, and signed by the administrator, indicated on June 20, 2013 the employee was terminated for not following the facility?s policy regarding entering a female resident?s room without an escort.A review of the facility?s policy titled, ?Entering Residents Room,? dated 2014, indicated the staff should ?never enter into a resident?s room of the opposite gender without the assistance of another staff member.?On July 23, 2014, during the hours of 1 p.m. to 3 p.m., subsequent interviews were conducted with the facility?s administrator, assistant administrator and DON collectively. They indicated they did not hear about the first reported abuse incident until June 11, 2013 and were not aware of the June 10, 2013 report. The assistant administrator stated the facility?s abuse policy indicated to report any allegations of abuse immediately or with 24 hours to the Department. However, the report was not sent to the Department until June 13, 2013, at 5 p.m.The facility failed: By not reporting the alleged abuse to the Department within 24 hours, as mandated by the State. The above violation, of not reporting the abuse allegations of Residents A, B and C immediately or within 24 hours had a direct or immediate relationship to the health, safety or security of residents. |
| 940000056 |
Vista Cove Care Center at Long Beach |
940011087 |
B |
22-Oct-14 |
R4L011 |
4905 |
Health and Safety Code Section 1418.91 (a) A long term health care facility shall report all incidents of alleged abuse or Suspected abuse of a resident of the facility to the department immediately, or within 24 hours. (b) A failure to comply with the requirements of the section shall be a class ?B? violation.The Facility failed to report allegations of abuse to the proper authorities.During a record review and concurrent interview with the Administrator on 8/6/14 at 3 PM, the Administrator was asked to provide written evidence of how the facility handled cases of alleged abuse. Three allegations of abuse were requested for review. The Administrator was unable to provide a log or record indicating the allegations he had investigated, however he supplied two records of abuse and the Director of Nursing (DON) supplied the third.The Administrative folder for allegation number 1 indicated that Resident 38 had made an allegation of physical and verbal abuse on 7/25/14. The SOC 341 (report of an allegation of adult/ elder abuse) had been faxed to the Ombudsmen on 7/28/14 three days after the event was reported. The Administrator stated the report was not sent to the DHS as required. He further stated he does not send a final investigative report of the allegation of abuse within 5 days to DHS as required.The Administrative folder for allegation number 2 indicated Resident 22 reported an incident of sexual abuse on 4/16/14 at 6:30 PM. The investigative report by the Administrator indicated in part, "after returning from a Good Friday Easter Service, I documented the investigation from home. No DHS fax number on hand. 4/19/14 report made to DHS, (three days after the incident was reported by Resident 22 to facility Administration). The administrative folder did not contain a SOC 341(report of an allegation of adult/ elder abuse) indicating who had been notified, including the Ombudsmen. There was no evidence that the ombudsmen or resident's responsible party had been notified.The Administrative folder for allegation number 3 indicated that Random Resident 34 had a complaint of verbal abuse that he addressed with the Administrator on 6/9/14. The Quality Improvement Interview and Observation form dated 6/9/14 indicated, "... the janitor rushed over to him after he finished what he was doing and said, "I was trying to finish something SIR in an irritated tone. He said he was startled the janitor rushed over to him." The Administrator stated he had not reported the allegation to DHS, the Ombudsmen or the resident's responsible party. During a group meeting on 8/6/14 at 3 PM, Random Resident 34 stated he brought up an incident against a night time janitor (JA 1) to the Administrator which happened a month ago in the dining room but Administrator did not do anything about it. Random Resident 34 stated, JA 1 said to him he can't take it anymore and made an action to hit him. Random Resident 34 stated Resident 28 was in the dining room at that time. Resident 28 nodded her head affirmatively.During a review of the clinical record for Resident 16 and concurrent interview with Licensed Nurse (LN) 4 on 8/6/14 at 10 AM, a form, untitled, dated 2/10/14 was reviewed. LN 4 stated this is Physician 1's Progress note. The note indicated, "Pt (patient) states they beat me up last night they tie me into a chair."During a telephone interview with Physician 1 on 8/11/14 at 11 AM, he stated he was unaware the statement, "Pt (patient) states they beat me up last night, they tie me into a chair" would be considered an allegation of abuse and was not aware if an investigation of the allegation was done by the facility.During a telephone conversation with the facility Ombudsmen Case Manager on 8/12/14 at 10 AM, she stated, "(Resident 38) called me with an allegation of abuse by a staff member and I called the facility Administrator and reminded him that he needed to report this allegation to DHS. I do not have any reports concerning (Residents 22, 28 or 34). I told the Administrator that all allegations of abuse need to be reported to DHS and the Ombudsmen.During an interview with the facility Director of Clinical Services (DCS) on 8/7/14 at 11:30 AM, after she had been made aware of the abuse allegations, she stated, a sweep of 40 alert residents had been conducted and 20 of the residents questioned had new allegations of abuse.The facility policy and procedure titled "Resident Abuse and Investigation" un-dated indicated, Administrator will notify all parties involved, including notifying DHS or the Long term care Ombudsmen.Therefore the facility failed to report all allegations of physical, sexual and verbal abuse to the required authorities per state and federal regulations. The above citation had a direct relationship to the health, safety and security of the residents. |
| 940000056 |
Vista Cove Care Center at Long Beach |
940011123 |
B |
12-Nov-14 |
ZDZH11 |
5326 |
The facility must not employ individuals who have been found guilty of abusing, neglecting, or mistreating residents by a court of law; or have had a finding entered into the State nurse aide registry concerning abuse, neglect, mistreatment of residents or misappropriation of their property; and report any knowledge it has of actions by a court of law against an employee, which would indicate unfitness for service as a nurse aide or other facility staff to the State nurse aide registry or licensing authorities. The facility must ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property are reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures (including to the State survey and certification agency). The facility must have evidence that all alleged violations are thoroughly investigated, and must prevent further potential abuse while the investigation is in progress. The results of all investigations must be reported to the administrator or his designated representative and to other officials in accordance with State law (including to the State survey and certification agency) within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. The facility failed to implement its abuse policies and procedures by failing to notify the Department (State licensing and certification agency) regarding abuse allegation immediately or within 24 hours of the alleged abuse in accordance with the facility's policy. On 9/4/13, at 11:10 a.m., during a telephone interview, Employee 1(clinical staff from the acute care hospital) stated that Resident A's family member reported that the resident told her she got into verbal altercation with a facility staff member. The resident said she hit the staff member and the staff member hit her back. A second staff member witnessed the incident, however, he did nothing and the facility did not have any documentation of the incident.On 9/4/13, at approximately 3:00 p.m., an unannounced investigation was conducted at the facility regarding an incident of alleged staff to resident verbal and physical abuse. On 9/10/13, at 2:50 p.m., a review of Resident A's clinical record indicated she was initially admitted to the facility on 7/16/13, with diagnosis which included fracture of radius and ulna, head of radius and dementia (loss of brain function that occurs with certain diseases and affects memory, thinking, language, judgment, and behavior).The initial Minimum Data Set (MDS - a standardized assessment and care plan tool), dated 7/22/13, indicated the resident was able to make her needs known, but required assistance in making medical decisions. The resident needed assistance with most of her activities of daily living (ADLs). A review of the discharge summary indicated that the resident was admitted on 7/16/13 and discharged on 8/14/13. The resident condition's at discharge indicated alert. In an interview on 9/10/13, at 1:00 p.m., Resident A's family member stated the resident reported she had a verbal altercation with a staff member and she hit the staff and the staff member hit her back. The family member stated she reported the incident to RN 1 and "nothing was done about it." On 9/19/13, at 3:05 p.m., during an interview, RN 1 stated that Resident A's family member reported the allegation to her and she interviewed the assigned certified nurse assistant (CNA 1) in the presence of the family member. CNA 1 denied the allegation. RN 1 stated she did not report the alleged abuse to the facility or to the State licensing and certification Agency. RN 1 provided a written declaration to the evaluator to that effect. During review of the facility's investigation report dated 8/23/13, it indicated Hospital Employee 2 (administrative staff from the acute care hospital) met with the facility's administrator. Employee 2 reported to the administrator that he received from Resident A's family member an alleged incident of verbal and physical abuse against Resident A by a facility staff member while the resident was in the facility. In an interview on 9/19/13, at 4:15 p.m., the administrator stated the facility investigated the abuse allegation; however the facility did not report the alleged abuse incident to the State licensing and certification Agency. The facility's policy and procedure stipulated that, in case of any suspected form of resident abuse, the individual employee receiving this information is required to immediately report to the abuse coordinator and to the Ombudsman and/or Department of Health Services. Additionally, the local police department will be notified within 24 hours. In case of serious bodily injury this notification must be within 2 hours.Therefore, the facility failed to implement its abuse policies and procedures by failing to notify the Department (State licensing and certification agency) regarding abuse allegation immediately or within 24 hours of the alleged abuse in accordance with the facility's policy. The above violation had a direct and immediate relationship to the health, safety, or security of Resident A. |
| 970000050 |
VERNON HEALTHCARE CENTER |
940011362 |
A |
31-Mar-15 |
X81111 |
16318 |
F279 - 42 CFR 483.20(k)(1). Comprehensive Care Plans. The facility must develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident?s medical, nursing, and mental, and psychosocial needs that are identified in the comprehensive assessment. F323 - 42 CFR 483.25 (h)(2). Accidents. The facility must ensure that each resident receives adequate supervision and assistance devices to prevent accidents. The facility failed to provide Resident 1 who was identified to be a high risk for falls, a safe environment that minimized complications associated with falls, and develop a plan of care that included the provision of a low bed, a bed alarm and placement of a mattress on the floor (a landing pad) beside the bed, according to the facility's policy and procedure for falls.These violations resulted in Resident 1's fall, sustaining a brain hematoma (a localized swelling filled with blood) with altered level of consciousness and grand mal seizure (a loss of consciousness and violent muscle contractions). Consequently, Resident 1 was transferred to the hospital for treatment. Resident 1 was admitted at the hospital for 10 days and was discharged to another skilled nursing facility under hospice care. Resident 1 died at the skilled nursing facility 10 days after discharge from the hospital. A review of Resident 1's clinical record indicated he was admitted on 11/12/12 and was readmitted to the facility on 1/21/13. Resident 1's diagnoses included difficulty in walking, history of right-sided CVA (cerebrovascular accident or stroke) with aphasia (a loss or impairment of the ability to produce and/or comprehend language, due to brain damage), generalized weakness, dementia (a progressive loss of brain function affecting memory, thinking, and behavior), and encephalopathy (a disease of the brain that alters brain function or structure). A review of Resident 1's care plan for falls, dated 11/15/12, indicated risk factors that included limited mobility, poor balance, decreased mental ability, decreased ability to communicate, unsteady when walking, and lack of awareness. The fall care plan's goal included Resident 1 would minimize his risk for fall through interventions. There was no documented evidence of interventions or measures established to address Resident 1's risk factors to prevent a fall and minimize injuries.A review of the Physician Orders for Life-Sustaining Treatment (POLST), dated 1/24/13, indicated Resident 1 was to receive CPR (cardiopulmonary resuscitation) if he has no pulse and is not breathing and full treatment if he has a pulse or he is breathing. The Minimum Data Set (MDS, an assessment and care screening tool), dated 5/20/13, indicated Resident 1 had long-term and short-term memory problems, required extensive assistance (staff provided weight bearing support and at times required full staff performance) to total assistance for bed mobility, transfer, ambulation, dressing, and personal hygiene and was incontinent (had no control) of bowel and bladder. A review of the "Fall Risk Assessment Form," dated 1/21/13, and 4/21/13, indicated Resident 1 had a high risk for falls. A review of the physician's order, dated 2/25/13, indicated for Resident 1 to have sheep skin padded cover on the bed side rails to protect the skin due to episodes of getting out of bed unassisted. However, Resident 1's care plan for falls , dated 11/15/12 was not updated to reflect Resident 1's behavior of getting out of bed unassisted (additional risk factor).A review of the Nurses' Progress Notes, dated 5/19/13, at 10:45 p.m., indicated a certified nursing assistant (CNA) heard a noise from Resident 1's room and found Resident 1 sitting on the floor next to his bed. Resident 1 had his back leaning against the bed and was facing the wall. Resident 1 was assessed by a licensed nurse, who indicated Resident 1 had not sustained any injuries. Resident 1 was assisted back to bed by two CNAs.A review of the 72 Hour Neuro (neurological) Check List (a form indicating a pre-printed time schedule on how often the neurological checks were to be done) indicated Resident 1?s blood pressure, level of consciousness, and pupils (the circle in the middle of the eye) signs were monitored every 30 minutes two times (on 5/19/13 at 10:45 p.m. and 11:15 p.m.) and every hour three times (on 5/20/13 at 12:15 a.m., 1:15 a.m., and 2:15 a.m.).The 72 Hour Neuro Check List indicated from 5/19/13 at 10:45 p.m. thru 5/20/13 at 2:15 a.m., Resident 1?s systolic blood pressure (the top number in the blood pressure, which measures the pressure in the arteries when the heart beats) was between 128-136 mmHg (millimeters of mercury); the diastolic blood pressure (the bottom number, which measures the pressure in the arteries between heartbeats) was between 70-76 mmHg; he was alert (level of consciousness); and his pupils were equal and responsive (to light). The next scheduled neuro check was on 5/20/13 at 4:15 a.m. The Nurses Notes, dated 5/20/13, at 4 a.m., indicated Resident 1 had a change of condition. Resident 1 was observed to be shaking (while on the bed) and his vital signs consisted of blood pressure [(BP) the pressure exerted by the circulating volume of blood on the walls of the arteries] was measured at 150/112 mmHg (normal reference range is less than 120/80 mmHg ), heart rate was 160 beats per minute (normal reference range from 60 to 100 beats per minute), respirations were 22 breaths per minute (normal reference range for an adult person at rest range from 12 to 16 breaths per minute), and temperature was 101 degrees Fahrenheit (normal reference range from 97.8 degrees F to 99 degrees F). The physician was notified at 4:02 a.m. and Resident 1 was transferred at 4:08 a.m. to the hospital via paramedics.A review of the hospital's "Emergency Department (ED) Medical Chart," dated 5/20/13, indicated Resident 1 arrived in the ED due to seizure and hypotension (abnormal low blood pressure). The ED Medical Chart indicated that on 5/20/13 at 4:38 a.m., Resident 1 had a tonic clonic seizure (formerly known as grand mal seizure, a type of generalized seizure that affects the entire brain) in the nursing home, post ictal (the altered state of consciousness after a seizure) with EMS (emergency medical services), and was given Versed (a drug that causes relaxation, sleepiness and can cause a partial or complete loss of memory during the use of the drug) en route (to the hospital).The ED Medical Chart indicated Resident 1 was placed on Trendelenburg position (head lower than feet) due to BP of 64/46 mmHg, Dilantin 1 gram (an antiseizure medication) was given intravenously (IV, directly into a vein), and a bolus (a dose) of 500 cubic centimeter (cc) 0.9 percent (%) normal saline (salt solution) was given via IV, and the resident was transferred to the intensive care unit (ICU) for close observation.A review of the History and Physical from the acute hospital, dated 5/20/13, indicated Resident 1 did not have any prior seizure. The resident?s physical examination indicated he was not alert and not oriented, and only responded to pain simulation. A review of the CT Scan (computed tomography [CT] scan uses x-rays to make detailed pictures of structures inside of the body) of the head, dated 5/20/13, indicated ?Impression: There is a 2 cm (centimeter) intraparenchymal hemorrhage (bleeding in the brain parenchyma [the main part of the brain]) in the left frontal lobe. There is an adjacent 8 cm wide x 4 cm in length subdural hematoma (a collection of blood on the surface of the brain and is usually the result of a serious head injury) at the left frontal region. The above is new in comparison to the prior study on March 3rd, 2011. There is opacification of the sphenoid sinus (means that there is material such as blood or mucus that is filling the sphenoid sinus that is located behind the nose and eyes), new from the prior study.? The neurologist consultation report, dated 5/20/13, indicated the reason for consultation was the left frontal intraparehnchymal hemorrhage of Resident 1. The physical examination section of the report indicated ?...There is no external evidence of head trauma. There are Battle signs (bruising which appears on the surface of the skin and is caused by the escape of blood into the tissues from ruptured blood vessels and the bruising appears behind one or both ears) or raccoon eyes (refers to a dark purple discoloration forming around the eyes, giving an appearance similar to that of a raccoon) ?? The neurologist consultation report also indicated Resident 1?s hemorrhage was without mass effect (the effect of a growing mass that results in secondary pathological effects by pushing on or displacing surrounding tissue) or midline shift (shift of the brain past the center line which can indicate problems such as intracranial [inside the skull] pressure). A review of Resident 1's MRI (magnetic resonance imaging, a test that uses magnetic and radio waves to take detailed pictures of organs and other structures inside the body) of the brain, which was performed to rule out underlying mass, dated 5/21/13, indicated Resident 1 had bleeding in his brain and had several hematomas: left front brain, subdural (on the surface) both sides, and deep in his brain. The MRI report also indicated that the dense material in the sphenoid sinus is possibly representing blood. The gastroenterologist undated consultation report conducted due to Resident 1?s feeding difficulty, indicated the resident was evaluated by both Neurology and Neurosurgery and the plan was to provide conservative care.The gastroenterologist consultation report also indicated Resident 1 was unable to swallow for the last 24 to 36 hours and the gastrostomy tube placement (also known as a feeding tube, a tube that is placed directly into the stomach through an abdominal wall incision for administration of food, fluids, and medications) was deferred for the next few days to assess the resident?s improvement in his mental status as recommended by the neurologist. The resident had a nasogastric (through the nose and down into the stomach) tube feeding in the interim. A review of the physician?s order, dated 5/29/13 and timed at 11:50 a.m., indicated Resident 1 was to be DNR (do not resuscitate) and to provide the resident with comfort measures (any action taken to promote the soothing of a patient, such as a back rub, a change in position, administration of selected medications or treatments) only. A review of the physician?s progress record, dated 5/29/13 and timed 1:45 p.m., indicated ?family has elected for comfort care measures & hospice (a philosophy of care that recognizes death as a natural part of life and seeks neither to prolong nor hasten the dying process) & no PEG (percutaneous endoscopic gastrostomy, a type of feeding tube) or other interventions.?According to the Discharge Summary from the hospital, dated 5/30/13, during the hospitalization, Resident 1 had an EEG (electroencephalogram, a test that detects electrical activity in your brain using small, flat metal discs or electrodes attached to your scalp) done and the result was consistent with seizure. The discharge summary report indicated Resident 1 was transferred to hospice as requested by the family. Resident 1?s discharge diagnoses were status post intracranial hemorrhage, subdural hematoma, dementia, history of stroke, and seizure disorder.A review of the physician order (from the hospital), dated 5/30/13, indicated to discharge Resident 1 to a skilled nursing facility with hospice care. Resident 1 went to another skilled nursing facility where he died on 6/9/13, 10 days after being discharged from the hospital.A review of Resident 1?s death certificate indicated he died on 6/9/13 in a skilled nursing facility, his death was not reported to a coroner, autopsy was not performed, and the immediate cause of his death was cardiac arrest. The underlying cause (disease or injury that initiated the events resulting in death) were multiple organ failure and cerebral vascular disease (a group of brain dysfunctions related to disease of the blood vessels supplying the brain). Other significant conditions contributing to his death but not resulting in the underlying cause were dementia, seizures, and stroke. On 2/11/14, at 1:45 p.m., during an interview, the licensed vocational nurse (LVN 1) stated Resident 1 was not provided with floor mattress and alarm in the bed prior to his fall on 5/19/13.On 2/11/14, at 2 p.m., during an interview, the MDS coordinator stated she did not see any floor mattress beside Resident 1's bed and no alarm in the bed prior to Resident 1's fall on 5/19/13.On 2/11/14, at 2:30 p.m., the director of nursing (DON) reviewed Resident 1?s fall care plan. After reviewing Resident 1?s fall care plan, the DON stated, during an interview, there should have been interventions or measures established in the fall care plan for Resident 1 prior to his fall on 5/19/13. The DON stated, while reviewing Resident 1?s fall care plan, that at the time of the fall, the height of Resident 1's bed was not in the low position, there was no floor mattress beside his bed and there was no alarm in the bed. The DON stated there were no fall precautions for Resident 1.On 2/11/14, at 3 p.m., during an interview, LVN 2 stated she did not see any floor mattress beside Resident 1's bed and there was no alarm in his bed on 5/19/13.On 2/11/14 at 3:15 p.m., during an interview, CNA 1 stated on the night of 5/19/13, she heard a loud noise, went to Resident 1's room, and found Resident 1 facing the wall while sitting on the floor. She stated there was no alarm on Resident 1's bed and she could not remember seeing any floor mattress beside his bed. During an observation with CNA 1, on 1/22/15 at 3:20 p.m., the space between the bed previously occupied by Resident 1 and the wall was about an arm?s length. On 2/11/14 at 4 p.m., during an interview, CNA 2 stated when he saw Resident 1 on the floor on 5/19/13, he did not see any alarm on Resident 1's bed and he could not remember seeing any floor mattress beside his bed. On 1/23/15 at 10:45 a.m., during an interview, Physician 1 (the facility?s Medical Director and Resident 1?s primary physician on 5/19/13) stated always assume that a fall occurred when a resident is found sitting on the floor. In the case of Resident 1, who had an unwitnessed fall, had no evidence of external trauma to the head, but had developed a bleed on the frontal lobe of his brain, Physician 1 stated without an autopsy, it would be hard to confirm the cause of the bleed. A review of the facility's policy and procedure titled, "Fall prevention and Management Program," revised 12/1/12, indicated to provide a safe environment that minimizes complications associated with falls. The licensed nurse and/or interdisciplinary team (IDT, a group consisting of the head of the different departments who work together to discuss a resident's care) will develop a plan of care according to the identified risk factors and root cause. Therefore, the facility failed to provide Resident 1 who was identified to be a high risk for falls, a safe environment that minimized complications associated with falls, and develop a plan of care that included the provision of a low bed, a bed alarm and placement of a mattress on the floor (a landing pad) beside the bed, according to the facility's policy and procedure for falls.These violations resulted in Resident 1's fall, sustaining a brain hematoma (a localized swelling filled with blood) with altered level of consciousness and grand mal seizure (a loss of consciousness and violent muscle contractions). Consequently, Resident 1 was transferred to the hospital for treatment. Resident 1 was admitted at the hospital for 10 days and was discharged to another skilled nursing facility under hospice care. Resident 1 died at the skilled nursing facility 10 days after discharge from the hospital. This failure presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result. |
| 970000050 |
VERNON HEALTHCARE CENTER |
940011431 |
B |
06-May-15 |
WN3911 |
13751 |
F225 - 42 CFR 483.13(c)(2) The facility must ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property are reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures (including to the State survey and certification agency). 42 CFR 483.13(c)(4) The results of all investigations must be reported to the administrator or his designated representative and to other officials in accordance with State law (including to the State survey and certification agency) within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.On 9/18/14 at 8:50 a.m., an unannounced visit was made to the facility to investigate four (4) entity reported incidents regarding resident to resident altercation between Resident 1 and 2, Resident 11 and 12, Resident 5 and 17, and Resident 6 and 17. a. Resident 1 punched Resident 2 in the stomach on 8/16/14 when Resident 1 wandered inside Resident 2's room. A certified nursing assistant (CNA) witnessed the incident but she did not report the incident to the administrator immediately.b. Resident 11 and 12 were in their wheelchairs trying to pass in the hallway on 8/5/14 and the residents' wheelchairs became entangled. Resident 11 allegedly hit Resident 12 but Resident 12 managed to block the hit without sustaining any injuries. The documentation of this incident was found in the grievance log but the social worker designee did not report the incident to the administrator. c. Resident 17 threw a cup of water at Resident 5 on 7/20/14. The documentation of this incident was found in the grievance log but the social worker designee did not report the incident to the administrator. d. Resident 17 threw a shoe at Resident 6 on 7/7/14. The documentation of this incident was found in the grievance log but the social worker designee did not report the incident to the administrator. Based on interview and record review, the facility failed to implement its policy and procedure for reporting abuse by failing to: 1. Report to the administrator and the Department (the Licensing and Certification Program) allegations of physical abuse, which included assault (the threat of bodily harm that reasonably causes fear of harm in the victim) and battery (the actual physical impact on another person) between residents, immediately (as soon as possible but not to exceed 24 hours after discovery of the incident) or within 24 hours of the observation, knowledge or suspicion of the physical abuse. 2. Report the findings of all investigations to the Department within 5 working days of the incident.a. Resident 1's clinical record indicated the resident was admitted to the facility on 4/25/14, transferred to the hospital on 8/20/14, and was re-admitted to the facility on 8/24/14 with diagnoses that included dementia (loss of brain function that affects memory, thinking, language, judgment, and behavior).Resident 1?s quarterly review assessment Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 7/30/14, indicated the resident was able to make his needs known and was usually able to understand others. He was moderately impaired (decisions poor; cues/supervision required) in cognitive skills for daily decision making and required limited assistance (resident highly involved in the activity; staff provide guided maneuvering) in walking and during locomotion (how the resident moves between locations). Resident 2's clinical record indicated the resident was admitted to the facility on 6/18/14 with diagnoses that included dementia and psychosis (a mental disorder).Resident 2's admission assessment MDS, dated 6/25/14 indicated Resident 2 was moderately impaired in cognitive skills for daily decision-making, needed extensive assistance (resident involved in activity, staff provide weight bearing support) when walking, and required limited assistance in locomotion (how the resident moves between locations).The certified nursing assistant (CNA) notes written on the form titled "Additional Notes," indicated that on 8/16/14 at 6:30 p.m., Resident 1 hit CNA 1 on her right side with a closed fist four (4) times, and twisted her right index finger and right arm. Resident 1 walked towards Resident 2 and hit that resident in the stomach. Resident 1 walked towards the security staff at the front door and hit the security staff also in the stomach. CNA 1 documented it was very hard to provide patient care to Resident 1. On 9/21/4 at 3:50 p.m., during an interview, the administrator stated she became aware of the altercation that happened between Resident 1 and 2 when a surveyor reported the incident to a staff on 9/9/14, 24 days after the altercation occurred. The administrator stated CNA 1 witnessed the altercation and she (the administrator) expected the witness to report the incident immediately to the licensed charge nurse and then the charge nurse to report the incident to the administrator.The facility's report indicated the incident was reported by the facility to the physicians, responsible parties, Ombudsman and the Department on 9/9/14. The facility reported the results of the investigation to the Department on 9/13/14.b. Resident 11?s clinical record indicated the resident was admitted to the facility on 6/18/14, with diagnoses that included paranoid schizophrenia (a mental illness), anxiety state, and encephalopathy (brain damage).The Minimum Data Set of Resident 11, dated 6/25/14, indicated the resident was severely impaired with his cognitive patterns for daily decision making and required extensive assistance by staff with activities of daily living. The resident was discharged to home on 8/17/14 with home health services. Resident 12?s clinical record indicated the resident was re-admitted to the facility on 8/29/14, with diagnoses that included depressive disorder, schizoaffective disorder, and anxiety state. The Minimum Data Set of Resident 12, dated 9/5/14, indicated the resident was severely impaired with her cognitive patterns for daily decision making and required total dependence by staff with activities of daily living. The resident was transferred to an acute hospital on 9/8/14, for psychiatric evaluation. The Resident Grievance/Complaint Investigation Report, dated 8/5/14, indicated Resident 12 claimed that while in the hallway, her wheelchair was entangled with Resident 11's wheelchair. Resident 11 poked Resident 12, Resident 12 told Resident 11 not to touch her, and then Resident 11 attempted to strike Resident 12. Resident 12 claimed that Staff 1 witnessed the incident. A documented statement from Staff 1 was attached to the report. Staff 1 wrote that she did not witness Resident 11 hit Resident 12 when their wheelchairs were entangled in the hallway. The facility's report indicated the administrator became aware of the incident on 9/10/14, 36 days after the altercation happened, during a review of the grievance log. The facility reported the results of the investigation to the Department on 9/14/14. Both residents were no longer staying at the facility.c. Resident 5's clinical record indicated the resident was admitted to the facility on 5/5/14 and re-admitted on 8/27/14 with diagnoses that included congestive health failure (CHF). The MDS dated 8/12/14 indicated Resident 5 was alert and able to make her needs known. Resident 17's clinical record indicated the resident was admitted to the facility on 7/7/14 with diagnoses that included schizophrenia (a mental illness). Resident 17 was discharged from the facility on 7/29/14.The Resident Grievance/Complaint Investigation Report indicated Resident 5 filed a grievance complaint on 7/20/14 and an investigation was initiated on 7/22/14 by the social services designee (SSD). According to the grievance complaint, Resident 5 alleged another resident (Resident 17) threw a cup of water and struck her in the back on 7/20/14 during the evening shift (3 p.m. thru 11 p.m.). The investigation report was not signed by the administrator.The facility's report indicated the administrator became aware of the incident on 9/10/14, 52 days after the incident, during a review of the grievance log. The facility reported the incident to the Ombudsman and the Department on 9/10/14. The facility reported the results of the investigation to the Department on 9/15/14.d. Resident 6's clinical record indicated the resident was admitted to the facility on 2/7/14 and re-admitted on 6/22/14 with diagnoses that included congestive heart failure (CHF). The MDS dated 6/28/14 indicated the resident was alert and able to make her needs known.Resident 17's clinical record indicated the resident was admitted to the facility on 7/7/14 with diagnoses that included schizophrenia (a mental illness). Resident 17 was discharged from the facility on 7/29/14.The Resident Grievance/Complaint Investigation Report indicated Resident 5, who was acting as an advocate for Resident 6, filed a grievance complaint on 7/8/14 and an investigation was initiated on the same day by the social services designee (SSD).The Resident Grievance/Complaint Investigation Report indicated the incident happened on 7/7/14 at 8 p.m. Resident 17 (a newly admitted roommate) was throwing items, which included a tennis shoe, out of the door and yelling for a Coke (a beverage) as Resident 5 and 6 were entering their room. Resident 6 was hit by a tennis shoe. Resident 5 stated she was never able to enter the room because she was subjected to this type of behavior. Resident 5 stated she was not told that the facility had mentally ill residents and she cannot handle this type of behavior. Resident 5 stated she wanted the admission department to better evaluate the residents that were admitted to the facility. The facility's report indicated the administrator became aware of the incident on 9/10/14, 65 days after, during a review of the grievance log. The facility reported the incident to the Ombudsman and the Department on 9/10/14. The facility reported the results of the investigation to the Department on 9/12/14. On 9/21/4 at 3:50 p.m., during an interview, the administrator stated she is the abuse coordinator for the facility and all allegations of abuse should be reported by staff immediately to the charge nurse and to her. The administrator stated the social service designee (SSD), who was aware of the incidents at that time, did not give her an explanation why she did not bring the allegations to the attention of the administrator immediately. The administrator stated the SSD informed her and the QAA (Quality Assessment and Assurance) Committee during their meetings that there were zero grievances in the facility. The administrator stated the social service designee (SSD) documented the resident-to-resident altercations in a grievance form when the incidents should be documented in an abuse allegation form because the incidents were abuse allegations.A review of the facility's policy and procedure titled "Reporting Abuse," dated 9/1/13, the facility staff will report known or suspected instances of abuse to the administrator, or his/her designee, as abuse coordinator. The facility will report known or suspected instances of physical abuse to the proper authorities by telephone or through a confidential internet reporting tool as required by state and federal regulation.The policy and procedure indicated that if the reportable event does not result in serious bodily injury, the Administrator of his/her designee, will make a telephone report to the local law enforcement agency within 24 hours of the observation, knowledge, or suspicion of the physical abuse. In addition, a written report shall be made to the local Ombudsman, the California Department of Public Health (Licensing and Certification), and the local law enforcement agency within 24 hours of the observation, knowledge, or suspicion of the physical abuse. If a suspected abuse is allegedly caused by a resident, who has been diagnoses with dementia, and a Licensed Nurse reasonably determines that there is no serious bodily injury, the Administrator, or his/her designee, shall report to the local Ombudsman or law enforcement agency by telephone as soon as practically possible, and file a written report within twenty-four (24) hours of the observation, knowledge, or suspicion of the abuse. The facility's policy and procedure also indicated the administrator, or his/her designee, shall provide the appropriate agency or individuals with a written report of the finding of the investigation within five (5) working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken and documented. Therefore, the facility failed to implement its policy and procedure for reporting abuse by failing to: 1. Report to the administrator and the Department (the Licensing and Certification Program) allegations of physical abuse, which included assault (the threat of bodily harm that reasonably causes fear of harm in the victim) and battery (the actual physical impact on another person) between residents, immediately (as soon as possible but not to exceed 24 hours after discovery of the incident) or within 24 hours of the observation, knowledge or suspicion of the physical abuse. 2. Report the findings of all investigations to the Department within 5 working days of the incident.The above violations had a direct or immediate relationship to the health, safety, or security of the residents. |
| 970000050 |
VERNON HEALTHCARE CENTER |
940011435 |
A |
06-May-15 |
WN3911 |
17360 |
F323 - 42 CFR 483.25 (h)(2). Accidents. The facility must ensure that each resident receives adequate supervision and assistance devices to prevent accidents. On 9/18/14 at 8:15 a.m., an unannounced visit was made to the facility to investigate an entity reported incident regarding an alleged resident to resident abuse that occurred on 8/16/14, when Resident 1 hit Resident 2 in the stomach. The facility failed to provide adequate supervision to Resident 1 by failing to: 1. Identify the hazards and risks of the resident?s wandering behavior.2. Implement the one-to-one (1:1) monitoring or supervision (an assigned staff supervises and closely watches/monitors a resident at all times) according to the plan of care that was developed to manage the resident?s wandering behavior. Resident 1, who had dementia (loss of brain function that affects memory, thinking, language, judgment, and behavior), was able to wander into the rooms of female residents, Resident 4, 5, 6, and 16, at various times between 4/25/14 and 9/20/14, and was able to enter the room of a male resident with dementia, Resident 3, and hit him on the left eye area of his face two weeks prior to 9/20/14 (exact date undetermined).The facility placed Resident 1 on 1:1 supervision on 9/8/14 to prevent him from hitting other residents and staff. On 9/18/14, Resident 1 was able to enter inside the room of Resident 5 and 6 by himself. On 9/20/14, Resident 1 was able to enter inside the room of Resident 4 by himself. These female residents, Resident 4, 5, and 6, felt threatened that Resident 1 might hit them. Resident 4 was scared that Resident 1 might do something inappropriate to her. This failure resulted in psychological harm to the female residents, who felt threatened by Resident 1's behavior, and had the potential to result in physical harm to Resident 1 himself and to other residents.A review of Resident 1's clinical record indicated the resident was admitted to the facility on 4/25/14, was transferred to the hospital on 8/20/14, and was re-admitted to the facility on 8/24/14 with diagnoses that included dementia and end stage renal (kidney) disease.According to the quarterly review assessment Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 7/30/14, Resident 1 was able to make his needs known and was able to understand others usually. He was moderately impaired (decisions poor; cues/supervision required) in cognitive skills for daily decision making, and required limited assistance (resident highly involved in the activity; staff provide guided maneuvering) in walking and during locomotion. The clinical record indicated Resident 1 was transferred to the hospital on 8/20/14 due to generalized weakness and anemia (the blood lacks healthy red blood cells). Resident 1's history and physical from the hospital, dated 8/20/14, indicated that at the time of the hospital admission, Resident 1 was noted to be severely confused, wandering off out of his room in the hallway with unsteady gait. Another hospital record of consultation, dated 8/1/14, indicated that Resident 1 appeared to wander the hallways without any direction. A progress note, dated 8/22/14, indicated Resident 1 had been wandering the hallways aimlessly. Resident 1 was discharged back to the facility on 8/24/14. The re-admission assessment of Resident 1, dated 8/24/14 at 12:55 p.m., indicated Resident 1 was confused and had poor safety judgment.According to the Elopement Risk Assessment, dated 8/24/14, Resident 1 was assessed as being at risk for potential elopement from the facility. The assessment indicated the resident was ambulatory with or without a device. There was no risk assessment conducted to identify the hazards and risks of Resident 1?s wandering inside the facility or inside other residents' rooms. The Change of Condition Notes, dated 9/8/14, indicated that Resident 1 was placed on a 1:1 monitoring, to prevent Resident 1 from striking out staff and other residents, after a surveyor informed a staff that Resident 1 hit staff members and Resident 2.According to the administrator, during an interview on 9/21/14 at 3:50 p.m., a surveyor brought to her attention a CNA note, dated 8/16/14 at 6:30 p.m., which indicated that Resident 1 hit Resident 2 in the stomach and a security staff at the front door. The CNA note indicated Resident 1 also hit CNA 1 with a closed fist four (4) times and twisted the CNA's right arm and right index finger, and Resident 1 continued to wander in and out of other resident?s rooms. The administrator stated, during another interview on 9/18/14 at 11:30 a.m., Resident 1 had wandered in the room of Resident 2 and punched Resident 2 in the stomach. The facility conducted an investigation of the incident that occurred on 8/16/14 and interviews with Resident 4 and 5 on 9/9/14. According to the interview record, Resident 4, an alert female resident, stated that Resident 1 wandered most of the evening. Resident 5, another alert female resident, stated Resident 1 had wandered inside her room at 3 a.m. in the morning and sat at the foot of her bed. Resident 5 stated Resident 1 came in her room, sat on her bed, and fell asleep. Resident 5 stated she had seen Resident 1 put up his fist at the staff when the staff tried to re-direct him and she had also seen Resident 1 strike a staff on two (2) different occasions.The psychiatrist progress notes, dated 9/10/14, indicated that Resident 1 was confused and disorganized, and wandered into other residents' rooms.The facility's letter to the Department, dated 9/12/14, indicated it was brought to the administrator's attention on 9/11/14 that Resident 3 had discoloration on his left eye area and the source of the injury was unknown.During an interview with Resident 13 (the roommate of Resident 3, a cognitively impaired male resident), on 9/20/14 at 1 p.m., the resident stated that during the evening shift at 7 p.m., while he was lying in bed, he saw Resident 1 wandering at the hallway and entering their room. Resident 1 sat on Resident 3's bed while Resident 3 was sleeping. Resident 3 woke up and tried to move his leg to get Resident 1 out of his bed. Resident 13 stated Resident 1 got mad and punched Resident 3 on his left eye which resulted in the discoloration on the left eye area. Resident 13 stated a female certified nursing assistant (CNA) came inside their room and took Resident 1 out of the room.The plan of care, dated 9/12/14, indicated that Resident 1 had dementia, had no capacity of making decisions, wanders, confused, resists care, disrobes, and had a history of hitting another resident. The resident goals were to decrease the episodes of wandering and to minimize his risk. One of the interventions was placing the resident on "one-on-one episode" or 1:1 supervision/monitoring. Prior to 9/12/14, the facility did not develop a plan of care to address and manage the resident's behavior of wandering inside other residents' rooms.The facility's policy and procedure titled, "Wandering & Elopement," dated 1/1/12, indicated that it was the policy of the facility to identify resident at risk for elopement and minimize any possible injury as a result of the elopement. The facility?s policy and procedure did not address the procedures to identify the hazards and risks of a wandering behavior, and manage the residents at risk for wandering inside the facility or inside other residents' rooms. During an interview, on 9/18/14 at 2:40 p.m., CNA 3 stated that Resident 1 wanders into female residents' rooms and everyone knew he is a wanderer and that he wanders into female rooms. CNA 3 stated Resident 1 wandered during the day and night. During an interview, on 9/20/14 at 10:05 a.m., Licensed Vocational Nurse (LVN) 1 stated since Resident 1 was admitted to the facility, she heard reports that Resident 1 wandered in other residents' rooms.On 9/18/14 at 9:15 a.m., during a concurrent interview with Resident 5 and 6, alert female residents who shared the same room, they stated Resident 1 had entered their room several times and had also entered other residents' rooms. Resident 5 and 6 stated Resident 1 became combative by hitting staff when the staff tried to get him out of another resident's room.On 9/18/14 at 9:20 a.m., during an interview, Resident 5 stated there was one incident when Resident 1 climbed on her bed at 3 a.m., sat at the foot of her bed with his legs spread open and facing her, and she had to call staff to get Resident 1 out of her room.During a concurrent interview, Resident 6 stated Resident 1 had entered her room and ate her food on her bedside table. Resident 6 stated she just allowed Resident 1 to eat her food because she would not fight him. Resident 6 stated she would just ask staff to buy her food because she would not fight Resident 1. On 9/18/14 at 11:30 a.m., during an interview, the administrator stated she was aware that Resident 1 had wandered in the room of Resident 2 and punched Resident 2 in the stomach, but she had no knowledge Resident 1 was wandering inside female residents' rooms.On 9/18/14 at 2:25 p.m., the clinical record of Resident 1 was reviewed with Registered Nurse (RN) 1. RN 1 stated, during a concurrent interview, that Resident 1 was placed on 1:1 supervision and this was a nursing intervention from the plan of care dated 9/12/14. RN 1 stated Resident 1 wandered in the facility but she was not aware he was wandering inside female residents' rooms. On 9/20/14 at 11 a.m., during an interview, Resident 4, an alert female resident, stated Resident 1 had entered her room more than four (4) times in the past and it happened during the day and night. Resident 4 stated there were times that she had to use the call light for the staff to get Resident 1 out of her room and there were times staff followed Resident 1 inside her room to get him out of her room. Resident 4 stated Resident 1 had attempted to climb on her bed a couple of times and she had to use the call light for staff to get him out of her room. Resident 4 also stated her roommate, Resident 16, had said before "Get off my bed" to Resident 1, when Resident 1 tried to climb on Resident 16's bed.During the course of the interview, Resident 4 stated Resident 1 was by himself inside her room "last night," estimating the time it happened as past midnight of 9/20/14. Resident 4 stated she used the call light so staff would go inside her room and get Resident 1 out of her room.Resident 4 stated a female staff entered her room to get Resident 1 out of her room after she pushed her call light. Resident 4 stated Resident 1 walked all the way inside her room without staff beside him. Resident 4 stated she felt scared by the presence of Resident 1 inside her room because she did not know what he (Resident 1) would do next and she had seen Resident 1 hit staff who tried to get him out of the room. Resident 4 stated she felt threatened that Resident 1 might hit her or do something inappropriate to her. Resident 4 stated she had a broken back, she could not lift her right arm, and she could not do anything to defend herself. On 9/20/14 at 11:25 a.m., during an interview, CNA 4 stated she was the assigned sitter (1:1 monitor) for Resident 1. CNA 4 stated she did not receive any report from the CNA of the outgoing shift that Resident 1 had wandered inside a female resident's room. CNA 4 stated that if there was anything unusual that occurred during the previous shift, she would get a report from the outgoing sitter. An attempt to interview Resident 1 was conducted after the interview with CNA 4, but Resident 1 did not answer the questions that were asked. On 9/20/14 at 2 p.m., during an interview, Resident 5 and 6 stated that Resident 1 entered their room by himself last Thursday, 9/18/14, at 8 p.m. and he just stood in front of their closets. Resident 5 and 6 stated they had to call a staff member who was passing by at the hallway to get Resident 1 out of their room. Resident 5 and 6 stated they felt threatened by the presence of Resident 1 inside their room because he might hit them.The clinical record of Resident 1 was reviewed with the director of nursing (DON) on 9/20/14 at 1:15 p.m. According to the DON, she did not see any documentation that Resident 1 had wandered inside another resident's room. The DON stated that at a minimum, she expected the staff to communicate when a resident wandered inside another resident's room.The DON stated that conducting an assessment and developing a care plan should be ongoing and could be done anytime. The DON stated the facility did not have a form to use as a tool for assessing and identifying the residents at risk for wandering inside other residents' rooms, and the ?Elopement Risk Assessment Form? was the only form/tool the facility had. The DON also stated that Resident 1 did not have a plan of care developed to address his wandering behavior inside another resident's room until 9/12/14. On 9/20/14 at 4:20 p.m., the administrator and the DON were informed that the facility's policy and procedure titled "Wandering & Elopement," dated 1/1/12, that they submitted, only addressed residents at risk for elopement. The administrator and DON could not provide any other policy and procedure that addressed the identification and management of residents at risk for wandering inside the facility, specifically inside other residents' rooms. A review of the physician's order, dated 9/20/14 and timed at 5:15 p.m., indicated an order to transfer Resident 1 to a hospital for evaluation due to his behavior of being a danger to others secondary to his aggressive behavior.According to the nursing notes, dated 9/20/14, the resident left the facility and was transported to the hospital at 7:15 p.m.A review of Resident 2's clinical record indicated the resident was admitted to the facility on 6/18/14 with diagnoses that included dementia and psychosis (a mental disorder). Resident 2's admission assessment MDS, dated 6/25/14 indicated Resident 2 was moderately impaired in cognitive skills for daily decision-making, needed extensive assistance (resident involved in activity, staff provide weight bearing support) when walking, and required limited assistance (resident involved in activity, staff provide guided maneuvering) in locomotion (how the resident moves between locations).A review of Resident 3's clinical record indicated the resident was re-admitted to the facility on 3/21/14 with admitting diagnoses of dementia. The MDS, 8/13/14, indicated Resident 3 was moderately impaired with his cognitive skills for daily decision making and required extensive assistance with activities of daily living. A review of Resident 4's clinical record indicated the resident was admitted to the facility on 4/21/14 and was re-admitted on 5/2/14 with diagnoses that included hyperlipidemia (high cholesterol) and hypertension (high blood pressure). The admission assessment MDS, dated 5/9/14, indicated was alert and able to make her needs known, unable to walk, needed extensive assistance in bed mobility, dressing, and toilet use, and she was totally dependent on staff for transfers. A review of Resident 5's clinical record indicated the resident was admitted to the facility on 5/5/14 and was re-admitted on 8/27/14 with diagnoses that included congestive heart failure (CHF, a condition that occurs when the heart is unable to pump enough blood to meet the needs of the body's tissues). The quarterly review assessment MDS, dated 8/12/14, the resident was alert and able to make her needs known, and needed supervision in performing activities of daily living. A review of Resident 6's clinical record indicated the resident was admitted to the facility on 2/7/14 and was re-admitted on 6/22/14 with diagnoses that included congestive heart failure (CHF). The admission assessment MDS, dated 6/28/14, indicated the resident was alert and able to make her needs known, needed limited assistance in walking, and required extensive assistance in bed mobility and transfers. A review of Resident 13's clinical record indicated the resident was re-admitted to the facility on 3/21/14 with diagnoses that included hypertension (high blood pressure). The MDS, dated 8/6/14, indicated the resident was alert and able to make his needs known. A review of Resident 16's clinical record indicated the resident was admitted to the facility on 4/8/11 and was re-admitted on 6/29/14 with diagnoses that included dementia. The MDS, dated 8/27/14, indicated the resident's speech was clear, her cognitive skills was moderately impaired, and she needed extensive assistance in activities of daily living. Therefore, the facility failed to provide adequate supervision to Resident 1 by failing to: 1. Identify the hazards and risks of the resident?s wandering behavior.2. Implement the one-to-one (1:1) monitoring or supervision (an assigned staff supervises and closely watches/monitors a resident at all times) according to the plan of care that was developed to manage the resident?s wandering behavior. This failure presented either an imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result. |
| 950000019 |
VISTA COVE CARE CENTER AT SAN GABRIEL |
950009759 |
B |
28-Feb-13 |
HH3111 |
4589 |
Title 22- Unusual Occurrence 72541- Occurrences such as epidemic outbreaks, poisonings, fires, major accidents, death from unnatural causes or other catastrophes and unusual occurrences which threaten the welfare, safety or health of patients, personnel or visitors shall be reported by the facility within 24 hours either by telephone (and confirmed in writing) or by telegraph to the local health officer and the Department. An incident report shall be retained on file by the facility for one year. The facility shall furnish such other pertinent information related to such occurrences as the local health officer or the Department may require. Every fire or explosion which occurs in or on the premises shall be reported within 24 hours to the local fire authority or in areas not having an organized fire service, to the State Fire Marshal. The facility must report any unusual occurrences such as epidemic outbreaks that threaten the welfare, safety or health of patients, personnel or visitors to this Department, within 24 hours. On October 24, 2012, at 2:20 p.m., an unannounced visit was made to the skilled nursing facility (SNF) to investigate an anonymous complaint regarding an allegation that the staff and family of staff had become infected with rash/scabies.The facility failed to report an unusual occurrence by failing to: 1. Report to the Department within 24 hours when four patients developed rashes that were suspected to be a scabies (a contagious infection caused by a tiny mite that is passed between people by close skin contact) outbreak. During the investigation of the unusual occurrence regarding the outbreak of scabies on October 24, 2012, at approximately at 2:25 p.m., the administrator during an interview stated that on October 23, 2012, that she did not notify the Department by telephone within 24 hours of the occurrence as required but rather, reported the unusual occurrence to the Department via mail.A review of the rash and treatment histories of the four patients revealed the following:1. Patient 1 on October 17, 2012, was noted with an inflamed body rash. On the same day, the physician ordered Elimite cream (used to treat scabies) to the whole body and the patient was provided with the treatment.2. Patient 2 on October 17, 2012, presented with a body rash. On the same day, the physician ordered Elimite cream to the whole body and the patient was provided with the treatment.3. Patient 3 on October 17, 2012, presented with a recurring generalized body rash and on October 19, 2012, the physician ordered Elimite cream to the whole body and the patient was provided with the treatment.4. Patient 4 on October 19, 2012, presented with upper extremity rashes, with red-pinkish macules (flat, distinct, colored area of skin). On the same day, the physician ordered Elimite cream to the whole body and the patient was provided with the treatment.A review of the facility?s written notification letter, indicated that the facility first notified the Department on October 23, 2012, of the occurrence of rashes, four days after Patient 1, 2 and 3, were identified with body rashes that required treatment with Elimite.There was no evidence that the facility notified the Department within 24 hours of the occurrences of the outbreak of scabies to include Patient 1, 2, 3 and 4, and neither was a letter received via mail from the facility.During an interview with the director of nursing (DON), on October 25, 2012, at 3:50 p.m., she stated that she had reported the four cases of rash to the public health nurse on October 19, 2012. During an interview with the dermatologist, on October 25, 2012, at 4:03 p.m., he stated that no skin scrapings were conducted during his visit to the facility on October 22, 2012, because patients had been treated with Elimite cream prior to his visit to the facility. The dermatologist further stated that the patients had clinical signs of scabies.The facility policy and procedure titled, "Outbreak of Communicable Disease," dated June 2010, indicated that the administrator will be responsible for telephoning a report to the health department.The facility failed to report an unusual occurrence by failing to: 1. Report to the Department within 24 hours when four patients developed rashes that were suspected to be a scabies (a contagious infection caused by a tiny mite that is passed between people by close skin contact) outbreak. These violations had a direct relationship to the welfare, safety and health of patients, personnel or visitors. |
| 950000019 |
VISTA COVE CARE CENTER AT SAN GABRIEL |
950012147 |
B |
24-Mar-16 |
3YJX11 |
6388 |
F 241 483.15(a) Dignity. The facility must promote care for residents in a manner and in an environment that maintains or enhances each resident?s dignity and respect in full recognition of his or her individually. Based on observation, interview and record review, the facility failed to ensure: Resident 1 was treated with respect and dignity during provision of care and not subjected to rough handling.Findings: On 1/15/15, the District Office received a facility reported incident, indicating that Resident 1 alleged that certified nurse assistant (CNA) 1 was rough handling her during care.On 1/16/15, at 8 a.m., the complaint investigation was conducted. A record review of the Admission Record indicated Resident 1 was admitted to the facility on 12/31/2014, with diagnoses that included congestive heart failure (CHF- a condition in which the heart can't pump enough blood to meet the body's needs) and abnormality of gait (manner or style of walking) and anemia (low iron in the blood).The Minimum Data Set (MDS- standardized assessment tool) dated 1/7/15, indicated the resident was able to understand others and make self -understood by others, required extensive assistance with one-person assist with transfer, ambulation in room and corridors, personal hygiene and toilet use. The MDS also indicated the resident was occasionally incontinent of bladder and frequently incontinent of bowel.The MDS also indicated the resident normally used wheelchair as a mobility device.During an interview with the administrator on 1/16/15, at 8:30 a.m., he stated the alleged abuse was still under investigation. He stated the CNA involved was suspended because of the allegation. A night shift (11p.m. to 7 a.m.) CNA 1 was angry and rough with Resident 1 when she asked for help to go to the toilet on 1/14/15 at 1:30 a.m. The resident also stated, that CNA 1 " held my hands too tight and threw my legs into the bed. "On 1/16/15, at 9 a.m., during an interview with the registered nurse (RN) supervisor, he stated that on 1/14/15, approximately 1 a.m., the North Station licensed vocational nurse (LVN) 1 informed him of a resident's complaint about CNA 1. The RN supervisor stated that he talked to the resident regarding concerns she had with CNA 1. The RN supervisor stated that he then removed CNA 1 and counseled her on her manner of speaking inappropriately to Resident 1 and how she handled the resident. The RN supervisor stated that he remembered that there had been another resident who had complaints regarding CNA 1.An interview was conducted with CNA 1 on 1/16/15, at 10:10 a.m. CNA 1 stated, " I came to work at 11 p.m., at around 11:30 p.m., there were 3 call lights on. I answered 2 call lights and told the 2 residents, " I will be with you in a minute, " and went to the third call light which was Resident 1's room. Resident 1 asked to be taken to the bathroom on a shower chair, which I did. I cleaned her up after then assisted her back to her bed. Then she called again and again. From 11 p.m. to 1 a.m., she called me 10 times but she only used the bathroom 3 times. I got mad at her and I told her too many call lights, made me crazy. My back was hurting me because her legs were swollen. My only mistake was I did not smile when I helped her.I know I did not abuse her, I don't abuse my residents. "CNA 1 stated, "No, I don't ask for help because they don't come help us, especially the licensed nurses."An interview was conducted with North Station licensed vocational nurse (LVN) 1 on 1/16/15, at 10:35. LVN 1 stated Resident 1 complained to her that CNA 1 was rough with her whenever the she called for help to go to the bathroom. LVN 1 added Resident 1 told her that CNA 1: "Was mad at me, she grabbed my hands so tight that they started to hurt me and threw my legs into the bed."LVN 1 also stated that Resident 1 did not complain of any pain during the time the CNA was mishandling her. She also stated that Resident 1 felt safe at the facility. On 1/16/15, at 11:30 a.m., Resident 1 was interviewed with a translator. Resident 1 initially stated that she remembered CNA 1. However, Resident 1 immediately changed her mind and refused further interview, stating, "No, I don't remember" however stated, that she felt safe in the facility. A review of CNA 1's Employment Record indicated a counseling report dated 5/24/10, revealed, a resident (Resident 2) complained that when CNA 1 put the pillows under her legs, she moved/worked fast. Another Employee Counseling Report dated 12/28/14, stated, "The CNA was rough with her and told her not to use the call light to ask for help because she has 22 patients and has no time to attend to her."Resident 2 stated this had happened before. Resident 2 further described that CNA 1 was rough, throwing bed linens at the foot of the bed. Both reports indicated CNA 1 refused to sign the counseling report and the facility did not have any disciplinary action related to the two incidents. The facility listed both complaints as "verbal warnings," and with a corrective action plan, "In-service and Counseling."Further review of the CNA's record indicated that on 7/3/14, she had the abuse training course, Preventing, Recognizing and Reporting Abuse.A review of the administrator's letter dated 1/19/15, indicated that "based on the facility's investigation, the facility cannot substantiate the allegation of abuse. It added that the employee was terminated due to failure to follow instructions that have been repeatedly discussed with the employee."A review of the facility's policy and procedure, Resident Rights, dated August 2009, indicated, employees shall treat all residents with kindness, respect and dignity.The facility's Abuse Prevention Program dated April 2006, indicated, c. " Identification of occurrences and patterns of potential mistreatment/abuse; andi. "The implementation of changes to prevent future occurrences of abuse." This investigation revealed CNA 1 had a pattern of roughly handling residents as per her employee record.The facility failed to ensure: Resident 1 was treated with respect and dignity during provision care and not subjected to rough handling. These violations had a direct relationship to the health, safety or security of the residents. |
| 950000077 |
VICTORIA CARE CENTER |
950013065 |
B |
21-Mar-17 |
3MU411 |
8398 |
483.24, 484.25(k) (l) Provide care/services for highest well-being.
Quality of life is a fundamental principle that applies to all care and services provided to facility residents. Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident?s comprehensive assessment and plan of care.
On 2/23/17, at 10 a.m., an unannounced facility reported incident investigation was conducted at the facility for an unrelated issue.
Based on observations, interviews, and record reviews, the facility failed to:
1. Thoroughly assess Resident 1 for the presence of skin rashes and itching.
2. Treat Resident 1, for a scabies infestation (a condition of very itchy skin caused by tiny mites that burrow into the skin which is easily spread from person to person by close contact, touching one's skin, sharing towels, linens, clothing and other personal items).
A review of the admission record indicated that Resident 1 was admitted to the facility 9/2/16, with diagnoses that included hypertension (high blood pressure), muscle wasting and history of fall. According to the Minimum Data Set (MDS), a standardized assessment tool dated 12/7/16, Resident 1 had the ability to make self-understood and had the ability to understand others. The MDS functional status (activities of daily living), under Section G indicated Resident 1 required extensive assistance for dressing, personal hygiene, bathing, and toilet use. The MDS indicated Resident 1 had no skin problems present.
At 10:30 a.m., on 2/23/17, Resident 1 was observed scratching his left hand vigorously. Resident 1 was observed with dry, scaly and crusted skin between his fingers. During a concurrent interview, with the assistance of Certified Nurse Assistant (CNA) 1, Resident 1 stated he had been scratching his hands for "several weeks." Resident 1 was asked by the Surveyor for permission to visually assess Resident 1's skin in the resident's room. Resident 1 was observed to have several raised reddened spots and black pinpoint scabs on the chest, back and shoulders. According to CNA 1, Resident 1's skin has been so dry that she had been applying body lotion to keep the skin moistened. CNA 1 also stated she was not aware if Resident 1 was receiving any skin treatments.
On 2/23/17, at 11 a.m., the Surveyor accompanied by the Registered Nurse (RN) Supervisor, Licensed Vocational Nurse (LVN) 1 and CNA 2 examined Resident 1. The RN Supervisor and LVN 1 confirmed that Resident 1's front and back of the left ring and little fingers had a heavy encrustation and one point open sore covered with dried blood. The RN Supervisor and LVN 1 described Resident 1's chest, back, and shoulders as having, "raised reddened spots, red papules (small rounded bumps rising from the skin) and black pinpoint scabs." LVN 1 further described the skin on the chest, back and shoulders as, "covered with raised red papules with tracking (blisters and bumps caused by the bites and burrows from the mite). Further observation indicated encrustation on Resident 1's right foot. At this time LVN 1, who was also the treatment nurse, stated that Resident 1 was currently receiving antibiotic (drugs that kill bacteria or slow their growth) treatment for a boil (skin abscess with a collection of pus that forms in the skin) on his armpit. LVN 1 stated that Resident 1 was not on any skin or wound treatment other than the oral (by mouth) antibiotics. In addition, both the RN Supervisor and LVN 1 stated that they did not know what a scabies infestation looked like. They both stated a physician or a Dermatologist (physician that specializes in skin diseases) had not seen Resident 1's skin condition. The RN supervisor agreed to arrange for an immediate physician consultation and had implemented isolation precaution (used to help stop the spread of germs from one person to another) for Resident 1.
A review of Resident 1's Weekly Summary, from 12/11/16 to 2/5/17, indicated Resident 1's skin was assessed as clear and intact. A review of Resident 1's Weekly Summary, dated 2/8/17, indicated Resident 1 was assessed to have a bluish discoloration to the left lower eye area, left cheek bone redness, and a superficial scratch to left lower face secondary to an altercation with another resident. On 2/15/17, Resident 1's Weekly Summary indicated that the skin was clear and intact, no new skin problems noted.
A review of Resident 1's Nurses' Notes from 12/11/16 to 2/23/17 no documentation was found which indicated that Resident 1 had a rash or had been complaining of itching or scratching himself.
During an interview with LVN 2 on 2/23/17, at 12 p.m., LVN 2 stated that skin assessments include a direct observation and assessment of the resident's skin condition from head to toe and should be documented in the weekly summary.
On 2/27/17, at 3 p.m., during a follow up visit to the facility, the Director of Nursing (DON) and Administrator stated that a skin scraping (test used to detect the presence of scabies) was done on Resident 1.
On 2/28/17, at 10 a.m., during a telephone interview the Administrator stated that Resident 1's skin scraping was positive for scabies. He also stated that they have been in communication with the Public Health Nurse.
On 3/1/17, the facility faxed the Physician's Progress Notes dated 2/28/17, that indicated Resident 1 had scabies. The Physician's Progress Notes, indicated multiple treatment modalities (treatment methods that cause a resident's symptoms to improve or worsen) that included Stromectol (medication to be taken by mouth to treat scabies), Elimite cream every week, wash clothes and linens, scabies prophylaxis (a measure taken to maintain health and prevent the spread of disease) to roommates and follow up assessment in two (2) weeks.
On a follow up visit on 3/2/17, at 2:30 p.m., during an interview with the DON, she stated that Resident 1 always had a skin rash since admission. The DON was not able to provide any documentation which indicated the facility's staff had assessed Resident 1 as having a rash prior to the Surveyor's visit.
The facility's policy and procedure titled, "Resident Examination and Assessment," dated 04/2007, indicated, "The purpose of the procedure is to examine and assess the resident for any abnormalities in health status, which provides a basis for the care plan." It also stated, "Notify the physician of any abnormalities such as, but not limited to: wounds or rashes on the resident's skin."
According to Prevention and Control of Scabies in California Long-Term Care Facilities California Department of Public Health Division of Communicable Disease Control in Consultation with Licensing and Certification, March 2008 (Guidelines and recommendations by the California Department of Public Health), Confirmation of Symptomatic Case(s): The diagnosis of typical scabies can be especially difficult in elderly persons living in long term care facilities. Their skin is generally dry and scaly and there may be pre-existing, chronic dermatological conditions for which oral or topical steroids have been prescribed. Usually, the first indication that a scabies infestation is evolving is complaints of itching and new onset of a rash by one or more residents within a period of 5-12 days. Exposed health care workers, volunteers and frequent visitors may also complain of itching and rash at about the same time. Skin scrapings, when performed properly, will almost always be positive in persons suspected of having atypical or crusted scabies. However, newly infested persons are more likely to have typical scabies and skin scrapings, even when repeated several time at different sites, may be negative.
The facility failed to:
1. Thoroughly assess Resident 1 for the presence of skin rashes and itching.
2. Treat Resident 1, for a scabies infestation.
The facility?s failure to thoroughly assess Resident 1for skin rashes and itching and treat Resident 1 for scabies, prolonged Resident 1?s discomfort due to a scabies infestation and had the potential of spreading to other residents, staff and visitors.
This violation presented a direct relationship to the health, safety or security of the residents. |
| 950000019 |
VISTA COVE CARE CENTER AT SAN GABRIEL |
950013198 |
A |
18-May-17 |
2H4H11 |
10516 |
?483.21(b)(3) Comprehensive Care Plans
The services provided or arranged by the facility, as outlined by the comprehensive care plan, must?
(1) Meet professional standards of quality.
?483.25(c) Treatment/Services to Prevent/Heal Pressure Ulcers
Based on the comprehensive assessment of a resident, the facility must ensure
that ?
(1) A resident who enters the facility without pressure sores does not develop pressure sores unless the individual's clinical condition demonstrates that they were unavoidable; and
(2) A resident having pressure sores receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing.
On 4/7/17, at 12:40 p.m., an unannounced visit was made to the facility for a recertification survey.
Based on observation, interview and record review, the facility failed to provide the necessary care and services to prevent pressure ulcer development (localized injury to the skin and underlying tissue usually over a bony prominence as a result of pressure or pressure in combination with shear and or/friction) or worsening of existing pressure ulcers. The facility failed to:
(a) Ensure Resident 10 did not lie on her back directly on the pressure ulcer.
(b) Implement the plan of care to turn and reposition Resident 10 in bed every two hours.
(c) Provide staff in service training for the proper positioning of a resident with pressure ulcer to promote healing and prevent further skin breakdown.
(d) Follow the staff in service training to prevent skin breakdown by positioning the resident every two hours off bony prominence area of the body.
(e) Monitor staff implementation of the in service training in preventing pressure ulcer development.
These failures resulted in Resident 10 developing an avoidable Stage IV pressure ulcer (full thickness tissue loss with exposed bone, tendon or muscle. Slough [yellow, tan, gray, green or brown] or eschar [tan, brown or black] may be present on some parts of the wound bed which often includes undermining and tunneling) to her sacrococcyx (sacral [a triangular shaped bone at the bottom of the spine] coccyx [tailbone]).
Review of Resident 10?s chart revealed that she is a 64 year old female that had been admitted to the facility on XXXXXXX16, without a pressure ulcer. Resident 10's diagnoses included diabetes mellitus (high blood sugar) and hypertension (high blood pressure).
A review of the Change of Condition SBAR (situation background assessment recommendation) indicated Resident 10 was assessed on 7/21/16, with a 3 centimeter (cm) in length (L) by 3 cm in width (W) unstageable pressure ulcer to her coccyx. On 7/29/16, the wound physician's notes indicated the resident's pressure ulcer had progressed to 3.5 cm (L) x 3 cm (W) unstageable sacrococcyx pressure ulcer. On 8/30/16, the sacrococcyx pressure ulcer had progressed to 4.5 cm (L) x 4.5 cm (W) Stage IV pressure ulcer.
A review of the Nursing Home to Hospital Transfer Form, dated 1/23/17, indicated Resident 10 was transferred to acute hospital with Stage IV sacrococcyx pressure ulcer. The resident was transferred to acute hospital due to an abnormal blood test results.
A review of the Nursing Admission/Readmission Data Collection form dated 1/30/17 indicated Resident 10 was readmitted to the facility with 7 cm (L) x 8.5 cm (W) x 3.8 cm (depth) Stage IV pressure ulcer to her sacrococcyx.
A review of the Braden Scale for Predicting Pressure Sore Risk (a nursing tool which uses a scoring system to evaluate a resident's risk of developing a pressure ulcer) indicated Resident 10 scored 15 on 6/14/16 and 11 on 1/30/17. A total score of 10 to 12 indicates a high risk for pressure ulcer development, and 15 to 18 indicates at risk for pressure ulcer development.
A review of the initial and quarterly Minimum Data Set (MDS a standardized assessment and care planning tool) dated 6/21/16 and 3/24/17, indicated Resident 10 was assessed with short term and long term memory recall problems, had no speech, was totally dependent in bed mobility (full staff performance every time during an entire 7 day period) with two persons physical assistance and was incontinent of bowel and bladder (lack of voluntary control over bowel movement and urination).
During multiple observations on 4/5/17, at 7:45 a.m., 8:45 a.m., 9:50 a.m., 10:55 a.m., 11:52 a.m., 12:50 p.m., 1:48 p.m., 2:50 p.m., 3:55 p.m., 4:25 p.m.; and on 4/6/17, at 6:15 a.m., 7:35 a.m., 8:55 a.m., 9:20 a.m., Resident 10 was observed lying on her back in bed with a wound vacuum (draws out fluid from the wound and increases blood flow to the area) attached to her sacrococcyx pressure ulcer. The resident had left sided weakness due to cerebrovascular accident (CVA an interruption of the blood supply to part of the brain) and was nonverbal.
On 4/6/17, at 9:30 a.m., CNA 1 (Certified Nursing Assistant 1) was interviewed in the presence of ADON (Assistant Director of Nursing). CNA 1 stated he was Resident 10?s regular caregiver. He was aware Resident 10 had a pressure ulcer on her sacrococcyx. He had attended an in- service training regarding turning and repositioning the resident every two hours in bed to prevent skin breakdown. CNA 1 stated he was unable to turn and reposition Resident 10 every two hours because he was busy taking care of another resident. CNA 1 stated when the resident lies on the site of the pressure ulcer it would get bigger due to pressure. CNA 1 stated no one told him not to reposition Resident 10 on her back.
During the treatment observation on 4/6/17, at 11:15 a.m., TN 1 (Treatment Nurse 1) measured the pressure ulcer. Resident 10 was observed with 10 cm (L) x 9.2 cm (W) and 1.5 cm in depth Stage IV pressure ulcer to her sacrococcyx. The pressure ulcer had 4 cm undermining from 10 to 2 o'clock. The wound bed had small amount of yellow slough (dead tissue). TN 1 cleansed the sacrococcyx pressure ulcer with Normal Saline (sterile mixture of salt and water), applied foam dressing and clear tape, and attached the canister wound vacuum to the pressure ulcer.
On 4/6/17, at 9:45 a.m., the medical record of Resident 10 was reviewed with MDS 1 (Minimum Data Set Nurse 1). The initial Care Plan for pressure ulcer prevention, dated 6/15/16, indicated Resident 10 was at risk for skin breakdown due to poor mobility, incontinence of bowel and bladder and fragile skin. The Care Plan interventions included turning and repositioning Resident 10 every two hours and as needed while in bed. The Care Plan interventions for unstageable coccyx pressure ulcer dated 7/21/16, unstageable sacrococcyx pressure ulcer dated 7/29/16, and Stage IV sacrococcyx pressure ulcer dated 8/30/16 and 1/30/17, were not revised to indicate which specific side the resident's body should be turned and repositioned every two hours while in bed to prevent further skin breakdown and to promote healing of the pressure ulcer. MDS 1 stated, "I thought repositioning and turning the resident every two hours in bed was enough." He stated when Resident 10 was lying directly on the pressure ulcer it will not heal due to pressure.
On 4/6/17, at 2:45 p.m., an interview with the DON (Director of Nursing) and TN 1 was conducted while reviewing with them the medical record of Resident 10. The DON stated the facility had a written repositioning schedule to turn and reposition, at least every two hours, residents with pressure ulcer and or residents who required assistance in bed mobility. The DON stated Charge Nurse and DSD (Director of Staff Development) were responsible for monitoring the residents repositioning schedule every two hours. TN 1 stated she did not know Resident 10 should not be repositioned on her pressure ulcer. They both stated staff did not have a written or visual monitoring system to ensure a resident with a pressure ulcer was not turned and repositioned directly on a pressure ulcer every two hours while in bed.
On 4/7/17, at 11:15 a.m., the DSD was interviewed in the presence of the DON. The In Service meeting minutes dated 3/9/17, indicated to turn and reposition the resident every two hours off bony prominence areas of the body to prevent skin breakdown. CNA 1 attended the in service training on 3/9/17. The DSD stated she in serviced the CNAs not to reposition the resident directly on the pressure ulcer. The in service training on 3/9/17 did not indicate the CNAs were educated for proper positioning of a resident with pressure ulcer to promote healing and prevent further skin breakdown. The DSD stated she was responsible for spot checking the CNAs if the residents were being turned and repositioned every two hours in bed on all shifts. The DSD stated spot checking of the CNAs should be done every day. She did not spot check CNA 1 to see if Resident 10 was not repositioned on her sacrococcyx pressure ulcer. The DSD stated the last time she spot checked the CNAs was on 3/31/17.
According to Medical Surgical Nursing Ninth Edition pages 186 to 187, "Prevention remains the best treatment for pressure sores. Reposition the patients frequently to prevent pressure sore at least every two hours and every hour in chair. Never position the patient directly on the pressure sore."
For Resident 10, the facility failed to:
(a) Ensure Resident 10 did not lie on her back directly on the pressure ulcer.
(b) Implement the plan of care to turn and reposition Resident 10 in bed every two hours.
(c) Provide staff in service training for the proper positioning of a resident with pressure ulcer to promote healing and prevent further skin breakdown.
(d) Follow the staff in service training to prevent skin breakdown by positioning Resident 10 every two hours off bony prominence area of the body.
(e) Monitor staff implementation of the in service training in preventing pressure ulcer development.
These failures resulted in Resident 10 developing an avoidable Stage IV pressure ulcer (full thickness tissue loss with exposed bone, tendon or muscle. Slough [yellow, tan, gray, green or brown] or eschar [tan, brown or black] may be present on some parts of the wound bed which often includes undermining and tunneling) to her sacrococcyx (sacral [a triangular shaped bone at the bottom of the spine] coccyx [tailbone]).
The above violations presented a substantial probability that death or serious physical harm would result to Resident 10. |
| 950000019 |
VISTA COVE CARE CENTER AT SAN GABRIEL |
950013199 |
A |
18-May-17 |
2H4H11 |
9449 |
?483.21(b)(3) Comprehensive Care Plans
The services provided or arranged by the facility, as outlined by the comprehensive
care plan, must?
(i) Meet professional standards of quality.
?483.25(c) Treatment/Services to Prevent/Heal Pressure Ulcers
Based on the comprehensive assessment of a resident, the facility must ensure that ?
(1) A resident who enters the facility without pressure sores does not develop
pressure sores unless the individual's clinical condition demonstrates that they were
unavoidable; and
(2) A resident having pressure sores receives necessary treatment and services to
promote healing, prevent infection and prevent new sores from developing.
On 4/7/17, at 12:40 p.m., an unannounced visit was made to the facility for a recertification survey.
Based on observation, interview and record review, the facility failed to provide necessary care and services to prevent pressure ulcer development (localized injury to the skin and underlying tissue usually over a bony prominence as a result of pressure or pressure in combination with shear and or/friction). The facility failed to:
(a) Implement the plan of care to offload Resident 17?s heels (take off pressure from the heels, to suspend) when in bed.
(b) Implement the physician's order for the use of a foot cradle on bed (a frame placed over the body of a bed to keep sheets and blankets off Resident 17's feet to provide pressure relief and ventilation to feet) for pressure ulcer management.
(c) Provide staff in service training for the proper positioning of a resident with pressure ulcer to promote healing and prevent further skin breakdown.
(d) Follow the staff in service training to prevent skin breakdown by positioning the resident every two hours off bony prominence area of the body.
(d) Monitor staff implementation of the in service training in preventing pressure ulcer development.
These failures resulted in Resident 17 developing an avoidable, unstageable pressure ulcer (full thickness tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough [yellow, tan, gray, green or brown] and or eschar [tan, brown or black] in the wound bed) to her left lateral (side) heel.
Review of Resident 17?s Admission/Readmission Data Collection dated 9/24/15, revealed that she is a 83 year old female that had been admitted to the facility without a pressure ulcer. Resident 17's diagnoses included dementia (a progressive deterioration of intellectual functions including memory loss) and osteoporosis (brittle bone).
A review of the quarterly MDS, dated 12/30/16, indicated Resident 17 was assessed with short and long term memory recall problems, required total dependence in bed mobility with two person physical assist, and was incontinent (no or insufficient voluntary control over urination or bowel movement) of bowel and bladder.
A review of the Braden Scale for Predicting Pressure Sore Risk (a nursing tool which uses a scoring system to evaluate a resident's risk of developing a pressure ulcer), dated 9/24/15, indicated Resident 17 scored 14 which indicated the resident was at moderate risk of developing pressure ulcer.
A review of the Change of Condition SBAR (situation background assessment recommendation) dated 1/27/17, indicated Resident 17 was assessed with 1 centimeter (cm) in length (L) x 1.5 cm in width (W) deep tissue injury pressure ulcer (DTI purple or maroon localized area of discolored intact skin or blood filled blister due to damage of underlying soft tissue from pressure and/or shear) to her left lateral heel. On 2/28/17, the wound physician notes indicated the resident's pressure ulcer had progressed to 1.1 cm (L) x 2.8 cm (W) unstageable left lateral heel pressure ulcer.
On 4/5/17, at 1:50 p.m., Resident 17 was observed lying on her back in bed. TN 1 lifted the blanket and the resident's heels were observed resting on the mattress. The resident's legs were observed contracted (shortening and hardening of the muscles and tendons often leading to deformity and rigidity of the joints). Her right leg was crossed over the left leg. Her left heel was observed with a dressing. Resident 17 stated her left heel "hurts like hell." Further observation on 4/5/17, at 2:55 p.m., and 4:05 p.m., the resident's heels were still resting on the mattress and there was no foot cradle (a frame placed over the body of a bed to keep sheets and blankets off the resident's feet to provide pressure relief and ventilation to the feet) on bed. On 4/6/17, at 7:40 a.m., 8:50 a.m., and 2:00 p.m., Resident 17's heels were also observed resting on the mattress. The foot cradle was on the resident's bed.
On 4/6/7, at 2:10 p.m., the treatment observation was conducted in the presence of the Assistant Director of Nursing. Resident 17 was observed with an unstageable pressure ulcer to her left lateral heel. TN 1 measured the resident's pressure ulcer 1.5 cm (L) x 2 cm (W). The wound bed had 100 percent yellow green slough. TN 1 cleansed the left lateral heel pressure ulcer with Normal Saline, applied Santyl ointment (debriding ointment), and covered the pressure ulcer with dry dressing.
During an interview on 4/6/17, at 2:28 p.m., CNA 2 stated Resident 17 was totally dependent in bed mobility. She was aware the resident had a pressure ulcer to her left heel. CNA 2 stated no staff member informed her to float Resident 17's left heel on a pillow while in bed. She was informed by a licensed staff (forgot her name) to only put a pillow under the resident's leg for comfort. CNA 2 stated she was not in serviced on how to properly position a resident with pressure ulcer of the heel. CNA 2 stated when the resident's left heel pressure ulcer was resting on the mattress the wound will get bigger and the resident will have pain. She did not know Resident 17 had a physician's order to apply a foot cradle on bed until 4/6/17. CNA 2 stated she was the regular caregiver for Resident 17.
During a record review and concurrent interview with DON and MDS 1 on 4/6/17, at 3:40 p.m., the initial Care Plan for pressure ulcer prevention for Resident 17, dated 9/25/15, indicated Resident 17 was at risk for pressure ulcer related to immobility and incontinence. The Care Plan interventions included positioning the resident with pillows to maintain proper body alignment whenever necessary and to provide pressure relieving device (unspecified). Resident 17 developed deep tissue injury pressure ulcer to her left lateral heel on 1/27/17, and the wound had progressed to unstageable pressure ulcer on 2/28/17. The Care Plan intervention, dated 1/27/17 and 2/28/17, indicated the heels were to be floated when Resident 17 was in bed. On 2/10/17, the physician ordered a foot cradle to be applied on Resident 17's bed for pressure ulcer management. The DON stated that the Charge Nurse and DSD were responsible for monitoring the care given to Resident 17 to ensure the resident's left lateral pressure ulcer was floated on the pillow while in bed. MDS 1 stated that Resident 17 had a foot cradle on bed but he did not know who removed the resident's foot cradle.
On 4/7/17, at 11:15 a.m., the staff in- service training records for pressure ulcer prevention were reviewed with DSD and DON. The In Service Meeting Minutes dated 4/18/16, 7/1/16, 7/20/16, and 3/9/17 did not contain information staff were educated about proper positioning of a resident with pressure ulcer to promote healing and prevent further skin breakdown. There were no lesson plans for the staff in service training of pressure ulcer prevention conducted on the above dates. In addition, the facility had a total of 42 CNAs; however, the DSD stated all CNAs did not receive the training because all of them were not working on the days of the in service. The DSD stated she did not reschedule the in- service training because she got busy. The DSD stated she was aware that the lesson plans were to be done and attached to the in service training sign in sheets but failed to do so.
The facility failed to:
(a) Implement the plan of care to offload the resident's heels (take off pressure from the heels, to suspend) when in bed.
(b) Implement the physician's order for the use of a foot cradle on bed (a frame placed over the body of a bed to keep sheets and blankets off Resident 17's feet to provide pressure relief and ventilation to feet) for pressure ulcer management.
(c) Provide staff in service training for the proper positioning of a resident with pressure ulcer to promote healing and prevent further skin breakdown.
(d) Follow the staff in service training to prevent skin breakdown by positioning the resident every two hours off bony prominence area of the body.
(d) Monitor staff implementation of the in service training in preventing pressure ulcer development.
These failures resulted in Resident 17 developing an avoidable, unstageable pressure ulcer (full thickness tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough [yellow, tan, gray, green or brown] and or eschar [tan, brown or black] in the wound bed) to her left lateral (side) heel.
These violations presented substantial probability that death or serious physical harm would result to Resident 17. |
| 960001274 |
VALLEY VILLAGE PARTHENIA HOUSE |
960009146 |
B |
19-Mar-12 |
VY3E11 |
3556 |
Title 22 76876(a) Medication and treatments shall be given only on the order of a person lawfully authorized to prescribe. On February 5, 2012 a recertification survey was conducted. Based on interview and record review the facility staff failed to: 1. Ensure all medications were given only on the order of a lawfully authorized person. Client 1 received medication that was prescribed by a Qualified Mental Retardation Professional for a total of 2 days.On February 5, 2012 at 9:09 a.m., during a reconciliation of the medication record, it was disclosed that there was a hand written order for Client 1 to receive Keflex 500 mg four times a day for 10 days. Further review of the medication administration record revealed the client began receiving the medication on February 4, 2012 and February 5, 2012 (2 days) without a physician order. On February 5, 2012 during an interview with the Qualified Mental Retardation Professional (QMRP) at 10:30 a.m., she stated she wrote the order Keflex 500 mg for the client to receive to treat "a pimple, boil, or redness on Client 1's thigh." The QMRP stated she spoke to an on call nurse (no name given) who told her to write an order for the client to receive Keflex 500 mg four times a day for 10 days. When the QMRP was asked if the physician or nurse assessed the client before the medication was administered she stated ?No.? The QMRP was then asked if there was a telephone order in the chart which directed her to administer the medication she stated, ?No.? On February 5, 2010 at 10:35 a.m., during an interview with the facility?s assigned registered nurse, she stated the client had not been seen by either the physician or herself. She stated there was an on-call nurse who should have assessed the client. When asked if the client had an appointment to see the physician regarding the redness, boil, and or pimple she stated the appointment for Client 1 to see the physician would be made the following day.Client 1 was admitted to the facility on December 15, 1990 with the diagnosis of Moderate Mental Retardation, and Down syndrome (Chromosome deficiency) The registered nurse was then asked if she directed the QMRP to write the order for the client to receive the medication, she answered, ?No.?On February 5, 2012 at 10:12 a.m., a review of Client 1's health record revealed there was no order from the physician for the client to receive Keflex 500 mg four times a day for 10 days. Additional review of the health records revealed there was no telephone order from the physician for the client to receive Keflex 500 mg four times a day for 10 days. There was also no mention in the records of the client having redness, a boil, or a pimple on the thigh.On February 5, 2012 at 10:15 a.m., during a review of the nursing notes dated February 1, 2012, it was revealed that there was no assessment or mention of redness or pimples, or boils on Client 1's thigh.Review of the facility?s "Medication Administration Policy and Procedure revealed medication shall be administered only on the order of a person lawfully authorized to prescribe. A review of the facility's policy titled "procedure for telephone or verbal orders ?disclosed, "telephone or verbal orders shall be received only from registered nurses. Failure of the facility staff to ensure all medications were given only on the order of a lawfully authorize person placed Client 1 at risk for harm. The above violation had a direct relationship to the health, safety, and security of Client 1. |
| 960002148 |
VALLEY VILLAGE CORBIN HOUSE |
960010498 |
B |
26-Feb-14 |
GGY411 |
3650 |
Health & Safety Code 1418.91 (a)(b) 1418.91 Reports of incidents of alleged abuse or suspected abuse of residents (a) A long-term care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the department immediately, or within 24 hours. (b) A failure to comply with the requirements of this section shall be a Class ?B? violation.On January 7, 2014 at 7:30 a.m., an unannounced visit was made to the facility to conduct a Fundamental Survey. Based on interview and record review, the facility?s administrative staff failed to: 1. Report an allegation of suspected abuse to the Department within 24 hours when Client 1 was noticed to have numerous discolorations on his upper and lower back area, back of the right upper arm and mid-buttock area. Client 1 stated Client 2 pinched him. According to Client 1?s admission record, the client was admitted to the facility on October 28, 1998, with diagnoses that included moderate intellectual disability, history of seizure disorder, and spastic cerebral palsy (a group of disorders that affect a person?s ability to move and maintain their balance and posture with stiff muscles). Client 1 was verbal, able to make his needs known and ambulatory.On January 7, 2014, the Special Incident Reports (SIRs) were reviewed. According to a SIR, dated November 11, 2013 at 7:30 a.m., staff was assisting Client 1 in the shower and noticed numerous discolorations on his upper and lower back , back of the right upper arm and two above the mid buttock area.According to the SIR (hand written by Staff A), dated November 10, 2013, regarding the incident on November 9, 2013 at 9:00 p.m., before Staff A left his work shift, Staff A checked on the clients, in their bedrooms. Client 1 lifted up his shirt and Staff A noticed markings on Client 1?s hip, knee, and leg. Staff A asked Client 1 about the markings. Client 1 told Staff A, Client 2 did it to him. Staff A called the nurse ?on call? and informed her about the incident. Staff A was informed by the nurse to make an incident report and fax it to the corporate office.On January 9, 2014 at 8:07 p.m., during an interview with Client 1, he stated Client 2 scratched and pinched him on his back and the right side of his hip during nighttime, the month of November 2013.On January 9, 2014 at 8:37 p.m., during an interview with Client 2, he stated he scratched Client 1. According to the physician?s documented office visit, dated November 11, 2013, Client 1 was assessed and treated. The physician?s report indicated there were multiple sites with contusions not elsewhere classified, ?I am not clear if this is some sort of an abuse in this patient, lives with other mentally retarded individuals." The report further noted the physician directed the home nurse to check for safety and he ordered x-rays, laboratory test and pain medications. On January 7, 2014 at 2:00 p.m., during an interview with the Qualified Intellectual Disabilities Professional/Administrator (QIDP/ADM), she stated she faxed the incident report to licensing, however she did not have a copy of the fax transmittal nor did she call the Department. There was no supportive documentation provided by the facility that the incident was reported. The facility?s administrative staff failed to: 1. Report an allegation of suspected abuse to the Department within 24 hours when Client 1 was noticed to have numerous discolorations on his upper and lower back area, right upper back arm and mid-buttock area. This failure had a direct relationship to the health, safety and security of Client 1. |
| 960001738 |
VALLEY VILLAGE ALTANO HOUSE |
960012737 |
B |
9-Nov-16 |
None |
2719 |
Health & Safety Code 1265.5 (f) Upon the employment of a 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 September 15, 2016, an unannounced visit was made to the facility for an annual certification survey. The facility failed to ensure fingerprinting clearance for one staff, Staff A, working in the facility was completed prior to having contact with the clients. This failure had the potential of not ensuring the safety and well-being of 12 clients residing in the facility. During a review of the ?Client Roster Information? dated September 15, 2016, it indicated 4 clients with diagnoses of mild intellectual disability (slower in developmental areas but able to learn practical life skills and able to function in daily life), 3 clients with diagnoses of moderate intellectual disability (developmentally functions below chronological age and can learn elementary health and safety habits), 2 clients with diagnoses of severe intellectual disability (considerable delay in development and require daily supervision and support), and 3 clients with diagnoses of profound intellectual disability (significant developmental delays in all areas and incapable of self-care). During a review of Staff A's employee file on September 15, 2016, no documented evidence of criminal clearance through the Department of Justice (DOJ) could be found. The employee file indicated a hire date of August 23, 2016. On September 15, 2016 at 1:40 p.m., a call was made to the Interactive Voice Response Unit for Criminal Clearance. The automated response system disclosed Staff A had no record on file. During a review of the "Request For Live Scan Service" undated, it indicated Staff A?s name was on the form, but the section for the agency completing the live scan was blank. During an interview with the human resources (HR) generalist, on September 20, 2016 at 10:25 a.m., she stated Staff A did not complete the fingerprint clearance. During an interview with the qualified intellectual disability professional (QIDP), on September 20, 2015 at 2:15 p.m., she stated Staff A works Saturdays and Sundays. The facility policy and procedure titled "Employment Requirements" undated indicated fingerprinting is administered by the Organization?s Human Resources Department at no charge to the employee. The employee must receive an acceptable background clearance. Failure to ensure fingerprinting clearance for Staff A had a direct relationship to the health, safety, or security of clients. |
| 960001738 |
VALLEY VILLAGE ALTANO HOUSE |
960012739 |
B |
9-Nov-16 |
None |
5125 |
W&I 4502 (h) Persons with developmental disabilities have the same legal rights and responsibilities guaranteed all other individuals by the United States Constitution and laws and the Constitution and laws of the State of California. No otherwise qualified person by reason of having a development disability shall be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity, which receives public funds. It is the intent of the Legislature that person with developmental disabilities shall have rights including, but not limited to, the following: (h) A right to be free from harm, including unnecessary physical restraint, or isolation, excessive medication, abuse, or neglect. The facility?s staff failed to: Ensure the safety of one client (Client 9) while using the wheelchair lift (mechanical platform designed to raise and lower to allow an individual with a wheelchair to enter and exit a vehicle). The failure of staff not looking where the client was being pushed in the wheelchair, and not waiting for the lift to be raised, resulted in Client 9 falling off the van to the ground. During an observation, on September 16, 2016 at 6:32 p.m., Staff A wheeled Client 8 off the lowered lift from the van and situated Client 8 on the side of the van next to Client 7. Staff A then locked Client 7's wheelchair brake and instructed Client 7 not to unlock his brake. The facility's transportation van was parked inside the day program's parking lot, as the clients were going to participate in the evening dance. During an observation, on September 16, 2016 at 6:34 p.m., Client 9, while seated in his wheelchair, fell backwards off the van, while the lift was still in a lowered position. The wheels and handles of the wheelchair impacted the ground first, then the back of the client's head hit the ground and the wheelchair rolled over to the right side. Staff B fell down from the van just as the client hit the ground. Client 9 sustained a reddened area on the right side of his forehead. During an interview with Staff B, on September 16, 2016 at 6:39 p.m., she demonstrated in the van how the client was facing towards the front seat as she stood in between the client and the front seat. Staff B stated she moved in a forward position as she pushed Client 9 backwards out of the van. Staff B stated she did not look to see if the lift was raised or lowered, and added she thought the lift would be raised because they were ?working fast.? During a review of the "Emergency Department Patient Discharge Instructions" dated September 16, 2016, indicated Client 9 visited the hospital because of a fall, and procedures done at the hospital included a computerized tomography (CT, series of x-ray images taken from different angles of the bones, blood vessels, and soft tissues) scan of the spine and head. During a review of Client 9's Admission Face Sheet, it indicated the client was admitted to the facility with a diagnosis of Profound Intellectual Disability (cognitive ability that is markedly below average level, incapable of self-care). During a review of the "Physical Therapy Assessment" dated August 17, 2016, it indicated continue with use of wheelchair for all community outings for adequate safety. During a review of the "Staff In-service Log" dated June 24, 2016, indicated wheelchair safety was the topic, and the discussion content included proper seatbelt securement on the bus, and proper wheelchair securement with equipment on the bus. The In-service Log indicated Staff B attended the training class. During a telephone interview with Staff C, on September 20, 2016 at 1:05 p.m., he stated he gave the in-service training for wheelchair safety dated June 24, 2016. Staff C stated two staff are involved when using the lift, one staff inside the van or bus, and the other staff outside on the ground. Regarding assisting clients off the van, Staff C stated the person working inside the vehicle needs to wait until the lift is up, and when that happens, that means the other staff is ready. Staff C stated the person working inside the van needs to wait for the second person to say they are ready with the lift raised. During an interview with Staff A, on September 20, 2016 at 3:35 p.m., she stated on the evening of Client 9's fall, she had taken Client 8 off the lift and positioned Client 8 next to Client 7 near the side of the van. Staff A stated she relocked Client 7's brakes and gave instructions in order for him to remain safely in the vicinity. Staff A stated she did not see Client 9 fall as she was not near the back of the van where the lift was located. Staff A also stated it was her usual practice to ensure clients were in a safe situation prior to returning to the lift, for example, when taking clients off the van near a main street. The failure of staff to look where the client was being pushed in the wheelchair and to wait for the wheelchair lift to be raised had a direct relationship to the health, safety and security of the client. |
| 910000016 |
VERMONT HEALTHCARE CENTER |
910013370 |
A |
2-Aug-17 |
YSBE11 |
10463 |
F 323
?483.25 (h) Accidents
The facility must ensure that -
(1) The resident environment remains as free from accident hazards as is possible: and
(2) Each resident receives adequate supervision and assistance devices to prevent accidents.
The facility failed to ensure the residents' environment remained as free from accident hazards as was possible; and each resident received adequate supervision and assistance devices to prevent accidents, including but not limited to:
1. Failure in providing adequate supervision, with the use of an assistance device, during transfer of Resident 1.
2. Failure to follow Resident 1's Physical Therapy (PT) and the Interdisciplinary Team's ([IDT] a team or group of people from different disciplines who work together towards a common goal of a resident) recommendations for the use of a lifting device during transferring.
This deficient practice resulted in Resident 1 sustaining a left ankle fracture (broken bone) requiring a transfer to the general acute care hospital (GACH) and undergoing a surgical procedure to repair the fracture (a break in continuity of bone). Resident 1 was hospitalized for seven (7) days and received intravenous ([IV] through the vein) and by mouth narcotic pain medications and antibiotics (medication used to treat infections).
On 9/7/16, at 7 a.m., an unannounced visit for an Entity Reported Incident (ERI) was conducted. The ERI indicated Resident 1 sustained a fracture to the left leg on 8/15/16.
A review of Resident 1's Admission Face Sheet indicated the resident was a 79 year-old female who was initially admitted to the facility on 4/30/10, and re-admitted on 8/24/16. Resident 1's diagnoses included unspecified poly-osteoarthritis (joint disease causing pain and stiffness), generalized muscle weakness, lack of coordination, atrial fibrillation (a quivering or irregular heartbeat that can lead to blood clots) requiring Coumadin administration (a blood thinner), and severe morbid obesity.
A review of Resident 1's Minimum Data Set (MDS), a standardized resident assessment and care-screening tool, dated 6/7/16, indicated Resident 1 was alert with a Brief Interview for Mental Status (BIMS) score of 15 (9-15= interviewable) and had no cognitive (mental) impairment for daily decision-making. According to the MDS, Resident 1 required a two + (plus) person physical assist in transferring between bed, chair, and wheelchair. The MDS, under Section G 0300, indicated Resident 1 was non-ambulatory, not steady moving from seated to a standing position, and required use of a wheelchair.
A review of Resident 1's Weights and Vitals Summary indicated the resident weighed 261 pounds on 8/9/16 (six days prior to the incident).
A review of Resident 1's care plan titled, "High Risk for Spontaneous / Pathological Fracture (the breaking of a bone) due to Osteopenia (bone loss)," dated 7/28/16, indicated the staff's plan of approach included to handle Resident 1 gently when moving the resident and report any pain, redness, and/or swelling of the extremities to the physician promptly.
A review of Resident 1's History and Physical (H/P), dated 2/2/16, indicated Resident 1 had the capacity to understand and make decisions. The H/P indicated Resident 1 was in the facility "for residency" due to mobility issues related to bilateral (both) knee osteoarthritis (OA).
A review of the Physical Therapy (PT) Progress and Discharge Summary, dated 2/27/16, and timed at 7:31 p.m., indicated Resident 1's current level with sit-stand transfers required a maximum assist with two people.
A review of Resident 1's Interdisciplinary Team Conference Record, dated 4/2/16, indicated the team addressed Resident 1's risk for falls with the potential for injury. The IDT Record indicated Resident 1's Fall Risk Assessment score was 11 (a score above 10 indicated a high risk for falls). The IDT concluded Resident 1 exhibited poor safety awareness, weakness, and joint pain and recommended for the CNAs to be taught the proper use of lift devices for transferring.
A review of a Situation Background Assessment Request (SBAR) Communication Form, dated 8/17/16, indicated on 8/16/16, Resident 1 had swelling and pain to the left ankle. Resident 1 had complaints of a pain level of five out of 10 (10 being the worst level of pain).
During an interview on 9/12/16 at 9:19 a.m., Certified Nursing Assistant 1 (CNA 1) stated she would normally use a standing lift device to transfer Resident 1 from one surface to another, but stated the standing lift device battery was charging at the time the resident wanted to be transferred. CNA 1 stated she and two other CNAs (CNA 2 and 3) manually transferred the resident back to bed on 8/16/16. CNA 1 stated she and CNA 2 lifted Resident 1 under the arms, while CNA 3 guided the wheelchair from behind during the transfer from the wheelchair to the bed. Resident 1 yelled out, "my feet." CNA 1 stated they lifted the resident's feet in the bed and informed the charge nurse of the resident's complaints of pain.
At 9:41 a.m., on 9/12/16, CNA 2 stated Resident 1 required a standing lift for transfers; however, the battery was low and was charging at the time the resident wanted to be transferred back to the bed. CNA 2 stated she called for assistance of CNA 1 and CNA 3 helped to transfer Resident 1. CNA 2 stated Resident 1 began to yell out, "My feet," during the transfer and they placed the resident in bed and called the charge nurse.
On 9/12/16 at 10:03 a.m., during an interview, CNA 3 stated she assisted with transferring Resident 1 back to bed on 8/16/16. CNA 3 stated she normally used the standing lift machine to transfer Resident 1, because she was "heavy" and she (CNA 3) could not personally lift the resident. CNA 3 stated she, and CNAs 1 and 2 helped to transfer the resident. However, Resident 1's legs never moved and the resident yelled out "My leg."
A review of a Physician's Order, dated 8/17/16, and timed at 6:55 a.m., indicated to do an x-ray of Resident 1's left ankle due to the complaint of pain.
During an interview on 9/12/16 at 9:56 a.m., a Licensed Vocational Nurse (LVN 1) stated she assessed Resident 1 after the incident (on 8/16/16) and administered pain medication. LVN 1 stated she asked the on-coming nursing staff on the 3 p.m. - 11 p.m. shift, to continue to monitor Resident 1. LVN 1 stated Resident 1 began to experience swelling on the 11 p.m. - 7 a.m. shift and an x-ray was ordered and done the following morning.
On 9/12/16 at 1:13 p.m., during an interview, Resident 1 stated she was dropped on her leg. Resident 1 stated, "The bed rail fell on my leg and busted my leg pretty good. This resulted in being transferred to the hospital (GACH) for an operation."
A review of the Licensed Nurse Progress Record, dated 8/16/16, and timed at 3 p.m., indicated Resident 1 had complaints of pain at a level of eight out of 10 to the left ankle, with redness and swelling. The note indicated the pain was relieved after receiving Norco (narcotic pain medication).
A review of the Physician Progress Note, dated 8/16/16, and timed at 3:30 p.m., indicated Resident 1 was seen and examined by the physician for concerns of a left ankle injury while being transferred from the chair to the bed. The resident struck her ankle along the metal part of the bed, causing immediate pain and swelling that was minimally improved with Norco. The physician documented the left ankle pain was secondary to a sprain (an injury to muscles or tendons) and doubted the resident sustained a fracture due to a recent negative x-ray on 7/28/16.
A review of Resident 1's x-ray results, dated 8/17/16, indicated Resident 1 sustained fragmented displaced fractures involving distal shafts of the left tibia and fibula (two bones of the lower leg).
A review of a Physician's Order, dated 8/17/16, and timed at 2:50 p.m., indicated to transfer Resident 1 to the GACH for a left lower leg fracture.
A review of the GACH's Emergency Room records, dated 8/17/16, indicated Resident 1 presented to the hospital with left leg pain and deformity, and was diagnosed with a left mid-shaft oblique tibia fracture ([oblique fracture] a fracture that may be caused by trauma, twisting, or spasm) after a fall during a transfer from the wheelchair to bed. Resident 1 was taken to the operating room on 8/19/16 and underwent an intramedullary nail placement (a metal rod placed within the cavity of a bone used to treat fractures). According to the GACH's inpatient progress note, dated 8/23/16 and timed at 1:20 p.m., Resident 1 required intravenous ([IV] through the vein) narcotic pain medication (Morphine Sulfate), and other narcotic pain medication by mouth (Norco) to control the post-surgical pain and IV antibiotics (medication to treat infections).
A review of the GACH's Inpatient Wound Care Progress Note, dated 8/18/16, and timed at 11:21 a.m., indicated Resident 1 began crying and stated "they might cut her left leg." Resident 1 had a splint (metal used to support and immobilize a broken bone) to the left lower leg.
A review of the GACH's Inpatient Progress Note, dated 8/19/16, and timed at 9:28 a.m., indicated Resident 1 felt "lousy (bad, miserable)" coming out of the operating room (OR) and her pain level was 10 out of 10.
A review of the GACH's Discharge Summary, dated 8/24/16, and timed at 2:09 p.m., indicated Resident 1 was discharged from the GACH on 8/24/16 (seven days after admission) back to the skilled nursing facility.
A review of the facility's undated policy and procedure titled, "Hoyer Lift," indicated the purpose of the policy was to move and lift a resident safely and prevent injuries to staff members.
The facility failed to ensure the residents' environment remained as free from accident hazards as was possible; and each resident received adequate supervision and assistance devices to prevent accidents, including but not limited to:
1. Failure in providing adequate supervision, with the use of an assistance device, during transfer of Resident 1.
2. Failure to follow Resident 1's Physical Therapy (PT) and the Interdisciplinary Team's recommendations for the use of a lifting device during transferring.
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. |
| 970000050 |
VERNON HEALTHCARE CENTER |
940013037 |
B |
10-Mar-17 |
7ZJH11 |
3971 |
42 CFR 483.25 Quality of Care
Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident?s comprehensive assessment and plan of care.
Based on interview and record review, the facility staff failed to implement an effective and timely pain management for Resident 4 by failing to:
1. Administer a sleeping medication to Resident 4, as requested by the resident, to relieve his insomnia (inability to sleep) secondary to his joint pain.
Resident 4 alleged that he was ignored when he requested his sleeping pill from the licensed vocational nurse (LVN 1). This deficient practice resulted in Resident 4 complaining of inability to sleep secondary to his joint pain.
On 1/31/17 at 2:28 p.m., during a group meeting, Resident 4 stated that licensed vocational nurse (LVN 1) did not give him a sleeping pill on the night of 1/30/17. Resident 4 stated that LVN 1 ignored his request to obtain a sleeping pill. Resident 4 stated that LVN 1 withheld administration of his and other residents? medications. Resident 4 stated that he notified LVN 5 who gave him his sleeping pill.
On 1/31/17 at 6:21 p.m., during an interview, the director of nurses (DON) stated that she was not notified by LVN 1 and LVN 5 regarding Resident 4 not receiving the medication to treat the resident?s insomnia when Resident 4 requested it. The DON stated that LVN 5 did not notify her that LVN 1 did not administer Resident 4 the insomnia medication.
On 2/2/17 at 6:05 p.m., during an interview, LVN 6 stated that Resident 4 complained of inability to sleep secondary to his joint pain.
On 2/2/17 at 6:40 p.m., during an interview, the director of staff development (DSD) stated that LVN 1 was assigned to Resident 4 on 1/30/17.
A review of Resident 4's Admission Record indicated the resident was a 64-year-old male, who was admitted to the facility on 1/8/17 with the diagnoses that included fracture of the sacrum (a break in the sacrum [a large triangular bone, it is the base of the spine and connects to the pelvis]), and osteoarthritis (degeneration of joint cartilage and the underlying bone, most common from middle age onward, it causes pain and stiffness, especially in the hip, knee, and thumb joints).
A review of Resident 4's Initial History and Physical, dated 1/10/17, indicated Resident 4 had the capacity to understand and make decisions.
A review of the Resident 4's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 1/16/17, indicated Resident 4 was cognitively intact and required extensive assistance (resident involved in activity; staff provide weight-bearing support) for transfers with one person physical assist.
A review of Resident 4's physician's orders, dated 1/27/17, indicated to give the resident Vistaril (a medication used to treat insomnia or inability to sleep) 25 milligrams (mg) as needed for insomnia.
A review of Resident 4's care plan titled "Insomnia," dated 1/27/17 indicated Resident 4 had a history of insomnia. The interventions included to administer medications as needed (PRN).
A review of Resident 4's medication administration record (MAR) indicated the resident did not receive Vistaril on 1/27/17, 1/28/17, 1/29/17, 1/30/17, and 1/31/17.
A review of the facility?s policy and procedure titled ?Pain Management,? revised on 11/2016, indicated the Nursing staff will implement timely interventions to reduce increase in severity of pain.
The facility staff failed to implement an effective and timely pain management for Resident 4 by failing to:
1. Administer a sleeping medication to Resident 4, as requested by the resident, to relieve his insomnia (inability to sleep) secondary to his joint pain.
This violation had a direct or immediate relationship to the health, safety, or security of Resident 4. |
| 970000050 |
VERNON HEALTHCARE CENTER |
940013034 |
B |
10-Mar-17 |
7ZJH11 |
5885 |
483.12(c) (1)-(4)
(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must:
(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures.
(2) Have evidence that all alleged violations are thoroughly investigated.
(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress.
(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.
483.12(b) The facility must develop and implement written policies and procedures that:
(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property,
(2) Establish policies and procedures to investigate any such allegations, and
(3) Include training as required at paragraph ?483.95,
Based on interview and record review, the facility failed to ensure that an allegation of verbal abuse reported by Resident 8?s family members against certified nursing assistant (CNA) was investigated and reported immediately to the administrator and to the Department (Licensing and Certification Program) as indicated in the facility?s abuse policy and procedures.
These failures had a potential to jeopardize the safety of Resident 8, and had a potential for reoccurrence of verbal abuse.
On 2/1/17 at 12:56 p.m., family member 1 (FAM 1), stated during a telephone interview that Resident 8 stated that CNA 2 yelled loudly and said derogatory words at Resident 8 on 1/6/17. FAM 1 and FAM 2 stated that they reported this allegation on 1/6/17 to the social service staff.
A review of Resident 8's Admission Record indicated that Resident 8 was initially admitted to the facility on 11/15/16 and was re-admitted on 12/28/16 with diagnoses that included dementia (a progressive deterioration of mental and physical functioning) with behavioral disturbance, and major depressive disorder (a persistent feeling of sadness and loss of interest).
A review of Resident 8's history and physical dated 12/29/16 indicated that Resident 8 did not have the capacity to understand and make decisions.
A review of Resident 8's Minimum Data Set (MDS, an assessment and care screening tool), dated 12/21/16, indicated that Resident 8 was severely impaired in cognitive skills for daily decision-making and required extensive assistance from staff for activity of daily living (ADLs).
A review of Resident 8's Grievance Complaint form dated 1/6/17 indicated that Resident 8's FAM 1 reported verbal misconduct of CNA 2 to social service staff.
On 1/31/17 at 5:42 p.m., social service staff (SS), stated that FAM 1 and FAM 2 had allegations of CNA 2 verbal misconduct towards Resident 8. SS stated that the allegations were not reported to the department and were not investigated. SS stated that the allegations of verbal misconduct of CNA 2 towards Resident 8 did not need to be investigated because she believed it was not abuse.
On1/31/17 at 6:24 p.m., the administrator (ADM), stated that he was the abuse coordinator. ADM stated he reviewed Resident 8's grievance record, and determined that FAM 1 and FAM 2's complaint regarding verbal misconduct was not considered abuse. ADM stated he did not Report FAM 1 and FAM 2's complaint about CNA 2 towards Resident 8 to the State Survey Agency (Licensing and Certification).
A review of 11/2016, facility's revised policy and procedures titled "Abuse- Reporting and Investigations," indicated the facility will report all allegations of abuse as required by law and regulations and promptly and thoroughly investigate reports of resident abuse, mistreatment, neglect, exploitation, misappropriation of resident property or injuries of unknown source. The policy and procedure indicated that if the allegations of abuse is allegedly caused by a resident, who had been diagnosed with dementia, and a Licensed Nurse reasonably determines that there is no serious bodily injury, the Administrator or his/her representative, will immediately notify, by telephone, the Ombudsman or law enforcement agency. In addition, a written report will be made to the local Ombudsman or law enforcement agency and the California Department of Public Health (Licensing and Certification) within 24 hours. The facility's policy and procedure also indicated that the individual who was conducting the investigation will consult daily with the Administrator concerning progress/findings of the investigation.
The facility failed to ensure that an allegation of verbal abuse reported by Resident 8?s family members against CNA was investigated and reported immediately to the administrator and to the Department as indicated in the facility?s abuse policy and procedures.
These failures had a potential to jeopardize the safety of Resident 8, and had a potential for reoccurrence of verbal abuse.
The above violation had a direct or immediate relationship to the health, safety, and security of Resident 8. |
| 970000050 |
VERNON HEALTHCARE CENTER |
940013031 |
B |
10-Mar-17 |
7ZJH11 |
8169 |
42 CFR 483.10 (g)(14)(i)(A)-(D) Notification of Changes.
(i) A facility must immediately inform the resident; consult with the resident?s physician; and notify, consistent with his or her authority, the resident representative(s) when there is-
(A) An accident involving the resident which results in injury and has the potential for requiring physician intervention;
(B) A significant change in the resident?s physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications);
(C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment)
(D) A decision to transfer or discharge the resident from the facility as specified in ?483.15(c)(1)(ii).
42 CFR 483.12(a)(1)
The facility must not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion.
42 CFR 483.25 Quality of Care
Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident?s comprehensive assessment and plan of care.
Based on observation, interview, and record review, the facility failed to provide the ordered and necessary care and services and ensure staff neglect did not occur to Resident 9 by failing to:
1. Ensure the licensed vocational nurse (LVN 8) notified Resident 9?s attending physician that the ordered urine test on 1/29/17 for the resident was not done because the resident refused to give a urine specimen.
2. Send to the laboratory for analysis the urine specimen obtained from Resident 9 on 2/3/17 via in and out straight catheter (an invasive procedure by placing a urinary catheter tube in the body to drain and collect urine from the bladder).
Resident 9, who had hematuria (blood in urine), did not have his urine specimen collected as ordered by the physician on 1/29/17. On 2/3/17, the physician made another order for urinalysis (a laboratory test to analyze the urine for infection and other diseases) and to collect the specimen by an in and out straight catheter. The urine specimen obtained from the resident was not sent to the laboratory for analysis. The physician made another order on 2/6 /17 (eight days after the initial order on 1/29/17) and the resident had to give a urine specimen again via in and out straight catheter.
This deficient practice resulted in Resident 9 experiencing an invasive procedure, the in and out straight catheterization, twice, which led to discomfort, due to staff neglect; a delay in diagnosing the cause of hematuria; and delayed intervention that had the potential to jeopardize the resident's health.
A review of Resident 9's Admission Record indicated the resident was an 82-year-old male, who was admitted to the facility on 3/3/15 and readmitted to the facility on 2/25/16 with diagnoses that included history of cellulitis (a serious bacterial infection characterized by skin redness that tends to expand, tenderness, pain, and warmth) of the right toe, dementia (loss of brain function that affects memory, thinking, language, judgement, and behavior), and anemia (a condition of having lower than normal number of red blood cells in the body).
A review of Resident 9's SBAR (Situation, Background, Appearance, Review and notify ? a tool to share patient information in a clear, complete, concise and structured format) Communication Form, dated 11/18/16 indicated that Resident 9 had a change of condition and was evaluated as having hematuria (blood in the urine). Resident 9 received oral antibiotics after the urinalysis result came out positive for infection.
A review of Resident 9?s Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 12/6/16 indicated the resident was usually able to verbalize needs when prompted or given time, responds adequately to simple direct communication, and was moderately impaired (decisions poor; cues/supervision required) in cognitive skills for daily decision making. The MDS indicated the resident required extensive assistance (resident involved in activity; staff provide weight-bearing support) from the staff in bed mobility, and personal hygiene and was frequently incontinent (having no or insufficient voluntary control over urination) of urine.
A review of Resident 9?s SBAR Communication Form, dated 1/29/17, indicated Resident 9 had an amber colored urine (darker than yellow). The SBAR Form indicated that the attending physician was notified and the physician ordered a urinalysis with culture and sensitivity to rule out infection.
On 2/2/17, at 9 a.m., during an interview and a concurrent record review with the medical records director (MRD), Resident 9's clinical records (chart) from 1/29/17 to 2/2/17 did not indicate documented evidence that the physician order, dated 1/29/17, to collect the urine specimen of Resident 9 was implemented and that the urine specimen was sent to the facility's laboratory for analysis.
On 2/2/17, at 9:30 a.m., LVN 8 stated he attempted to collect the urine of Resident 9 on 1/29/17 by asking the resident to urinate in the specimen cup but Resident 9 refused several times. LVN 8 stated he did not notify the attending physician that the urine was not collected from Resident 9 because he assumed that the charge nurse or the nurse supervisor will notify the physician. LVN 8 stated he did not attempt to get an order from the physician to collect Resident 9's urine via an in and out straight catheterization knowing Resident 9 was incontinent and was unable to urinate independently.
On 2/6/17, at 2 p.m., during an interview, the registered nurse (RN 2) stated they notified the attending physician on 2/3/17 (five days after the initial physician order, dated 1/29/17) that Resident 9 urinalysis test ordered on 1/29/17 was not done. RN 2 stated that the physician ordered to collect the resident's urine specimen via in and out straight catheterization on 2/3/17. However, RN 2 was unable to find the urinalysis result collected on 2/3/17 in the resident's clinical record.
On 2/6/17, at 3 p.m., during an interview, RN 2 stated she found out that Resident 9's urine specimen was not sent out to the laboratory for analysis. RN 2 stated she found Resident 9's urine specimen, collected on 2/4/17, via straight catheterization, still stored in the facility's specimen refrigerator. RN 2 stated she instructed LVN 9 to collect from Resident 9 another urine specimen that day (2/6/17) via straight catheterization because the urine specimen (collected on 2/4/17) was already old.
A review of the facility?s policy and procedure titled, ?Refusal of Treatment,? revised on 1/1/12, indicated the attending physician will be notified of refusal of treatment in a timeframe determined by the resident?s condition and potential serious consequences of the refusal.
A review of the facility?s policy and procedure titled, ?Abuse-Prevention Program,? revised on 11/2016, indicated the facility does not condone any form of resident abuse, neglect and/or mistreatment and develops Facility policies, procedures, training programs, and systems in order to promote an environment free from abuse and mistreatment.
The facility failed to provide the ordered and necessary care and services and ensure staff neglect did not occur to Resident 9 by failing to:
1. Ensure the licensed vocational nurse (LVN 8) notified Resident 9?s attending physician that the ordered urine test on 1/29/17 for the resident was not done because the resident refused to give a urine specimen.
2. Send to the laboratory for analysis the urine specimen obtained from Resident 9 on 2/3/17 via in and out straight catheter (an invasive procedure by placing a urinary catheter tube in the body to drain and collect urine from the bladder).
These violations had a direct or immediate relationship to the health, safety, or security of patients. |
| 970000050 |
VERNON HEALTHCARE CENTER |
940013039 |
B |
10-Mar-17 |
7ZJH11 |
10195 |
483.12(a)(1)
The facility must not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion.
483.12(a)(3)(i-iii)(4)(c)(1)-(4)
(a) The facility must-
(3) Not employ or otherwise engage individuals who-
(i) Have been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law;
(ii) Have had a finding entered into the State nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property; or
(iii) Have a disciplinary action in effect against his or her professional license by a state licensure body as a result of a finding of abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property.
(4) Report to the State nurse aide registry or licensing authorities any knowledge it has of actions by a court of law against an employee, which would indicate unfitness for service as a nurse aide or other facility staff.
(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must:
(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures.
(2) Have evidence that all alleged violations are thoroughly investigated.
(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress.
(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.
483.12(b)(1)(2), 483.95(c)(2)
(b) The facility must develop and implement written policies and procedures that:
(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property,
(2) Establish policies and procedures to investigate any such allegations, and
(c)(2) Procedures for reporting incidents of abuse, neglect, exploitation, or the misappropriation of resident property.
On 1/28/17 at 9:52 a.m., an unannounced visit was made to the facility to investigate an allegation of staff to resident physical abuse involving an unknown resident and that the DSD (Director of Staff Development) was made aware and did not do anything.
Based on observation, interview, and record review, the facility failed to implement its policy and procedures on Abuse by failing to:
1. Promptly and thoroughly investigate all allegations of abuse including, but not limited to, physical and verbal abuse and mistreatment.
2. Report immediately to the administrator of the facility and to the Department (Licensing and Certification Program) immediately (as soon as possible) but not to exceed 24 hours after discovery of the incident) or within 24 hours of the knowledge of the allegations of abuse.
3. Report the findings of all abuse investigations to the Department in accordance with the facility's policy and procedure.
4. Screen all nurse aide employees against the State Nurse Aide Registry.
5. Protect and prevent further potential abuse or mistreatment.
Resident 2 alleged that CNA 1 rough handled him like a football during transfer from wheelchair to bed on 1/26/17. Resident 2 stated that the DSD was made aware of the abuse incident on 1/27/17. The DSD did not investigate and did not report the abuse allegation involving CNA 1 to the Administrator and to the Director of Nursing (DON).
A review of Resident 2's record titled, ?Face Sheet (admission record)? indicated Resident 2 was a 66 year old male admitted to the facility on 3/17/06, and was readmitted to the facility on 3/07/16 with diagnoses that included severe morbid obesity and hemiplegia (paralysis of one side of the body).
A review of Resident 2's history and physical dated 3/10/16 indicated Resident 2 had the capacity to understand and make decisions.
A review of Resident 2's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 12/7/16, indicated Resident 2 was cognitively intact and required one person assist with transfers.
On 1/28/17 at 2:55 p.m., Resident 2 was awake sitting on a wheelchair (w/c) outside in the patio area. Resident 2 stated that CNA 1 rough handled him like a football during transfer from w/c to bed on 1/26/17. Resident 2 stated that DSD was notified of the abuse incident on 1/27/17.
On 1/28/17 at 3:23 p.m., the DSD stated that Resident 2 informed him on 1/27/17 that Resident 2 did not want CNA 1 to be assigned to Resident 2. DSD stated that Resident 2 requested a female CNA. DSD stated he did not investigate the reason as to why Resident 2 did not want CNA 1 to be assigned to him. DSD stated he only reassigned CNA 1 to a different resident assignment. DSD stated he did not report CNA 1 to the Administrator and to the DON. DSD stated that Resident 2?s abuse allegation was not reported to the Department.
On 1/28/17 at 3:50 p.m., during an interview, DON stated that she was not aware of Resident 2?s allegation of abuse regarding CNA 1. DON stated she did not know regarding Resident 2?s abuse allegation and it was not reported to the Department.
On 1/31/17, at 5 p.m., during a concurrent review of CNA 1's personnel files and interview, the DSD stated he was responsible for obtaining certificates, licenses, and background checks prior to employing CNAs. The DSD stated that background checks consisted of criminal record verification and an OIG (Office of the Inspector General) exclusion list. The DSD stated he was not aware of the "State Nurse Aide Registry." During the review of CNA 1's personnel files there was no documented evidence that the DSD verified CNA 1's status against the State Nurse Aide Registry and the Licensing and Certification Verification (L&C) website of the Department. The DSD stated he does not print out the page of the L&C Verification Detail Page at the CDPH (California Department of Public Health) website after he verified if the certificate of a CNA is active or not because it was a waste of paper.
On 1/31/17 at 6:21 p.m., during an interview, the Administrator stated that he was the abuse coordinator and was not aware of Resident 2?s abuse allegation and was not reported to the Department.
A review of the facility's policy and procedure titled, "Abuse- Prevention Program," revised November 2016 indicated, ?Facility promotes an environment free from abuse and mistreatment.? Screening/Hiring Protocols: (A) The Facility conducts criminal background checks prior to hiring an applicant. (D) The license or certification from the appropriate issuing board is checked for an active and unencumbered license or certification prior to hire. (E) The Facility does not knowingly employ individuals who have had a disciplinary action taken against his/her professional license by a state licensure body as result of a finding of abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property.
The facility?s policy titled, ?Abuse-Prevention Program,? revised November 2016 did not indicate on how the facility staff was to identify any suspicious bruising of residents, occurrences, patterns, and trends that may constitute of abuse. The same policy did not indicate on how staff was to protect and prevent further potential abuse or mistreatment while the investigation is in progress.
A review of the facility's policy and procedure titled, "Abuse- Reporting and Investigations," revised 11/2016 indicated the facility will report all allegations of abuse as required by law and regulations and promptly and thoroughly investigate reports of resident abuse, mistreatment, neglect, exploitation, misappropriation of resident property or injuries of unknown source.
The policy and procedure indicated that if the allegations of abuse is allegedly caused by a resident, who had been diagnosed with dementia, and a Licensed Nurse reasonably determines that there is no serious bodily injury, the Administrator or his/her representative, will immediately notify, by telephone, the Ombudsman or law enforcement agency. In addition, a written report will be made to the local Ombudsman or law enforcement agency and the California Department of Public Health (Licensing and Certification) within 24 hours.
The policy and procedure indicated that the individual who was conducting the investigation will consult daily with the Administrator concerning progress/findings of the investigation.
Therefore, the facility staff failed to implement its policy and procedures on Abuse by failing to:
1. Promptly and thoroughly investigate all allegations of abuse including, but not limited to, physical and verbal abuse and mistreatment.
2. Report immediately to the administrator of the facility and to the Department (Licensing and Certification Program) immediately (as soon as possible but not to exceed 24 hours after discovery of the incident) or within 24 hours of the knowledge of the allegations of abuse.
3. Report the findings of all abuse investigations to the Department in accordance with the facility's policy and procedure.
4. Screen all nurse aide employees against the State Nurse Aide Registry.
5. Protect and prevent further potential abuse or mistreatment.
These violations had a direct or immediate relationship to the health, safety, or security of Resident 2. |
| 970000050 |
VERNON HEALTHCARE CENTER |
940013036 |
A |
10-Mar-17 |
7ZJH11 |
28714 |
42 CFR 483.10 (g)(14)(i)(A)-(D) Notification of Changes.
(i) A facility must immediately inform the resident; consult with the resident?s physician; and notify, consistent with his or her authority, the resident representative(s) when there is-
(A) An accident involving the resident which results in injury and has the potential for requiring physician intervention;
(B) A significant change in the resident?s physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications);
(C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment)
(D) A decision to transfer or discharge the resident from the facility as specified in ?483.15(c)(1)(ii).
42 CFR 483.12(a)(1)
The facility must not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion.
42 CFR 483.12(c)(1)-(4)
(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must:
(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures.
(2) Have evidence that all alleged violations are thoroughly investigated.
(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress.
(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.
42 CFR 483.12(b)(1)-(3), 483.95(c)(1)(2)
(b) The facility must develop and implement written policies and procedures that:
(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property,
(2) Establish policies and procedures to investigate any such allegations, and
(3) Include training as required at paragraph ?483.95,483.95(c) Abuse, neglect, and exploitation. In addition to the freedom from abuse, neglect, and exploitation requirements in ? 483.12, facilities must also provide training to their staff that at a minimum educates staff on-
(c)(1) Activities that constitute abuse, neglect, exploitation, and misappropriation of resident property as set forth at ? 483.12.
(c)(2) Procedures for reporting incidents of abuse, neglect, exploitation, or the misappropriation of resident property.
?Neglect? means failure to provide good and services necessary to avoid physical harm, mental anguish, or mental illness (42 CFR ? 488.301).
42 CFR 483.25 Quality of Care
Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident?s comprehensive assessment and plan of care.
42 CFR 483.25 (f)(1)ÿ Mental and Psychosocial functioning.
Based on the comprehensive assessment of a resident, the facility must ensure that?
(1) A resident who displays mental or psychosocial adjustment difficulty, receives appropriate treatment and services to correct the assessed problem.
42 CFR 483.75(l)(1) Clinical Records
(1)The facility must maintain clinical records on each resident in accordance with accepted professional standards and practices that are complete; accurately documented; readily accessible; and systematically organized.
The clinical record must contain sufficient information to identify the resident; a record of the resident's assessments; the plan of care and services provided; the results of any preadmission screening conducted by the State; and progress notes.
On 1/28/17 at 9:52 a.m., an unannounced visit was conducted at the facility to investigate an anonymous complaint regarding a resident, who was put on her stomach while in bed and later died.
Based on observation, interview, and record review, the facility failed to provide Resident 10 with the necessary care and services to attain or maintain the highest practicable physical, mental, psychosocial well-being, in accordance with comprehensive assessment and plan of care; to conduct a comprehensive assessment during a change of condition; to ensure that Resident 10 received proper treatment and care for mental health disorders; to not abuse residents; to immediately inform and consult with the resident's physician when there was a change in the resident's physical, mental or psychosocial status; to develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents; and to thoroughly investigate all alleged violations involving abuse, neglect, or mistreatment; including but not limited to, failures to:
1. Conduct an assessment during a change of condition in Resident 10?s behavior manifested by agitation and screaming, and episodes of three unwitnessed falls from the bed.
2. Ensure licensed nurses and certified nursing assistants (CNAs) provided appropriate care and interventions to manage Resident 10?s aggressive behavior.
3. Notify Resident 10?s attending physician of the resident?s change of condition in behavior and the episodes of three unwitnessed falls in order to implement appropriate care and interventions for the resident.
4. Prevent staff-to-resident neglect and mistreatment by providing training to facility staff on how to manage aggressive behaviors of a mentally ill, obese person.
5. Ensure that all alleged violations involving neglect and mistreatment are reported by the staff immediately, but not later than 2 hours after the allegation is made to the administrator of the facility, to the Department (the Licensing and Certification Program), and the adult protective services.
6. Investigate thoroughly violations of neglect and mistreatment by a registered nurse (RN 1) and three certified nursing assistants (CNA 6, 8, and 9) when they were managing the aggressive behavior of Resident 10 by holding her down while the resident was in a prone position (a body position in which one lies flat with the chest down and back up) in bed to prevent the resident from falling from the low bed. Investigate thoroughly also the violations of neglect and mistreatment by a licensed vocational nurse (LVN 5) and CNA 5, who took over the care of Resident 10 during the night shift and allowed the resident to stay in a prone position until she was found unresponsive with no pulse on 10/19/16 at 4:16 a.m.
7. Investigate thoroughly the events that led to Resident 10?s death.
8. Implement its policy and procedure to protect residents from neglect and mistreatment.
Resident 10, who weighed more than 435.6 pounds (lbs) and who could not change her position in bed independently, had a behavioral episode (agitation) and falling from her bed three times on 10/18/16 from 5 p.m. to 6 p.m. Four facility staff members ? RN 1, CNA 6, 8, and 9 - responded to the resident's behavior by placing her in a prone position and holding her down on a low bed. RN 1 did not conduct an assessment to determine if the resident was having a change of condition. The physician was not notified of the resident?s aggressive behavior and her three episodes of falls. The physician, director of nursing, and the administrator were not informed that the resident was found unresponsive with no pulse in a prone position. The facility staff did not receive appropriate training to manage a behavioral episode of a mentally ill, obese resident. The facility did not conduct an investigation that led to the suspicious death of Resident 10.
A review of Resident 10's face sheet (admission record) indicated Resident 10 was a 59-year-old female, who was admitted to the facility on 2/27/16 and was readmitted on 10/15/16. Resident 10?s diagnoses included morbid severe obesity; schizophrenia (a long-term mental disorder, leading to faulty perception, inappropriate actions and feelings, withdrawal from reality and personal relationships); and extrapyramidal and movement disorder (a degenerative disease, such as Parkinsonism or chorea, that affects the brain and is characterized by tremor, muscular rigidity or weakness, and involuntary movements). The resident was pronounced dead at the facility on 10/19/16 at 4:24 a.m.
A review of Resident 10?s document titled, ?Physician Orders for Life-Sustaining Treatment (POLST),? dated 6/3/16, indicated Resident 10 was to receive full treatment (primary goal of prolonging life by all medically effective means).
A review of Resident 10?s Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 9/2/16, indicated Resident 10 was alert and cognitively intact for decision making; required extensive assistance (resident involved in activity, staff provide weight bearing support) requiring two person assistance for bed mobility (how resident moved to and from lying position, turned side to side, and positioned body while in bed); and was totally dependent on transfers requiring two person assistance.
A review of Resident 10?s general acute care hospital (GACH) records titled, ?Emergency Department Note-Physician,? dated 10/11/16, and timed at 9:59 a.m., indicated Resident 10 weighed 435.6 pounds and was admitted to the GACH secondary to a history of frequent falls and increasingly agitated behavior at the care facility .
A review of Resident 10's Initial History and Physical, dated 10/16/16, indicated Resident 10 had fluctuating capacity to understand and make decisions.
A review of Resident 10's care plan titled, "Psychotropic Medication," dated 10/15/16, indicated Resident 10 had schizophrenia and anxiety disorder, and had the behavior of hitting, throwing things, and screaming. The nursing interventions included but not limited to listening to any of Resident 10's concerns and to speaking to Resident 10 in a calm voice.
A review of Resident 10's care plan titled, "Activities of Daily Living," dated 10/17/16, indicated that Resident 10 was dependent on staff for bed mobility and that nursing interventions were to handle Resident 10 gently and observe joint limitations.
A review of Resident 10's care plan titled, "Cognition," dated 10/17/16, indicated Resident 10 had altered thought process related to periods of confusion and disorientation. The nursing interventions included but were not limited to observing the resident for changes in mental status and reporting to the physician as indicated.
A review of Resident 10?s record titled ?Activities of Daily Living (ADL) Documentation,? dated 10/17/16, indicated that Resident 10 was dependent on staff for bed mobility.
A review of Resident 10's Nurses Notes, dated 10/19/16 and timed at 8:36 a.m., indicated that a licensed vocational nurse (LVN 5) received a report from a certified nursing assistant (CNA 5) at 4:16 a.m. to go the Resident 10's room because something was not right. The nursing notes indicated that upon LVN 5's assessment of Resident 10, the resident was not breathing and had no pulse. Cardiopulmonary (heart and lungs) resuscitation (CPR, a medical procedure involving repeated compression of a patient's chest, performed in an attempt to restore the blood circulation and breathing of a person who has suffered cardiac arrest) was initiated and the 911 emergency services was called. The paramedics/fire department emergency responders arrived and took over the resuscitation of Resident 10. The paramedics pronounced Resident 10 dead at 4:24 a.m. (eight minutes from the time the resident was found at 4:16 a.m. as unresponsive). LVN 5 notified Resident 10's attending physician (MD 1) of the resident's death and MD 1 spoke with the police regarding signing the resident's death certificate.
A review of Resident 10?s records titled ?Prehospital Care Report Summary Los Angeles Fire Department (LAFD),? dated 10/19/16, and timed at 4:32 a.m., indicated that Resident 10 was found by LAFD unresponsive in bed at 4:21 a.m., and no CPR was initiated due to Resident 10 was found to have ?Post-Mortem Lividity,? (livor-mortis, a purple coloration of lower parts of the body, except in areas of contact pressure, appearing within 30 minutes to 2 hours after death, as a result of gravitational movement of blood within the vessels), and was in asystole (the absence of any heartbeat). Resident 10 was pronounced dead at 4:24 a.m., by a member of the LAFD. The records indicated that LAFD had responded to Resident 10 twice the week prior to Resident 10?s death because Resident 10 had episodes of falling out of bed. The notes indicated that Resident 10 was last spoken to 4-5 hours prior to LAFD arrival and that an unidentified staff member of the facility ?never? saw Resident 10 awake or communicating.
On 1/28/17 at 10:09 a.m., during an interview, CNA 4 stated Resident 10 was incontinent and two persons were needed to move her while in bed. CNA 4 stated that Resident 10 liked to be facing up while lying in bed and Resident 10 did not like to be in bed on her stomach. CNA 4 stated the facility staff needed to use a lifter (machine to assist with transfers) to transfer Resident 10 from bed to a wheelchair and from the wheelchair to the bed.
On 1/28/17 at 2:23 p.m., during a telephone interview, Resident 10's family member (FAM 3) stated that Resident 10 required assistance to change position in bed.
On 1/28/17 at 2:35 p.m., during an interview, CNA 7 stated that Resident 10 required total assistance with bed mobility.
On 2/13/17 at 1 p.m., during a telephone interview, CNA 9, stated that on 10/18/16 at approximately 5 p.m., Resident 10 was found agitated and was found on the floor mats between bed C and bed B (Resident 10 was assigned to bed C). CNA 9 stated that RN 1, CNA 6, CNA 8, and CNA 9 used a linen sheet to lift Resident 10 and transferred Resident 10 back to bed C. CNA 9 stated he did not know the reason why Resident 10 was on the floor mats.
During the interview, CNA 9 stated that on 10/18/16 at approximately 5:20 p.m., Resident 10 was found agitated and was found on the floor mats a second time between bed C and bed B. CNA 9 stated that RN 1 told CNA 6, CNA 8, and CNA 9 to put Resident 10 in bed B because bed B was lower than bed C. CNA 9 stated that RN 1 stated that bed B was lower than bed C and that it would prevent Resident 10 from falling again. CNA 9 stated he did not know the reason why Resident 10 was on the floor mats.
During the interview, CNA 9 stated that on 10/18/16 at approximately 5:45 p.m. or 6 p.m., Resident 10 was found on the floor mat for the third time and that Resident 10 was very agitated. CNA 9 stated that CNA 6, CNA 8, and CNA 9 used a linen sheet to transfer Resident 10 to bed B. CNA 9 stated that Resident 10 was too heavy and was very agitated and was mumbling unknown words and that CNA 6, CNA 8, and CNA 9 did not have enough strength to carry Resident 10?s weight and that Resident 10 just landed flat on her stomach in bed B. CNA 9 stated that RN 1 was aware that Resident 10 was positioned flat on her stomach in bed B and that RN 1 told CNA 6, 8, and 9 to leave her flat on her stomach.
On 2/3/17 at 7:40 a.m., during an interview, CNA 3 stated that Resident 10 needed two (2) or more people to assist her with bed mobility and was not able to change positions by herself in bed.
On 2/3/17 at 8:17 a.m., during an interview, a physical therapist (PT) stated that Resident 10 was not able to change from a prone (face down) position to supine (face up) position on her own. PT stated Resident 10 needed the assistance of two people with bed mobility.
On 2/3/17 at 1:32 p.m., during an interview, Resident 11 (Resident 10's roommate) stated that Resident 10 was screaming for nurses to help her on 10/18/16 before 11 p.m., and that the nurses did not respond to Resident 10's call for help. Resident 11 stated that around 11 p.m., RN 1 came in the room with four other staff members and were holding Resident 10 down against her bed. Resident 11 stated Resident 10 was agitated and was screaming, and was requesting to see a doctor. Resident 11 stated that the facility staff should have listened when Resident 10 was calling for help.
On 2/6/17 at 2:27 p.m., during an interview, CNA 7 indicated Resident 11 was very alert and was an accurate reporter.
A review of Resident 11's clinical record indicated Resident 11 was admitted to the facility on 9/20/13 and was readmitted on 1/26/16 with diagnoses of osteoarthritis (degeneration of joint cartilage and the underlying bone, causing pain and stiffness, especially in the hip, knee, and thumb joints) and diabetes (a metabolism disorder that affects the body's ability to use blood sugar).
A review of Resident 11's History and Physical, dated 1/9/17, indicated Resident 11 had the capacity to understand and make decisions.
A review of Resident 11's MDS, dated 12/20/16, indicated Resident 11 was cognitively intact for daily decision making.
On 2/3/17 at 1:50 p.m., during an interview, RN 1 stated that he responded to Resident 10's call for help (on 10/18/16). RN 1 stated that he did not assess Resident 10's condition and he did not check the resident's vital signs. RN 1 stated that Resident 10 was agitated and that RN 1 and other facility staff members held her down in bed between 11:15 p.m. to 11:30 p.m. (on 10/18/16), to prevent Resident 10 from falling from the low bed. RN 1 stated that Resident 10 was placed on a regular sized standard bed and that the bed was on its lowest position to prevent the resident from falling from bed. RN 1 stated that both side rails of Resident 10 were up. RN 1 stated that there was no documentation regarding Resident 10's agitation in the clinical record and that he did not inform the resident's doctor regarding the resident's episodes of aggression.
During the interview, RN 1 stated "I do not recall," receiving training on obese residents with history of behavioral issues.
On 2/6/17 at 12:44 p.m., during an interview, the maintenance supervisor (MS) stated that he was not aware that Resident 10 was using a regular standard size bed on 10/19/16. The MS measured a regular standard bed and stated that the width of a regular standard bed was 34 and ? inches. The MS stated Resident 10 would not be able to turn by herself to a prone positon while in a regular standard size bed due to the bed's width.
On 2/3/17 at 3:14 p.m., during an interview, CNA 6 stated that he assisted RN 1 on 10/18/16 around 11 p.m. and RN 1 asked CNA 6 to reposition Resident 10 back to bed. CNA 6 stated that Resident 10 was agitated and was screaming. CNA 6 stated that CNA 6, RN 1, and two other facility staffs (CNA 6 could not remember the names) repositioned the resident in bed but he could not remember what position Resident 10 was placed on.
During the interview with CNA 9 on 2/13/17 at 1 p.m., she stated that Resident 10 landed on her stomach [prone position] in bed B during a transfer by RN 1, CNA 6, 8, and 9 from the floor mat to the bed on 10/ 18/16 at 5:45 p.m. or 6 p.m. Resident was found unresponsive in a prone position on 10/19/16 at 4:16 a.m.
On 2/3/17 at 7:19 a.m., during an interview, CNA 5 stated she found Resident 10 lying on her stomach and unresponsive on 10/19/16 around 4:15 a.m. CNA 5 stated she called LVN 4 and LVN 5 for help and they assisted her to turn Resident 10 on her back. CNA 5 stated that Resident 10's bed was on its lowest positon.
On 2/3/17 at 8:35 a.m., during a telephone interview, LVN 4 stated that she found Resident 10 lying flat on her stomach (on 10/19/16) and the resident was unresponsive and was on a regular size bed. LVN 4 stated she did not feel Resident 10's pulse. LVN 4 stated she had to kneel down because Resident 10's bed was on its lowest position. LVN 4 stated that she and other facility staff members turned Resident 10 to lie on her back and to begin chest compressions. LVN 4 stated she assumed that LVN 5 notified MD 1 regarding Resident 10's lying in a prone position.
On 2/3/17 at 7:59 a.m., during a telephone interview, LVN 5 stated that she was assigned to Resident 10 on 10/19/16 during the night shift. LVN 5 stated that she called 911 and notified MD 1 that the "fire department" emergency responders (paramedics) pronounced Resident 10 deceased.
On 2/3/17 at 10:42 a.m., the director of nursing (DON) stated that Resident 10's clinical record did not indicate Resident 10 had any change of condition prior to her death. The DON stated that LVN 5 notified her of Resident 10's death but LVN 5 did not mention that Resident 10 was found unresponsive in a prone position on 10/19/16 at 4:16 a.m.
During a concurrent interview, the DON stated that she was not expecting the licensed nurses to write an incident report for Resident 10's death because she did not believe it was a suspicious death. The DON stated there was no investigation done regarding Resident 10's death.
When asked if the DON knew that Resident 10 was found not breathing and pulseless in a prone position, the DON answered, "Really? Who told you that?" The DON stated that Resident 10's death was not considered a coroner's case.
On 2/6/17 at 12:55 p.m., during an interview, RN 2 stated that Resident 10's clinical record did not indicate that Resident 10 was screaming for help on 10/18/16 around 11 p.m. RN 2 stated that if any resident had any episodes of screaming or calling for help, the nurses were supposed to assess and document any change of condition, and the nurses needed to notify the doctor. RN 2 stated that there was no nursing assessment done for Resident 10 while the resident was having a screaming episode.
On 2/3/17 at 10:23 a.m., the administrator (ADM) stated that Resident 10's death was not investigated because MD 1 did not tell him to investigate the death. The ADM stated he did not call MD 1 to discuss Resident 10's unexpected death. The ADM stated MD 1 did not refer the death to the coroner's office for an autopsy. The ADM stated that he assumed that Resident 10's death was not suspicious. ADM stated that the facility staff did not report to him that Resident 10s was in a prone position when found unresponsive. The ADM stated he assumed that he did not have to investigate and report Resident 10's death to the Department.
On 2/3/17 at 12:01 p.m., MD 1 stated that he was not notified by LVN 4 or LVN 5 that Resident 10 was found lying in a prone position while unresponsive and pulseless (on 10/19/16). MD 1 stated he did not interview LVN 4 or LVN 5 as to what position Resident 10 was found. MD 1 stated that in his professional opinion as a medical doctor, if LVN 4 and LVN 5 told him that Resident 10 was found prone and unresponsive with no pulse, he would have called the police and started an investigation. MD 1 stated he would call Resident 10's prone position very suspicious and he would have ordered an autopsy.
A review of Resident 10?s death certificate indicated the resident died on 10/19/16. The immediate cause of death was cardiac arrest (a sudden stop in effective and normal blood circulation due to failure of the heart to pump blood). The underlying cause leading to the immediate cause of death was coronary artery disease. No autopsy was conducted.
A review of the facility's policy and procedure titled, "Unusual Occurrence Reporting," with a revision date of 8/1/12, indicated that unusual occurrences, such as death of a resident, needed to be reported to the appropriate agency within 24 hours.
A review of the facility's policy and procedure titled, "Change of Condition Notification," with a revision date of 4/1/15, indicated that the facility required licensed nurses to assess a resident's change of condition and determine which nursing interventions were appropriate.
A review of the facility's policy and procedure titled, ?Abuse ? Investigations,? revised on October 5, 2015, indicated ?If the Administrator received a report of an incident or suspected incident of resident abuse, mistreatment, neglect, or injuries of unknown source, the Administrator or designee will initiate an investigation immediately.?
The facility?s ?Abuse-Investigations? policy and procedure indicated the Administrator or designee will notify the law enforcement immediately by telephone of an initial report of alleged physical abuse resulting in serious bodily injury. Serious bodily injury means an injury involving extreme physical pain, substantial risk of death, or protracted loss or impairment of function of a bodily member, organ or of mental faculty, or requiring medical intervention, including but not limited to hospitalization, surgery, or physical rehabilitation. The Administrator or designee will also notify the Long Term Care Ombudsman and the Department by telephone and in writing within two (2) hours of initial report.
The facility failed to provide Resident 10 with the necessary care and services to attain or maintain the highest practicable physical, mental, psychosocial well-being, in accordance with comprehensive assessment and plan of care; to conduct a comprehensive assessment during a change of condition; to ensure that Resident 10 received proper treatment and care for mental health disorders; to not abuse residents; to immediately inform and consult with the resident's physician when there was a change in the resident's physical, mental or psychosocial status; to develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents; and to thoroughly investigate all alleged violations involving abuse, neglect, or mistreatment; including but not limited to, failures to:
1. Conduct an assessment during a change of condition in Resident 10?s behavior manifested by agitation and screaming, and episodes of three unwitnessed falls from the bed.
2. Ensure licensed nurses and certified nursing assistants (CNAs) provided appropriate care and interventions to manage Resident 10?s aggressive behavior.
3. Notify Resident 10?s attending physician of the resident?s change of condition in behavior and the episodes of three unwitnessed falls in order to implement appropriate care and interventions for the resident.
4. Prevent staff-to-resident neglect and mistreatment by providing training to facility staff on how to manage aggressive behaviors of a mentally ill, obese person.
5. Ensure that all alleged violations involving neglect and mistreatment are reported by the staff immediately, but not later than 2 hours after the allegation is made to the administrator of the facility, to the Department (the Licensing and Certification Program), and the adult protective services.
6. Investigate thoroughly violations of neglect and mistreatment by a registered nurse (RN 1) and three certified nursing assistants (CNA 6, 8, and 9) when they were managing the aggressive behavior of Resident 10 by holding her down while the resident was in a prone position (a body position in which one lies flat with the chest down and back up) in bed to prevent the resident from falling from the low bed. Investigate thoroughly also the violations of neglect and mistreatment by a licensed vocational nurse (LVN 5) and CNA 5, who took over the care of Resident 10 during the night shift and allowed the resident to stay in a prone position until she was found unresponsive with no pulse on 10/19/16 at 4:16 a.m.
7. Investigate thoroughly the events that led to Resident 10?s death.
8. Implement its policy and procedure to protect residents from neglect and mistreatment.
Violations of these regulations, jointly, separately or in any combination, presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result. |
| 970000050 |
VERNON HEALTHCARE CENTER |
940013033 |
B |
10-Mar-17 |
7ZJH11 |
9044 |
42 CFR 483.12(c)(1)(2)(3)
(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must:
(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures.
(2) Have evidence that all alleged violations are thoroughly investigated.
(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress.
42 CFR 483.12(b)(1)(2)
(b) The facility must develop and implement written policies and procedures that:
(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property,
(2) Establish policies and procedures to investigate any such allegations, and
Based on observation, interview, and record review, the facility staff failed to implement its facility?s policy and procedure for investigating injury of unknown origin, and for abuse prevention, reporting, and investigation for Resident 9 by failing to:
1. Describe Resident 9?s injury of unknown source objectively and not speculate as to the cause.
2. Report allegations of abuse and injuries of unknown origin immediately, but not later than 24 hours after the allegation is made, to the administrator of the facility, the law enforcement, the ombudsman, and to the Department (the State licensing and certification program.
3. Investigate thoroughly the injury of unknown origin.
4. Implement its abuse and injury of unknown origin policy and procedure.
A registered nurse (RN 2) speculated that the palm-sized redness on Resident 9?s face was cellulitis (a bacterial infection); therefore, Resident 9?s injury was not reported to the administrator, law enforcement and the state agencies, and not thoroughly investigated to determine if the resident was abused.
These deficient practices created an unsafe environment for the resident.
A review of Resident 9's Admission Record indicated the resident was an 82-year-old male, who was admitted to the facility on 3/3/15 and readmitted to the facility on 2/25/16 with diagnoses that included history of cellulitis (a serious bacterial infection characterized by skin redness that tends to expand, tenderness, pain, and warmth) of the right toe, dementia (loss of brain function that affects memory, thinking, language, judgement, and behavior), and anemia (a condition of having lower than normal number of red blood cells in the body).
A review of Resident 9?s Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 12/6/16 indicated the resident was usually able to verbalize needs when prompted or given time, responds adequately to simple direct communication, and was moderately impaired (decisions poor; cues/supervision required) in cognitive skills for daily decision making. The MDS indicated the resident required extensive assistance (resident involved in activity; staff provide weight-bearing support) from the staff in bed mobility, and personal hygiene and was frequently incontinent (having no or insufficient voluntary control over urination) of urine.
A review of Resident 9?s SBAR (Situation, Background, Appearance, Review and notify ? a tool to share patient information in a clear, complete, concise and structured format) Communication Form, dated 12/1/16 timed at 8 a.m., indicated Resident 9 had a palm-sized reddened area to the right side of the face that was warm to touch but no signs and symptoms of pain.
On 2/2/17, at 4:30 p.m., during an interview, the licensed vocational nurse (LVN 3) stated that the reason why the redness to Resident 9?s face needed to be reported to the director of nursing (DON) and the administrator because it was a mark on the face and could be a sign of abuse.
On 2/2/17, at 4:55 p.m., during a concurrent interview with the DON and LVN 3, LVN 3 stated that the DON was informed about the redness on Resident 9?s face through a telephone call. The DON stated she was aware of the redness noted on Resident 9's face on 12/1/16. The DON stated she did not investigate Resident 9?s redness to the face because she was informed that it was cellulitis (a skin infection) and she "thought" the resident received antibiotics for it. A concurrent review of Resident 9?s clinical record with the DON indicated there was no documented evidence that the resident received antibiotics for cellulitis during that time.
On 2/6/17, at 2 p.m., during an interview, the registered nurse (RN 2), who spoke to Resident 9's attending physician on 12/1/16 after she assessed the redness on the resident's face, stated she assumed the redness on Resident 9?s face was cellulitis given the resident's history and she informed the attending physician that it might be cellulitis. RN 2 stated the attending physician did not order any medications or treatment but ordered to monitor the resident?s face and to call the physician back if the resident?s condition worsened. RN 2 stated she was not sure of the source of the redness to the resident's face and the redness disappeared approximately within 3 days. RN 2 stated ?it must not have been cellulitis.?
A review of Resident 9s? physician?s Medicine Progress Notes, dated 12/3/16, two days after RN 2 called the physician to inform of the resident?s redness to the face did not indicate a diagnosis of cellulitis to the face.
There was no documented evidence that Resident 9 was treated or diagnosed by the attending physician for cellulitis to the face upon reviewing the resident?s clinical records from dates 12/1/16 to 2/2/17. RN 2 did not follow the facility?s policy and procedure to not speculate about causes of unexplained injuries by informing Resident 9?s attending physician that the redness to the face could be cellulitis. The DON could not provide documented evidence that a thorough investigation was completed for Resident 9's injury of unknown source and that the injury of unknown source was reported to the Department within 24 hours upon discovery.
A review of the facility?s policy and procedure titled, ?Injuries of Unknown Origin- Investigation,? revised on 11/18/15, indicated the facility will investigate thoroughly and address unexplained injuries promptly. The facility policy and procedure indicated the following:
a. Any descriptions in the medical record must be objective and sufficiently detailed and should not speculate about causes.
b. The medical director or attending physician is responsible for reviewing and verifying conclusions about the possibility of a medical or other similar cause of the findings.
c. The administrator will decide whether to undertake an investigation of the injury.
A review of the facility's policy and procedure titled, ?Abuse ? Reporting & Investigations,? revised on 11/2016, indicated it is the facility?s policy ?to protect the health, safety, and welfare of Facility residents by ensuring that all reports of resident abuse, mistreatment, neglect, exploitation or injuries of an unknown source are promptly and thoroughly investigated.? The facility policy and procedure indicated the following:
a. Allegations of abuse, neglect, mistreatment, or exploitation are to be reported to the Administrator or designated representative immediately.
b. Notify the law enforcement, Long Term Care Ombudsman and the Department by telephone and in writing within two (2) hours of initial report of alleged physical abuse resulting in serious bodily injury, which included substantial risk of death).
The facility staff failed to implement its facility?s policy and procedure for investigating injury of unknown origin, and for abuse prevention, reporting, and investigation for Resident 9 by failing to:
1. Describe Resident 9?s injury of unknown source objectively and not speculate as to the cause.
2. Report allegation of abuse and injuries of unknown origin immediately, but not later than 24 hours after the allegation is made, to the administrator of the facility, the law enforcement, the ombudsman, and to the Department (the State licensing and certification program.
3. Investigate thoroughly the injury of unknown origin.
4. Implement its abuse and injury of unknown origin policy and procedure.
These violations had a direct or immediate relationship to the health, safety, or security of Resident 9 and all other resident. |
| 970000050 |
VERNON HEALTHCARE CENTER |
940013038 |
B |
10-Mar-17 |
7ZJH11 |
8254 |
42 CFR 483.12(a)(1)
The facility must not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion.
42 CFR 483.12(c)(1)-(4)
(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must:
(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures.
(2) Have evidence that all alleged violations are thoroughly investigated.
(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress.
(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.
42 CFR 483.12(b)(1)(2)
(b) The facility must develop and implement written policies and procedures that:
(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property,
(2) Establish policies and procedures to investigate any such allegations
Based on interview, and record review, the facility failed to implement its abuse prevention, reporting, and investigation policy and procedure for Resident 4 by failing to:
1. Prevent staff to residents (Resident 4 and other residents) verbal abuse.
2. Ensure that all allegations of abuse and neglect are reported by the facility staff immediately or within 24 hours after the allegations are made, to the administrator of the facility, the law enforcement, the Long Term Care Ombudsman, and the Department (the Licensing and Certification Program).
3. Investigate thoroughly allegations of abuse and neglect.
4. Implement effectively the facility?s abuse prevention, reporting, and investigation policy and procedure.
Residents 4 verbalized experiencing insult and sarcasm (the use of words that mean the opposite of what one really want to say in order to insult someone) from a certified nursing assistant (CNA 1) and a licensed vocational nurse (LVN 1) and alleged that certified, licensed, and unlicensed staff members talk down on residents. This deficient practice had the potential to result in the residents having emotional distress and feeling unsafe in the facility.
On 1/31/17, at 2:25 p.m., during a group interview, Residents 4 stated he had heard a licensed vocational nurse (LVN 1) say to other residents "Shut the hell up," ignored residents who call for help at night, and did not like how other facility staff (licensed nurses and certified nursing assistants) treated him like a child and not as an adult. Resident 4 stated he did not want to say names of the licensed staffs but would like the nurses to have "better manners."
During the group interview, Residents 4 stated CNA 1 was sarcastic when he talks to them. Residents 4 stated CNA 1 and other licensed and unlicensed nursing staff talk down to them and had a "jerky attitude" (someone who treats other people badly).
On 1/31/17 at 2:28 p.m., during a group meeting, Resident 4 stated that licensed vocational nurse (LVN 1) did not give him a sleeping pill on the night of 1/30/17. Resident 4 stated that LVN 1 treated him like a child and not like an adult by ignoring his request to obtain a sleeping pill. Resident 4 stated that LVN 1 withheld the administration of medications to him and to the other residents. Resident 4 stated he witnessed LVN 1 treating other residents in a disrespectful manner and by using harsh language such as "Shut the hell up," when other residents requested medications. Resident 4 stated that LVN 1?s action made him irritated and upset.
On 1/31/17 at 6:21 p.m., the director of nurses (DON) stated that LVN 5 did not notify her regarding Resident 4's allegations that LVN 1 was treating Resident 4 like a child and denying him the insomnia medication.
On 2/2/17 at 6:40 p.m., during an interview, the director of staff development (DSD) stated that LVN 1 was assigned to Resident 4 on 1/30/17.
A review of Resident 4's Admission Record indicated the resident was a 64-year-old male, who was admitted to the facility on 1/8/17 with the diagnoses that included fracture of the sacrum (a break in the sacrum [a large triangular bone, it is the base of the spine and connects to the pelvis]), and osteoarthritis (degeneration of joint cartilage and the underlying bone, most common from middle age onward, it causes pain and stiffness, especially in the hip, knee, and thumb joints).
A review of Resident 4's Initial History and Physical, dated 1/10/17, indicated Resident 4 had the capacity to understand and make decisions.
A review of the Resident 4's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 1/16/17, indicated Resident 4 was cognitively intact and required extensive assistance (resident involved in activity; staff provide weight-bearing support) for transfers with one person physical assist.
A review of Resident 4's physician's orders, dated 1/27/17, indicated to give the resident Vistaril (a medication used to treat insomnia or inability to sleep) 25 milligrams (mg) as needed for insomnia.
A review of Resident 4's care plan titled "Insomnia," dated 1/27/17 indicated Resident 4 had a history of insomnia. The interventions included to administer medications as needed (PRN).
A review of Resident 4's medication administration record (MAR) indicated the resident did not receive Vistaril on 1/27/17, 1/28/17, 1/29/17, 1/30/17, and 1/31/17.
A review of the facility?s policy and procedure titled, ?Abuse-Prevention Program,? revised on 11/2016, indicated the facility does not condone any form of resident abuse, neglect and/or mistreatment and develops Facility policies, procedures, training programs, and systems in order to promote an environment free from abuse and mistreatment.
A review of the facility's policy and procedure titled, ?Abuse ? Reporting & Investigations,? revised on 11/2016, indicated it is the facility?s policy ?to protect the health, safety, and welfare of Facility residents by ensuring that all reports of resident abuse, mistreatment, neglect, exploitation or injuries of unknown source are promptly and thoroughly investigated.? The facility?s policy and procedure indicated the following:
a. Allegations of abuse, neglect, mistreatment, or exploitation are to be reported to the Administrator or designated representative immediately.
b. Notify the law enforcement, Long Term Care Ombudsman and the Department by telephone immediately or as soon as practicable, and in writing within 24 hours including weekends of all other types of allegations of abuse.
The facility failed to implement its abuse prevention, reporting, and investigation policy and procedure for Resident 4 by failing to:
1. Prevent staff to residents (Resident 4 and other residents) verbal abuse.
2. Ensure that all allegations of abuse and neglect are reported by the facility staff immediately or within 24 hours after the allegations are made, to the administrator of the facility, the law enforcement, the Long Term Care Ombudsman, and the Department (the Licensing and Certification Program).
3. Investigate thoroughly allegations of abuse and neglect.
4. Implement effectively the facility?s abuse prevention, reporting, and investigation policy and procedure.
These violations had a direct or immediate relationship to the health, safety, or security of Resident 4. |
| 970000050 |
VERNON HEALTHCARE CENTER |
940013035 |
B |
10-Mar-17 |
7ZJH11 |
8001 |
42 CFR 483.12(a)(3), (c)(1)(2)(3)
(a) The facility must-
(3) Not employ or otherwise engage individuals who-
(i) Have been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law;
(ii) Have had a finding entered into the State nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property; or
(iii) Have a disciplinary action in effect against his or her professional license by a state licensure body as a result of a finding of abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property.
(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must:
(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures.
(2) Have evidence that all alleged violations are thoroughly investigated.
(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress.
CFR 483.12(b)(1)(2)
(b) The facility must develop and implement written policies and procedures that:
(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property,
(2) Establish policies and procedures to investigate any such allegations, and
Based on interview and record review, the facility staff failed to implement its abuse prevention, reporting, and investigation policy and procedure for Resident 1 by failing to:
1. Ensure that all allegations of abuse are reported by the facility staff immediately or within 24 hours after the allegations are made, to the administrator of the facility, the law enforcement, the Long Term Care Ombudsman, and the Department (the Licensing and Certification Program).
2. Investigate thoroughly allegations of abuse.
3. Verify from the State nurse aide registry if CNA 1 had a finding concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident?s property prior to CNA 1?s hire.
4. Implement effectively the facility?s abuse prevention, reporting, and investigation policy and procedure.
These deficient practices had the potential for abuse to occur, and to create an environment of fear and feeling of being unsafe in the facility.
A review of Resident 1's admission record (face sheet) indicated Resident 1 was a 75-year-old male, who was re-admitted to the facility on 8/30/16 with diagnoses of major depressive disorder (a persistent feeling of sadness and loss of interest) and morbidly severe obesity (an excessive amount of body fat).
A review of Resident 1's Minimum Data Set (MDS), a standardized assessment and care-screening tool, dated 12/7/16, indicated Resident 1 was severely impaired in cognitive skills for daily decision making and was total dependent on staff to provide personal hygiene and required two people assist for bed mobility.
A review of Resident 2?s admission record (face sheet) indicated Resident 2 was a 66-year-old male with diagnoses that included hypertension (high blood pressure).
A review of Resident 2?s MDS, dated 12/7/16, indicated Resident 2 was alert and his cognition (ability to think and reason) was intact.
On 1/28/17 at 2:55 p.m., during an interview, Resident 2 (roommate of Resident 1) stated he reported to the director of staff development (DSD) that CNA 1 treated residents roughly and that CNA 1 was abusive to his roommate, Resident 1. Resident 2 stated CNA 1 called Resident 1 the ?N? word.
On 1/28/17 at 2:58 p.m., during an interview, Resident 1 stated that CNA 1 called him a derogatory name and rough handled him during care. Resident 1 stated that while CNA 1 was providing care, CNA 1 pushed him against the side rail and he hit his head.
On 1/28/17 at 3:23 p.m., during an interview, the DSD stated he did not investigate the reason as to why Resident 1 did not want CNA 1 to be assigned to him. The DSD stated he only re-assigned CNA 1 to a different assignment. The DSD stated he did not report CNA 1 to the administrator and to the director of nursing (DON).
On 1/28/17 at 3:50 p.m., during an interview, the DON stated that she was not aware of Resident 1?s allegations regarding CNA 1. The DON stated that the DSD should have told her about the allegations.
On 1/31/17, at 5 p.m., during an interview and concurrent record review of CNA 1's personnel files and interview, the DSD stated he was responsible for obtaining certificates, licenses, and background checks prior to employing a CNA. The DSD stated that background checks consisted of criminal record checks and an OIG (Office of the Inspector General) exclusion list. The DSD stated he was not aware of the "State Nurse Aide Registry."
During the review of CNA 1's personnel files with the DSD, there was no documented evidence that the DSD verified CNA 1's status against the State Nurse Aide Registry and the Licensing and Certification Verification (L&C) website of the Department. The DSD stated he does not print out the page of the L & C Verification Detail Page at the CDPH (California Department of Public Health) website after he verified if the certificate of a CNA was active or not because it was a waste of paper.
A review of the facility?s policy and procedure titled, ?Abuse-Prevention Program,? revised on 11/2016, indicated the facility does not condone any form of resident abuse, neglect and/or mistreatment and develops Facility policies, procedures, training programs, and systems in order to promote an environment free from abuse and mistreatment.
A review of the facility's policy and procedure titled, ?Abuse ? Reporting & Investigations,? revised on 11/2016, indicated it is the facility?s policy ?to protect the health, safety, and welfare of Facility residents by ensuring that all reports of resident abuse, mistreatment, neglect?are promptly and thoroughly investigated.? The facility policy and procedure indicated the following:
a. Allegations of abuse, neglect, mistreatment, or exploitation are to be reported to the Administrator or designated representative immediately.
b. Notify the law enforcement, Long Term Care Ombudsman and the Department by telephone immediately or as soon as practicable, and in writing within 24 hours including weekends of all other types of allegations of abuse.
The facility staff failed to implement its abuse prevention, reporting, and investigation policy and procedure for Resident 1 by failing to:
1. Ensure that all allegations of abuse are reported by the facility staff immediately or within 24 hours after the allegations are made, to the administrator of the facility, the law enforcement, the Long Term Care Ombudsman, and the Department (the Licensing and Certification Program).
2. Investigate thoroughly allegations of abuse.
3. Verify from the State nurse aide registry if CNA 1 had a finding concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident?s property prior to CNA 1?s hire.
4. Implement effectively the facility?s abuse prevention, reporting, and investigation policy and procedure.
These violations had a direct or immediate relationship to the health, safety, or security of Resident 1 and other residents in the facility. |
| 970000050 |
VERNON HEALTHCARE CENTER |
940013032 |
B |
10-Mar-17 |
7ZJH11 |
6648 |
483.12(c) (1)-(4)
(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must:
(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures.
(2) Have evidence that all alleged violations are thoroughly investigated.
(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress.
(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.
483.12(b) The facility must develop and implement written policies and procedures that:
(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property,
(2) Establish policies and procedures to investigate any such allegations, and
(3) Include training as required at paragraph ?483.95,
Based on interview and record review, the facility failed to ensure that Resident 8?s injury of unknown origin (bruises [skin discoloration]) reported by the family member was investigated and reported immediately to the administrator and to the Department (Licensing and Certification Program) as indicated in the facility?s abuse policy and procedures.
As a result, Resident 8?s possible cause of bruises to the left arm and upper chest was not identified, had a potential that the resident was not receiving the care that she needed, and/or potential of physical abuse/rough handling by care staff.
A review of Resident 8's Admission Record indicated that Resident 8 was initially admitted to the facility on 11/15/16 and was re-admitted on 12/28/16 with diagnoses that included dementia (a progressive deterioration of mental and physical functioning) with behavioral disturbance, and major depressive disorder (a persistent feeling of sadness and loss of interest).
A review of Resident 8's history and physical dated 12/29/16 indicated that Resident 8 did not have the capacity to understand and make decisions.
A review of Resident 8's Minimum Data Set (MDS, an assessment and care screening tool), dated 12/21/16, indicated that Resident 8 was severely impaired in cognitive skills for daily decision-making and required extensive assistance from staff for activity of daily living (ADLs).
A review of Resident 8's interdisciplinary team (IDT) conference record dated 12/5/16 indicated that Resident 8?s family member reported that the resident had skin discoloration on left arm and chest area on 12/3/16 at 7 p.m. The IDT notes further indicated that the DON was going to investigate what had occurred.
On 2/1/17 at 12:56 p.m., family member 1 (FAM 1), stated during a telephone interview that Resident 8 had several unknown bruises on his left upper arm and chest on 12/3/16 or 12/5/16. FAM 1 stated she and FAM 2 informed LVN 3. FAM 1 stated no investigation was done.
On 2/2/17 at 4:06 p.m., registered nurse (RN 1) stated that Resident 8's medical record indicated that Resident 8 had a skin discoloration and bruising on left arm on 12/5/16. RN 1 stated that Resident 8's bruising was considered an injury of unknown cause and that an investigation should have been conducted.
On 2/2/17 at 4:33 p.m., LVN 3 stated that FAM 1 and FAM 2 reported Resident 8's bruises found on 12/5/16 to her. LVN 3 stated she reported the bruises to the DON via text message and LVN 3 stated she did not do a proper skin body assessment.
On 2/2/17 at 4:39 p.m., The DON stated that Resident 8 had a large bruise to his left arm. The DON stated she believed Aspirin caused Resident 8's left arm to bruise or that perhaps Resident 8 put his left arm around the side rail. DON stated she did not conduct a proper investigation. DON stated that the IDT notes indicated that an investigation was supposed to be conducted but it was never done. DON stated there was no care plan or any documentation in place regarding Resident 8 putting his left arm around the side rail. The DON stated she did not report the bruises to the administrator.
A review of 11/2016, facility's revised policy and procedures titled "Abuse-Reporting and Investigations," indicated the facility will report all allegations of abuse as required by law and regulations and promptly and thoroughly investigate reports of resident abuse, mistreatment, neglect, exploitation, misappropriation of resident property or injuries of unknown source. The policy and procedure indicated that if the allegations of abuse is allegedly caused by a resident, who had been diagnosed with dementia, and a Licensed Nurse reasonably determines that there is no serious bodily injury, the Administrator or his/her representative, will immediately notify, by telephone, the Ombudsman or law enforcement agency. In addition, a written report will be made to the local Ombudsman or law enforcement agency and the California Department of Public Health (Licensing and Certification) within 24 hours. The facility's policy and procedure also indicated that the individual who was conducting the investigation will consult daily with the Administrator concerning progress/findings of the investigation.
The facility failed to ensure that Resident 8?s injury of unknown origin (bruises [skin discoloration]) reported by the family member was investigated and reported immediately to the administrator and to the Department as indicated in the facility?s abuse policy and procedures.
As a result, Resident 8?s possible cause of bruises to the left arm and upper chest was not identified, had a potential that the resident was not receiving the care that she needed, and/or potential of physical abuse/rough handling by care staff.
The above violation had a direct or immediate relationship to the health, safety, and security of Resident 8. |
| 970000050 |
VERNON HEALTHCARE CENTER |
940013027 |
B |
10-Mar-17 |
7ZJH11 |
8892 |
?483.13(c)(1)(i) Staff Treatment of Residents
a) The facility must-
(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion
?483.13(c)(2) The facility must ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property are reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures (including to the State survey and certification agency).
?483.13(c)(4) The facility must have evidence that all alleged violations are thoroughly investigated, and must prevent further potential abuse while the investigation is in progress.
Based on interview, and record review, the facility failed to ensure that Resident 7?s allegations of not receiving pain medications and being talked to in a derogatory manner by a licensed vocational nurse were thoroughly investigated, and to report immediately this allegation to the administrator of the facility and to the Department (Licensing and Certification Program) as indicated in the facility?s abuse policy and procedures.
As a result, Resident 7 did not receive necessary pain medication to relieve her pain, which constituted neglect and the alleged licensed vocational nurse was not removed from providing care to the resident which had a potential for further neglect and mental anguish to the resident.
A review of Resident 7's Admission Record indicated that the resident was originally admitted to the facility on 3/10/12 and readmitted on 1/29/17 with diagnoses that included osteoarthritis (due to aging and wear and tear on a joint), chronic pain syndrome (pain that lasts a long time), and schizophrenia (a psychotic disorder marked by severely impaired thinking, emotions, and behaviors).
A review of the Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 1/16/17 indicated that Resident 7 was able to verbalize needs and had clear comprehension of verbal content. The MDS indicated Resident 7 was moderately impaired (decisions poor; cues/supervision required) in cognitive skills for daily decision-making and was totally dependent on staff in bed mobility, transfers, locomotion and was unable to walk. The MDS indicated that Resident 7 had occasional pain that was rated at an 8 on a zero to ten scale (zero being no pain and ten as the worst pain).
A review of the Resident Grievance/Complaint Investigation Report, dated 1/24/17 indicated that Resident 7 alleged not receiving medications. A documented statement was attached from the Appeals and Grievance Department of Resident 7's Health Plan dated 1/24/17 notifying the facility of several allegations of Resident 7. The note indicated that one of the complaint allegations was being given another medication and not receiving any medication for her pain and the licensed vocational nurse (LVN 2) telling her that "You are going to take what I give you or nothing at all." Further review of the Resident Grievance/Complaint Investigation Report indicated that the administrator became aware of the incident on 1/31/17, seven days after the complaint/grievance was received.
A review of the facility document titled "Employee Interview; Operational Manual- Abuse and Neglect," dated 1/27/17, indicated that LVN 2 was interviewed about an allegation claimed by Resident 7 to take her medications she gives her or nothing at all. The Employee Interview indicated that LVN 2 stated that Resident 7 did not complain about her or requested a different charge nurse to take care of her. The Employee Interview further indicated that Resident 7 only takes pain medications as needed and refuses routine medications. There was no documented evidence that a thorough investigation was completed for Resident 7's allegations of verbal abuse, and not receiving the appropriate pain medication for her pain. There was no documented evidence that Resident 7 or any other possible witnesses were interviewed aside from LVN 2.
On 1/31/17, at 5:42 p.m., during an interview, social service director (SSD 1) stated she conducted the initial investigation of Resident 7's allegation of not receiving her pain medications by reviewing the resident's Medication Administration Record (MAR). SSD 1 stated that she informed the director of nurses (DON). SSD 1 stated she could not substantiate Resident 7's allegations upon review of the resident's clinical record because the resident had periods of hallucinations and history of refusing medications. There was no documented evidence that Resident 7 was interviewed regarding the allegation or was asked the reason why she did not want her current pain medication.
On 2/2/17, at 6 p.m., during an interview, Resident 7 stated she kept on telling the facility and LVN 2 that her current pain medication (Norco) was not working and that she wanted Tylenol with codeine because it was the pain medication that worked for her in the past. Resident 7 stated "I am a diabetic, I have arthritis in my fingers, hands, all over my body, and I have pain every day." Resident 7 stated she was taking the Norco because she did not have a choice. Resident 7 further stated that she told LVN 2 about her concerns with her pain medication but LVN 2 ignored her concerns and stated "I'm not giving you nothing; you won't get nothing at all." Resident 7 stated the attitude of the nurses in the facility was very poor, tend to ignore residents, and possess bad manners. Resident 7 stated referring to the conversation with LVN 2, "It was not the right way to talk to a person."
On 2/3/17, at 3:30 p.m., during an interview, LVN 2 stated she was aware of Resident 7's concerns with her pain medication and request to receive Tylenol with codeine. LVN 2 stated she had told Resident 7 that she only had Norco ordered for her pain medication and did not receive Tylenol with codeine in the past since the resident was admitted to the facility. LVN 2 stated that she did ask Resident 7 why she was requesting Tylenol with codeine.
On 1/31/17, at 6:24 p.m., during an interview, the Administrator who was the abuse coordinator stated he is the only one who screens abuse allegations. The Administrator stated that every abuse allegation should be reported to the department and other law enforcement agencies. The Administrator stated that he reviewed the complaint/grievance of Resident 7 but did not do further investigation or report it to the Department because the SSD 1 already conducted an investigation and concluded it was not abuse because the resident had history of refusing medications.
A review of 11/2016, facility's revised policy and procedure titled "Pain Management," indicated the licensed nurse will notify the attending physician if a resident's pain has not been relieved with current pain medication.
A review of 11/2016, facility's revised policy and procedures titled "Abuse- Reporting and Investigations," indicated the facility will report all allegations of abuse as required by law and regulations and promptly and thoroughly investigate reports of resident abuse, mistreatment, neglect, exploitation, misappropriation of resident property or injuries of unknown source. The policy and procedure indicated that if the allegations of abuse is allegedly caused by a resident, who had been diagnosed with dementia, and a Licensed Nurse reasonably determines that there is no serious bodily injury, the Administrator or his/her representative, will immediately notify, by telephone, the Ombudsman or law enforcement agency. In addition, a written report will be made to the local Ombudsman or law enforcement agency and the California Department of Public Health (Licensing and Certification) within 24 hours. The facility's policy and procedure also indicated that the individual who was conducting the investigation will consult daily with the Administrator concerning progress/findings of the investigation.
The facility failed to ensure that Resident 7?s allegations of not receiving pain medications and being talked in a derogatory manner by a licensed vocational nurse were thoroughly investigated by interviewing the resident involved, and to report immediately this allegation to the administrator of the facility and to the Department as indicated in the facility?s abuse policy and procedures.
As a result, Resident 7 did not receive necessary pain medication to relieve her pain, which constituted neglect and the alleged licensed vocational nurse was not removed from the resident?s care while the investigation was in progress which had a potential for further neglect and mental anguish to the resident.
The above violation had a direct or immediate relationship to the health, safety, and security of Resident 7. |
| 970000050 |
VERNON HEALTHCARE CENTER |
940013040 |
B |
10-Mar-17 |
7ZJH11 |
8429 |
483.12(a) (1)
The facility must not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion.
483.12(c) (1)-(4)
(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must:
(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures.
(2) Have evidence that all alleged violations are thoroughly investigated.
(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress.
(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.
483.12(b) (1) (2), 483.95(c) (2)
(b) The facility must develop and implement written policies and procedures that:
(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property,
(2) Establish policies and procedures to investigate any such allegations, and
(c)(2) Procedures for reporting incidents of abuse, neglect, exploitation, or the misappropriation of resident property.
On 1/28/17 at 9:52 a.m., an unannounced visit was made to the facility to investigate an allegation of abuse.
Based on observation, interview, and record review, the facility failed to implement its policy and procedures on Abuse by failing to:
1. To protect and prevent mental abuse and neglect for Resident 6.
2. Promptly and thoroughly investigate all allegations of abuse including, but not limited to, neglect.
3. Report immediately to the administrator of the facility and to the Department (Licensing and Certification Program) immediately (as soon as possible) but not to exceed 24 hours after discovery of the incident) or within 24 hours of the knowledge of all alleged violations involving neglect.
Resident 6, who complained of 9/10 (pain rating scale: zero [0] for no pain, 1-3 mild pain, 4-6 moderate pain, 7-9 severe pain, and 10 the worst possible pain) was not given his pain relief ointment medication (Voltaren 1percent [%] gel, medication used to treat inflammation [swelling] and pain) when requested that caused the resident to experience unnecessary severe knee pain for 17 days and the physician?s order was to give Voltaren 1 % gel to both knees three times a day as needed (PRN) for joint pain.
A review of Resident 6's record titled, ?Face Sheet (admission record)? indicated the resident was a 74 year old male admitted to the facility on 7/7/16 with diagnoses that included bilateral (both) primary osteoarthritis of knee (joint pain with activity, night pain, morning stiffness, limited motion, joint inflammation, crepitus or noise from the knee, and deformity) and anxiety (feeling of worry, nervousness, or unease, typically about an imminent event or something with an uncertain outcome).
A review of Resident 6's care plan titled, "Pain," dated 7/13/16, indicated Resident 6 had a history of bilateral knee, leg, and arm pain, and the interventions were to provide pain medications as ordered.
A review of Resident 6's record titled, ?Initial History and Physical,? undated, indicated Resident 6 had the capacity to understand and make decisions.
A review of Resident 6's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 1/12/17, indicated Resident 6 was able to verbalize needs and had clear comprehension of verbal content and was cognitively intact for daily decision-making. The MDS indicated Resident 6 required extensive assistance (weight bearing support and at times requires full staff performance) with transfers.
A review of Resident 6's record titled, ?Physician Orders,? dated 1/13/17, indicated to give diclofenac sodium (generic name for Voltaren) 1 % gel 2-4 grams to both knees three times a day as needed (PRN) for joint pain.
On 1/31/17 at 3:28 p.m., Resident 6 was observed sitting on a wheelchair. During an interview, Resident 6 stated that Licensed Vocational Nurse (LVN) 3 did not give his pain relief ointment medication (Voltaren 1% gel). Resident 6 stated he requested the ointment the third and fourth week of January for his knee pain. Resident 6 stated he complained of 9/10 pain. Resident 6 stated LVN 3 and the other nurses ignored him when he requested for the pain relief ointment medication for his knee pain.
On 1/31/17 at 3:36 p.m., LVN 7 stated that Resident 6 complained about not receiving his pain medications. During a review of Resident 6?s record titled, ?Routine Medication Administration Record,? with LVN 7, LVN 7 stated that the last dose the Voltaren 1% gel was given to Resident 6 was on 1/14/17, 17 days ago. LVN 7 stated she did not know why it was not given to Resident 6. LVN 7 stated that the Voltaren 1% gel was ordered for Resident 6 to receive three times a day PRN for joint pain. An inspection of Resident 6?s medications with LVN 7, Voltaren 1% gel was in the medication cart. A review of the pharmacy receipt indicated the Voltaren 1% gel was delivered to the facility on 12/16/17. LVN 7 stated she did not report Resident 6's allegation about not receiving his pain medications.
On 2/3/17 at 8:15 a.m., during an interview, Physical Therapist (PT) 1 stated that Resident 6 was receiving physical therapy exercises. PT 1 stated that it was important for Resident 6 to receive pain relief medications to avoid discomfort and assist with mobility. PT 1 stated Resident 1 been complaining of bilateral knee pain during physical therapy exercises but did not ask how much pain.
A review of the facility's policy and procedure titled, "Abuse- Prevention Program," revised November 2016 indicated, ?The Facility does not condone any form of resident abuse, neglect, misappropriation of resident property, exploitation, and/or mistreatment. . .? ??Neglect? is defined as failure to provide goods and services necessary to avoid physical harm, pain, mental anguish, or emotional distress.?
A review of the facility's policy and procedure titled, "Abuse- Reporting and Investigations," revised dated 11/2016, indicated the facility will report all allegations of abuse a required by law and regulations and promptly and thoroughly investigate reports of resident abuse, mistreatment, neglect, exploitation, misappropriation of resident property or injuries of unknown source.
The policy and procedure indicated that if the allegations of abuse is allegedly caused by a resident, who had been diagnosed with dementia, and a Licensed Nurse reasonably determines that there is no serious bodily injury, the Administrator or his/her representative, will immediately notify, by telephone, the Ombudsman or law enforcement agency. In addition, a written report will be made to the local Ombudsman or law enforcement agency and the California Department of Public Health (Licensing and Certification) within 24 hours.
Therefore, the facility failed to implement its policy and procedures on Abuse by failing to:
1. To protect and prevent mental abuse and neglect for Resident 6.
2. Promptly and thoroughly investigate all allegations of abuse including, but not limited to, neglect.
3. Report immediately to the administrator of the facility and to the Department (Licensing and Certification Program) immediately (as soon as possible) but not to exceed 24 hours after discovery of the incident) or within 24 hours of the knowledge of all alleged violations involving neglect.
These violations had a direct or immediate relationship to the health, safety, or security of Resident 6.
Resident 6 |
| 940000025 |
VIEW HEIGHTS CONVALESCENT HOSPITAL |
940013554 |
AA |
3-Nov-17 |
ATHB11 |
17511 |
F157
? 483.10 (g) (14) Notification of changes
A facility must immediately inform the resident; consult with the resident?s physician; and if known, notify the resident?s legal representative or an interested family member when
there is
(B) A significant change in the resident?s physical, mental, or psychosocial status (that
is, a deterioration in health, mental, or psychosocial status in either life-threatening
conditions or clinical complications);
F309
?483.25 Quality of Care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices, including but not limited to the following:
?488.301 Definitions
Neglect means failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness.
On 7/10/17, an unannounced investigation was conducted at the facility after the Department received an entity Reported incident (ERI) from the facility on 7/6/17, alleging a resident (Resident 1) complained of heartburn and requested medication. Resident 1 then fell to the floor, suffered a heart attack, and was pronounced deceased by the paramedics on 7/5/17 at 9:39 p.m.
Resident 1 had a history of chest pain and had been transported to the general acute care hospital (GACH) for pain relief. On the day of Resident 1?s cardiac arrest she had been complaining of chest pains and then fell down. Resident 1 required assistance to return to her room and was unable to communicate her needs.
Based on observation, interview, and record review, the Department determined that the facility failed to provide Resident 1 with the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being and notify the nurse and physician when the resident?s condition changed, including but not limited to:
1. Failure to provide the necessary care and services to Resident 1 when there was a change in the resident?s condition, including CPR.
2. Failure to notify the nurse when Resident 1, who had a history of chest pains and rapid heartbeat, complained of heartburn (known as acid indigestion, a burning sensation in the central chest or upper central abdomen) for approximately eight hours.
3. Failure to adhere to the facility?s policy and assess Resident 1?s change in condition and report to the physician.
4. Failure to call 911 (emergency services) timely after Resident 1 complained of chest pain and had fallen twice, while holding her chest. The paramedics were not called until 16 minutes after Resident 1 complained of chest pain.
These deficient practices caused a delay in diagnosis, care, and treatment, which resulted in Resident 1 having a heart attack and being pronounced deceased by the paramedics nine hours after the resident initially complained of heartburn.
A review of Resident 1?s Admission Face Sheet indicated the resident was a 40 year-old female who was admitted to the facility on 9/7/16 with the following diagnoses, Hepatitis C (infection that causes liver inflammation and liver damage), asthma (a condition which results in narrowing of the airways and difficulty in breathing) schizoaffective disorder (a chronic mental health condition) and tachycardia (rapid heart rate).
A review of Resident 1?s quarterly Minimum Data Set (MDS), an assessment and care screening tool, dated 6/23/17, indicated the resident was moderately impaired in cognition (ability to reason and think). The MDS indicated Resident 1 was independent with activities of daily living ([ADLs,] routine everyday activities) such as eating, bathing, dressing, toileting, and walking.
A review of Resident 1?s Nurse?s Notes, dated 1/20/17, and timed at 8:44 a.m., and on 1/23/17 and timed at 5:35 a.m., indicated the resident was complaining of chest pain. The physician was called and notified and ordered Mylanta (a medication used to relieve heartburn, acid indigestion or gas discomfort) 30 milliliters and to reassess the resident in 30 minutes. [was the resident reassessed and please add information about additional past chest pain incidents that led to hospital visits.]
On 7/10/17 at 1:26 p.m., during an interview and a review of a declaration (a formal written statement), Certified Nurse Assistant 1 (CNA 1) stated on 7/5/17 after lunch, at approximately 12:15 p.m., the resident complained to her of having heartburn and stated she was going to lie down in bed. CNA 1 stated she went on her lunch break and did not report Resident 1?s complaint of heartburn pain to a charge nurse and she was not aware if the charge nurse was informed. CNA 1 stated she should have notified and reported to the charge nurse of Resident 1?s complaint of heartburn so the resident could receive medications.
On 8/29/17 at 5:20 p.m., during an interview, the Assistant Director of Nursing (ADON) stated when a resident complained of heartburn, it was considered a change in condition and it should have been reported to the charge nurse immediately, so that the charge nurse could assess the resident. The ADON stated the charge nurse would assess the location of discomfort, onset, and the quality of discomfort. The ADON stated based on the findings of the assessment, the charge nurse could offer medications as needed (PRN medications). The ADON stated after the administration of PRN medications then the charge nurse should assess the resident for the effectiveness of the PRN medication and notify physician if not effective. The ADON stated heartburn could be mistaken for chest pain and each individual could experience chest pain differently.
On 7/14/17 at 12:30 p.m., during observation of the facility?s video footage dated 7/5/17, the day of the incident, the following was observed and verified by the Administrator as the events that occurred with Resident 1:
a. At 8:56 p.m., Resident 1 came out of her room and approached the nurse?s station looking into the nurse?s station. The Administrator stated Resident 1 collapsed to the floor and CNA 4 approached the resident.
b. At 8:57 p.m., Resident 1 was observed with her hands over her chest and Licensed
Vocational Nurse (LVN 1) came out of the nurse?s station to see the resident.
c. At 8:57.51 p.m., LVN 1 and CNA 4 assisted Resident 1 up from the floor and back to the room.
d. At 8:58.11 p.m., CNA 4 left Resident 1?s room and walked down the hallway.
e. At 8:58.22 p.m., LVN 1 came out of Resident 1?s room and went to the nurse?s station. The Administrator verified at this time it appears that Resident 1 was in the room unattended.
f. At 8:58.44 p.m., LVN 1 reentered Resident 1?s room.
g. At 8:58.47 p.m., Registered Nurse (RN 1) and CNA 4 entered Resident 1?s room.
h. From 8:59 p.m. to 9:11 p.m., the staff was observed going in and out of Resident 1?s room.
i.At 9:12 p.m., staff was seen bringing in an oxygen tank into Resident 1?s room (16 minutes after the resident had fallen complaining of chest pain).
j. At 9:20 p.m., the paramedics were seen outside of Resident 1?s room in the hallway of the facility.
A review of the facility?s incident note, dated 7/5/17, indicated at 8:50 p.m., Resident 1 walked to the nurse?s station and stated she had heartburn and requested Mylanta, while the resident was touching her stomach area. The incident note indicated when Licensed Vocational Nurse 1 (LVN 1) turned to prepare the Mylanta she heard another nurse ask the resident ?what was wrong?? After seeing Resident 1 fall to the floor. LVN 1 asked Resident 1 if she was okay and the resident replied, ?Yes.? The incident note indicated the staff assisted Resident 1 to her feet and escorted her to her room, but the resident had lost her balance again, while in the room, near the bed, and the staff had to assist her to the floor. According to the incident note, Registered Nurse 1 (RN 1) supervisor was notified and immediately came to see Resident 1. The incident note indicated Resident 1?s vital signs ([VS], measurements of the body?s most basic functions and include temperature, heart rate, respiratory rate, and blood pressure) were: blood pressure 130/108, heart rate 82, and oxygen saturation was 89%. The incident note indicated at 9:14 p.m., on the same day, emergency 911 was called and arrived at 9:18 p.m. The incident note indicated at 9:39 p.m. on 7/5/17, Resident 1 was declared deceased.
On 7/10/17 at 4:22 p.m., during an interview, CNA 4 stated on 7/5/17 at approximately 8:50 p.m., she and Licensed Vocational Nurse 1 (LVN 1) were at the nurse?s station. CNA 4 stated Resident 1 came to the nursing station requesting Mylanta for heartburn and resident fell to the floor. CNA 4 stated Resident 1 had her hands over her chest and stated that she did not feel good and her chest hurt. CNA 4 stated she and LVN 1 were assisting Resident 1 back to her room and the resident lost her balance and was assisted to the floor next to her bed. CNA 4 stated she went to get the supervisor, Registered Nurse 1 (RN 1). CNA 4 stated when RN 1 arrived to see Resident 1, the resident was not verbally responsive and could only make sounds like ?huh? huh.? CNA 4 stated when Resident 1 stopped making sounds and became unresponsive, RN 1 initiated chest compression (a lifesaving technique to restore blood circulation to the brain and other organs). CNA 4 stated LVN 1 called 911 for emergency help and once the paramedics arrived they provided cardiopulmonary resuscitation ([CPR] lifesaving procedure to restore blood circulation and provide rescue breathing) to Resident 1, but the resident was declared deceased by the paramedics.
On 7/10/17 at 4:43 p.m., during an interview, LVN 1 stated on 7/5/17 at 8:50 p.m., after the resident fell complaining of chest pain with labored breathing she was taken to her room. LVN 1 stated 911 was not called until Resident 1 became unresponsive and stopped breathing.
On 7/11/17 at 6:57 a.m., during an interview, RN 1 stated when she arrived in Resident
1?s room on 7/5/17 she saw the resident on the floor. RN 1 stated there was no oxygen being delivered to the resident and no vital signs had been assessed for the resident at that time. RN 1 stated Resident 1 was not able to produce words. RN 1 stated vital signs were taken: blood pressure 131/108 (normal reference range [NRR] 120/80), heart rate 82 (NRR 60-100), and fluctuating oxygen saturation between 80 to 90% (NRR 95-100%). RN 1 stated Resident 1 was placed on her side because the resident had a tendency to drool. RN 1 stated when she checked Resident 1?s carotid pulse (carotid pulse located on either side of the front of the neck just below the angle of the jaw and was used to determine the heart rate [pulse]), the pulse was thready (weak and difficult to feel). Resident 1 became unresponsive and RN 1 initiated chest compression on Resident 1, who was on the floor next to her bed. RN 1 stated at 9:12 p.m. (same day) (16 minutes after the resident complained of chest pain and had falling to the floor twice) the physician and an emergency call was made to 911. RN 1 stated she requested for an oxygen tank and Ambu bag (resuscitator bag used to assist with emergency breathing) from the staff. RN 1 stated once the paramedics arrived, they took over, but Resident 1 was pronounced deceased at 9:39 p.m., on 7/5/17 at the facility. RN 1 stated the staff had only informed her that Resident 1 had requested Mylanta for heartburn, but no other information was provided to her regarding the resident?s change of condition.
On 8/29/17 at 5:20 p.m., during an interview, the ADON stated when a resident complained of chest pain, the staff should assess the quality and location of pain and it was a medical emergency and 911 should be called as soon as possible. The ADON stated the facility did not have a specific policy and procedure on chest pain and emergency care.
A review of CNA 1?s witness statement indicated on 7/5/17 at 9:10 p.m., Resident 1 was lying on her side and staff was assessing the resident?s vital signs. The witness statement indicated Resident 1 was initially breathing shallow and then stopped breathing and moving. The witness statement indicated the staff was told to get an oxygen tank, but no one knew how to work it.
A review of RN 1?s written declaration, dated 8/22/17, indicated that CNA 4 came to her and stated, ?I don?t know what is going on with the resident (Resident 1), but the charge nurse told me to call you.? The declaration indicated upon assessment of Resident 1, the resident?s pulse was difficult to feel and had minimal response with fluctuating oxygen saturation of 80 to 85%. The declaration indicated when Resident 1 became unresponsive, she (RN1) asked the charge nurse to call the physician and 911, because the resident?s condition was deteriorating very fast.
A review of LVN 1?s written declaration, dated 8/29/17, indicated when Resident 1 was on the floor in her room, LVN 1 turned the resident on her left side because the resident appeared uncomfortable. The declaration indicated when RN 1 came in, she asked LVN 1 to take Resident 1?s vital signs. The declaration indicated LVN1 went to the nurse?s station to call the physician and left a message for the physician and then RN1 instructed her to call 911.
A review of the Fire Department?s Prehospital Care Report Summary, dated 7/6/17, indicated a call was received at 9:12 p.m. (which was approximately 15 minutes after Resident 1 complained of chest pain). The paramedics arrived and made contact with Resident 1 at 9:19 p.m. The report indicated the chief complaint and the provider impression was cardiac arrest (heart stop beating). The report indicated at 9:20 p.m., Resident 1 was assessed as unresponsive and unconscious (not alert and awake) lying supine (lying face upward) on the floor pulseless (no pulse) and apneic (breathless or respiratory arrest) with no trauma. The report indicated Resident 1 was in ventricular fibrillation (a serious heart rhythm, in which the heart quivers [tremble/shakes] and the heart cannot pump any blood causing cardiac arrest) and CPR was attempted but was unsuccessful. Resident 1?s Glasgow Coma Score was 3 (a scoring system used to describe the level of consciousness with a score between 3 and 15; 3 being the worst and 15 being the best). The report indicated the facility?s staff stated Resident 1 was unresponsive for 10 minutes before calling the Fire Department and total time w/o CPR before EMS arrival. The report indicated Resident 1 was pronounced dead at 9:39 p.m.
On 8/29/17 at 5:20 p.m., during review of Resident 1?s health record and concurrent interview, the Assistant Director of Nursing (ADON) stated Resident 1 had a diagnosis of tachycardia and history of complaining of chest pain. The ADON stated, after reviewing the record, that there were no care plans to address Resident 1?s tachycardia and complaints of chest pain, and there should have been. The ADON stated a care plan should include interventions for the resident to meet the resident?s goals.
A review of the facility?s policy and procedure titled, ?Change in a Resident?s Condition,? dated 2015, indicated ?Our facility shall promptly notify the resident, his or her attending physician, and Conservator/Los Angeles Public Guardian of changes in the resident?s medical/mental condition. The nurse supervisor/ charge nurse will notify the resident?s attending physician or on-call physician when there has been: A significant change in the resident?s physical/emotional/mental condition? Instructions to notify the physician of changes in the resident?s condition.?
A review of Resident 1?s Certificate of Death, dated 8/21/17, indicated the Resident 1 expired on 7/5/17 at 9:39 p.m. with the immediate cause of death being cardiorespiratory failure (the heart and lungs failure).
Based on observation, interview, and record review, the Department determined that the facility failed to provide Resident 1 with the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being and notify the nurse and physician when the resident?s condition changed, including but not limited to:
1. Failure to provide the necessary care and services to Resident 1 when there was a change in the resident?s condition.
2. Failure to notify the nurse when Resident 1, who had a history of chest pains and rapid heartbeat, complained of heartburn (known as acid indigestion, a burning sensation in the central chest or upper central abdomen) for approximately eight hours.
3. Failure to adhere to the facility?s policy and assess Resident 1?s change in condition and report to the physician.
4. Failure to call 911 (emergency services) timely after Resident 1 complained of chest pain and fallen twice, while holding her chest. The paramedics were not called until 16 minutes after Resident 1 complained of chest pain.
These violations jointly, separately, or in any combination, presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result and has a direct proximate cause of death for Resident 1. |
| 080000801 |
VILLAGE SQUARE HEALTHCARE CENTER |
080013648 |
B |
30-Nov-17 |
WQ5N11 |
9608 |
F309
483.25(h)(2)
Each resident receives adequate supervision and assistance devices to prevent accidents.
The facility staff failed to protect 1 of 1 sampled residents (1) during a toilet to a wheelchair transfer. As a result, Resident 1 fell and experienced pain and discomfort from an acute right non-displaced tibia fracture (aligned broken bone in the lower leg). In addition, Resident 1 did not see a physician for treatment of the fracture until the following day.
On 7/10/17 at 3 P.M. an initial on-site visit was made to investigate a facility self-reported fall injury for Resident (1), in an assisted toilet to a wheelchair transfer.
Resident 1 was admitted to the facility on 9/29/16 and 6/25/17, with diagnoses that included a urinary tract infection, lack of coordination, and history of right ankle stress fracture (small crack found in weight bearing bones), per the Resident Face Sheets.
According to Resident 1's Emergency Physician Documentation, on 7/3/17 at 8:47 A.M., Resident 1 fell on both knees at the facility. The Emergency Physician Documentation recorded an acute (new) fracture of the right proximal tibia (part of leg bone nearest the knee) with an abrasion below the right knee.
On 7/11/17, the medical record review indicated Resident 1 scored 15 out of 15 points on the Brief Interview for Mental Status assessment, dated 4/13/17. This meant Resident 1 was alert, oriented to make decisions.
The Minimum Data Set (MDS) assessment, on 4/13/17, indicated Resident 1 did not walk and required the assistance of one person for all transfers, which alerted the facility to create a care plan. Resident 1's balance was not steady and required staff to stabilize her when they moved her on and off the toilet and transferred between the wheelchair and bed which also alerted the facility to create a care plan.
A review of Resident 1's Care Plans failed to find a care plan for her individual transfer/support needs from toilet to wheelchair.
The Physical Therapy Evaluation Summary, completed on 6/28/17, indicated Resident 1 was unable to walk and required 75 % physical assistance.
The Occupational Therapy Evaluation Summary completed on 6/28/17, indicated Resident 1 was 100% dependent for toilet transfers. Resident 1 could not stand or step without loss of balance.
On 7/10/17 at 4:10 P.M., Resident 1 was observed sitting in bed. A leg immobilizer (light weight splint) was on her right leg. Resident 1's right lower leg had discolored bruising from knee to ankle.
On 7/10/17 at 4:10 P.M., Resident 1 said, on 7/2/17, she put on the bathroom call light for staff assistance with personal hygiene after using the toilet. Per Resident 1, CNA 1 came to help. Resident 1 said she told CNA 1 she "couldn't stand," but CNA 1 "had me stand." Resident 1 said CNA 1 lifted her into a standing position but "couldn't support me." Resident 1 said she fell and "fractured my knee." Resident 1 said the wheelchair and bathroom grab bars were too far to reach. Resident 1 said her wheelchair wasn't next to the toilet, motioning with her hands the distance was 14 to 16 inches away. Resident 1 said this fracture had caused her pain and numbness in her right leg, especially upon moving or turning in bed. Resident 1 said CNA 1 didn't use a gait belt (strap used as a belt by caregivers in transfers) to help lift and balance her.
On 7/12/17 at 6:07 A.M., in an interview, CNA 1 said she saw Resident 1's bathroom call light, "around 4:30 P.M." CNA 1 said she assisted Resident 1 to stand up from the toilet and step forward towards the opposite wall grab bars. CNA 1 said she didn't use a gait belt because Resident 1 didn't need that kind of help. CNA 1 said she cleaned Resident 1 and applied a new brief and then Resident 1's knees gave out. CNA 1 denied Resident 1 fell to the floor. CNA 1 said CNA 2 heard her cries for help and assisted her to get Resident 1 back to bed. CNA 1 said she reported this to the nurses (LN 1 and LN 2) immediately.
On 7/13/17 at 3:50 P.M., the DON provided CNA 1's written statement. It was dated, 7/2/17 at 4:30 P.M. and indicated, "As I was getting [Resident 1] off the toilet she stand up and she was complaining her knees hurts and then while I was helping her to the [wheel]chair her knees give out."
On 9/5/17 at 1:30 P.M., CNA 2 said she was familiar with Resident 1's care but wasn't assigned to her, on 7/2/17. CNA 2 said she took Resident 1 by wheelchair to the bathroom toilet. CNA 2 said Resident 1 could not take steps. CNA 2 said she parked Resident 1's wheelchair next to the toilet and physically lifted Resident 1 to stand and turn to sit on the toilet. CNA 2 said she placed the red bathroom call light in Resident 1's hand and told her to pull it when she was finished.
CNA 2 said she was in the hallway and heard Resident 1's roommate crying out. CNA 2 said she entered the bathroom and saw CNA 1 there and Resident 1 was on her knees in front of the toilet. CNA 2 said Resident 1 complained her right leg was hurt and numb. CNA 2 said she helped CNA 1 lift Resident 1 under her arms first to the toilet. CNA 2 said she stayed with Resident 1 and CNA 1 left to get the licensed nurse. CNA 2 said LN 3 came into the bathroom and examined Resident 1's right knee. CNA 2 said LN 3 told them it wasn't Resident 1's knee but her leg. CNA 2 said LN 3 directed them to have Resident 1 stand (bear weight) to transfer back to the wheelchair. LN 3 then directed Resident 1 be put back to bed.
On 7/12/17 at 10:30 A.M., in a telephone interview, LN 3 said, on 7/2/17 at around 5:30 P.M., she was asked to assess Resident 1 for right knee pain. LN 3 didn't ask Resident 1 what caused the pain. LN 3 said she had no knowledge Resident 1 fell. LN 3 explained Resident 1 didn't verbalize she had fallen until 8 P.M., when she continued to complain of right knee pain. LN 3 said she notified the on-call physician and x-rays were ordered.
On 9/5/17 at 3 P.M., LN 1 said she was administering medications on 7/2/17 when CNA 1 reported Resident 1's right knee was hurt in a transfer. LN 1 said she asked LN 3 to go to the room and assess Resident 1's knee. LN 1 said she saw Resident 1 later when she was complaining of right leg pain so the physician was called for x-ray orders.
Record review of Resident 1's facility X-ray Report, dated 7/3/17 at 2:57 A.M., indicated Resident 1's leg bone had a non-displaced fracture through the proximal tibia. This report was faxed to the physician at 3 A.M. Resident Progress Notes documentation by LN 5, dated 7/3/17 at 12:45 P.M., entry indicated, "Pt (patient) came back from ER..." "Pt had non displaced (aligned bone) fracture through right tibia, there is a knee immobilizer in place."
On 9/7/17 at 12:19 P.M., PT (Physical Therapist) 1 was interviewed with the DON and Administrator 2. After reviewing the Physical Therapy Summary, dated 6/28/17, PT 1 said Resident 1 required an assist of one person assuming up to 70% of the lift for the transfer. PT 1 said Resident 1 would need a strong person for the assist. PT 1 said he did not share his report with licensed nurses but expected them to read it in the medical record.
On 9/11/17 at 2:12 P.M., in a joint conference with the DON and Administrator 2, Occupational Therapist (OT) 1 explained the Occupational Therapy Summary, dated 6/28/17. OT 1 said the evaluation of Resident 1's functional ability was made 5 days before her fall. OT 1 continued that Resident 1 could not maintain a standing balance and, when standing with support, could not take a step. OT 1 said this evaluation became part of Resident 1's record and was not reported to licensed staff. OT 1 said she taught one CNA at the bedside how to work with the resident.
On 9/11/17 at 11 A.M., CNA 1's personnel file was reviewed with the DON. In orientation, on 11/11/16, CNA 1 watched a video on how to transfer residents. Per the DON, the facility didn't complete an evaluation of performance until 1 year after orientation. CNA 1 did not attend Transfers in-service training provided to CNAs in February, 2017.
On 9/11/17 at 2:24 P.M., in an interview, the DON acknowledged there was no transfer care plan in place to direct CNA care in Resident 1's transfer needs. The DON acknowledged Nursing Services were responsible for Resident 1's injury fall during the toilet to wheelchair transfer.
The facility's Individual Safety Responsibilities: Nursing, signed by CNA 1 on 11/11/16, indicated, "Nursing Aides are required to wear and use gait belts while on duty. They are considered part of the uniform. They are to be used with dependent patients."
The facility's P/P entitled Fall Prevention, release date 12/1/2005, indicated, "This is a program that has been designed to make a concerted effort to provide each patient with adequate supervision and assistive devices to prevent or decrease the risk of injury from falls."
The facility's P/P entitled Resident Transfer: Gait Belt, release date 8/15/2002, indicated, "A gait belt is used to transfer residents who do not have full function to safely transfer or ambulate without assistance, or who prefer using a gait belt."
The facility failed to implement their transfer and gait belt policies and procedures by failing to:
1. Use a gait belt.
2. Use correct wheelchair placement for transfer.
The facility's failure to implement transfer policies and procedures, put all the residents at risk for falls.
These violations had a direct relationship to the health, safety, and/or sense of security of residents. |
| 070000009 |
VISTA MANOR NURSING CENTER |
070013654 |
B |
5-Dec-17 |
2R4D11 |
9534 |
F323-483.25(d)(1)(2)(n)(1)-(3) FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES
(d) Accidents.
The facility must ensure that -
(1) The resident environment remains as free from accident hazards as is possible; and
(2) Each resident receives adequate supervision and assistance devices to prevent accidents.
(n) - Bed Rails. The facility must attempt to use appropriate alternatives prior to installing a side or bed rail. If a bed or side rail is used, the facility must ensure correct installation, use, and maintenance of bed rails, including but not limited to the following elements.
(1) Assess the resident for risk of entrapment from bed rails prior to installation.
(2) Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation.
(3) Ensure that the bed's dimensions are appropriate for the resident's size and weight.
The facility failed to prevent accidents and injury for Resident 3 when the facility failed to provide two-person assistance during a change of her incontinent pads. This failure resulted in Resident 3's fall with a fracture of the right femur (the bone located within the human thigh extending from the hip to the knee) and an open reduction internal fixation (ORIF - is a type of surgery used to stabilize and heal a broken bone).
Review of Resident 3's clinical record indicated she was admitted on 12/1/16 with diagnoses including abnormal posture, hypertension (HTN, abnormally elevated blood pressure), diabetes mellitus (DM, a condition in which the body's ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose in the blood and urine), malignant neoplasm (abnormal growth of tissue) of bladder. Resident 3's Minimum Data Set (MDS, an assessment tool) dated 12/07/16, indicated the resident BIMS (Brief Interview for Mental Status- an assessment tool for cognition) score of 13 indicating cognitively intact and was totally dependent that required two or more persons physical assistance with bed mobility and toilet use.
Review of Resident 3's Fall Risk Assessment dated 12/1/16 indicated she had a score of 13. A score of 10 or more indicated high risk for fall.
Review of Resident 3's Resident Data Collection dated 12/1/16 indicated she was dependent on personal hygiene and grooming. Resident 3's ADL records for the months of February and March 2017, indicated Resident 3 was dependent with two-person assistance for bed mobility and toilet use.
Review of Resident 3's ADL impairment care plan dated 12/5/16, indicated she was dependent and required two-person assistance with activities of daily living (ADLs, such as bed mobility, transfer, toileting and personal hygiene) related to bilateral knee contractures, history of left shoulder fracture, gall bladder cancer (CA - is a group of diseases involving abnormal cell growth with the potential to invade or spread to other parts of the body), DM, HTN, depression, hydrocephalus (a condition in which there is an accumulation of cerebrospinal fluid (CSF - a clear fluid that surrounds the brain and spinal cord) within the brain.
Review of Resident 3's Interdisciplinary team's (IDT, composed of different disciplines like nursing, social service, activities, rehabilitation, maintenance, who work together toward a common goal) care conference summary and quarterly review of bowel and bladder evaluation plan dated 3/8/17 indicated, she was totally dependent, incontinent with bladder and bowel and dependent from the staff for toileting needs.
Review of Resident 3's toileting needs care plan dated 12/5/16, indicated Resident 3 was incontinent (unable to voluntarily control retention) of both bowel and bladder that required total assistance.
Review of the potential for fall care plan dated 12/5/16 indicated Resident 3 was dependent for toileting status and had the potential to fall related to history of fracture left shoulder, right arm, and right foot osteomyelitis (inflammation of bones), narcotic and analgesic (pain medication) use, antihypertensive (medications to treat high blood pressure), hypoglycemia (low blood sugar level) that required assistance with ADLs PRN (as needed).
Review of Resident 3's Nurses notes dated 3/16/17 indicated the resident was found sitting on the floor, complained of pain on legs and thigh upon assessment and was given pain medication. The doctor was notified and an X-ray (procedure that creates imaging pictures of the inside of the body) was done. The physician's order dated 3/16/17 at 9:00 p.m. indicated X-ray of right and left leg, and right and left thigh STAT (immediately) due to complaint of pain.
Review of Resident 3's Change in Condition Post Fall report dated 3/16/17 indicated the resident was seen sitting on the floor on the left side of her bed. Per report, the certified nursing assistant (CNA) while changing the resident's diaper turned the resident to the left side, the CNA tried to prevent the fall but because the resident's weight was too much she put the resident to sit on the floor.
Review of Resident 3's Change in Condition Post - fall IDT done on 3/17/17 indicated, during an interview with the resident, she stated a CNA was helping her turn to her left side during incontinent care when she suddenly started to slip slowly out of bed. The CNA tried to put her back to bed but because of the resident's weight the CNA eased her down to the floor. The IDT post fall recommendation included two-person assistance for ADLs, educate and train CNA for proper technique during ADL care.
Review of Resident 3's findings of the X-ray of the right femur (two views) done on 3/17/17 indicated, there was a relatively acute angulated and moderately displaced supracondylar (a round part at the end of a bone where it fits into another bone) fracture of the distal right femur.
Review of Resident 3's nurses notes dated 3/17/17 indicated, the attending doctor was notified of Resident 3's X-ray findings with order to transfer Resident 3 to the acute hospital for further evaluation and management of right distal (situated away from the center of the body) fracture. Resident 3 was transferred to the acute hospital on 3/18/17 at 1:20 p.m.
Review of the acute hospital's diagnostic imaging report done on 3/18/17 indicated, right femoral shaft fracture (a break of the long, straight part of the thigh bone) of uncertain age. The imaging report done on 3/19/17 after the surgery indicated fluoroscopic (an imaging technique that uses X-rays to obtain real-time moving images of the interior of an object) spot images for intramedullary rod (also known as an intramedullary nail (IM nail) is a metal rod forced into the medullary cavity of a bone used to treat fractures of long bones of the body) placement right femur.
Review of Resident 3's readmission to the facility on 3/22/17, included diagnoses of HTN, hyperlipidemia (elevated lipid level), DM, and s/p (status post) right knee surgery with ORIF.
During Resident 3's observation and concurrent resident interview done on 11/14/17 at 8:30 a.m., Resident 3 stated, the fall happened when only one CNA assisted her to turn to her left side to change her diaper. She slipped out of bed after being turned to her left side, and fell on her right knee. Per resident, the CNA was alone at that time. The CNA should have asked for another staff for help which they usually do.
During an interview with registered nurse F (RN F) on 11/15/17 at 7:42 a.m., she validated, Resident 3 needed two-person assistance with all her ADLs.
During a phone interview with registered nurse H (RN H) on 11/15/17 at 10:30 a.m., she confirmed that the CNA worked by herself when changing Resident 3's diaper.
During an interview with licensed vocational nurse I (LVN I) on 11/15/17 at 1:50 p.m., she stated that the CNA reported working by herself when the resident was turned in bed while changing her diaper and fell on the floor. Per LVN, the CNA stated, she did not follow the two-person assistance needed during the ADL care.
During an interview and record review with the assistant director of nursing (ADON) on 11/15/17 at 2:10 p.m., she stated Resident 3 was a high risk for falls and required two-person assistance during ADLs. Per the ADON, if the CNA followed the care plan indicating two-person's assistance during the ADL care, the fall could have been prevented.
Review of the facility's 10/14/15 revised policy on "Falls Management", indicated a fall is an unintentional change in position coming to rest on the ground, floor or onto the next lower surface. Each resident must be assessed on admission using the Fall Risk Assessment form for potential risk for falls in order to take preventive approach. Identify the reason and/or risk factors for the fall in order to prepare a plan of care to reduce the potential for future falls.
The facility failed to prevent accidents and injury for Resident 3 when the facility failed to provide a two-person assistance during a change of her incontinent pads. This failure resulted in Resident 3's fall with a fracture of the right femur (the bone located within the human thigh extending from the hip to the knee) and an open reduction internal fixation (ORIF - is a type of surgery used to stabilize and heal a broken bone).
This had a direct relationship to the health, safety, or security of residents. |
| 070000003 |
VASONA CREEK HEALTHCARE CENTER |
070013583 |
B |
30-Oct-17 |
XY4011 |
3167 |
T22 DIV5 CH3 ART1-72038 Direct Caregiver "Direct caregiver" means a registered nurse, as referred to in Section 2732 of the Business and Professions Code, a licensed vocational nurse, as referred to in Section 2864 of the Business and Professions Code, a psychiatric technician, as referred to in Section 4516 of the Business and Professions Code, and a certified nurse assistant, or a nursing assistant participating in an approved training program, as defined in Section 1337 of the Health and Safety Code, while performing nursing services as described in sections 72309, 72311 and 72315. A person serving as the director of nursing services in a facility with 60 or more licensed beds cannot be a direct caregiver.
Initial implementation of this section shall be contingent on an appropriation in the annual Budget Act or another statute, in accordance with Health and Safety Code Section 1276.65(i).
The facility failed to ensure a nursing assistant (NA) who provided direct care to Patient 1 was certified and trained.
Review of Patient 1's Minimum Data Set (MDS, an assessment tool) dated 8/5/17 indicated, she was cognitively intact and used a bedpan for bladder elimination when in bed.
During an interview with Patient 1 on 10/17/17 at 12:20 p.m., she stated, the nursing assistant (NA A) assisted her to use the bedpan, but he did not place the bedpan properly on her buttocks.
During an interview with NA A on 10/24/17 at 9:25 a.m., he stated, certified nursing assistant B (CNA B) was busy when Patient 1 called for help to use the bedpan. He also stated, CNA B gave him instructions on how to put the bedpan to the patient. NA A stated, Patient 1 started to cry and told him, "You do not know what you are doing."
During an interview with CNA B on 10/17/17 at 2:42 p.m., she stated, she was assisting another patient when NA A told her Patient 1 needed a bedpan. CNA B stated, she gave an instruction to NA A on how to put the bedpan to Patient 1. She also stated, when she was busy assisting other patients NA A would help other patients to change their incontinent briefs by himself.
During an interview with staffing coordinator C (SC C) on 10/17/17 at 12:30 p.m., he stated, nursing assistants were not supposed to do patient care by themselves.
During an interview with the administrator (AD) on 10/17/17 at 1:50 p.m., he stated, NA A was not supposed to provide direct care to Patient 1.
Review of NA A's employee file, indicated NA A had no certification or approved training programs attended as required.
Review of nursing assistant duties and responsibilities indicated, to assist certified nursing assistants or nurses on activities of daily living of the patient such as toileting, incontinent care, bathing, dressing, grooming ambulating, transferring, and positioning.
Therefore, the facility failed to ensure an NA who provided direct care to Patient 1 was certified or trained.
The above violation has a direct or immediate relationship to patient health, safety, and security. |
| 950000077 |
VICTORIA CARE CENTER |
950013678 |
B |
6-Dec-17 |
3TR311 |
7850 |
F 323 (d) Accidents.
The facility must ensure that ?
(1) The resident environment remains as free from accident hazards as is possible; and
(2) Each resident receives adequate supervision and assistance devices to prevent accidents.
On 10/29/17, an unannounced recertification survey was conducted.
Based on observation, interview, and record review the facility failed to provide adequate supervision to prevent falls for Resident 2, who was assessed as high risk for falls by failing to:
Implement the plan of care that Resident 2 was at risk for falls and injury, therefore needing extensive assistance (resident involved activity, staff provide weight bearing support) in all of her activities of daily living and maintain visual checks when up in a wheelchair when necessary.
Certified Nurse Assistant (CNA) 1 left Resident 2 unattended in the bathroom while in a wheelchair and fell when Resident 2 was trying to wheel herself out of the bathroom.
As a result of this failure, Resident 2 sustained swelling, bruising, and skin tear to the left forehead with active bleeding that needed to be cauterized (burn the skin or flesh of a wound with a heated instrument or caustic substance) to stop the bleeding.
A review of the Admission Record indicated Resident 2 was readmitted to the facility on 10/2/17, with diagnoses that included chronic obstructive pulmonary disease (COPD), obstructive lung disease characterized by long term poor airflow); bronchitis (an inflammation of the bronchial tubes, the airways that carry air to your lungs); and abnormalities of gait and mobility.
Review of the facility's Resident Admission Assessment dated 10/2/17, indicated Resident 2 required an extensive assistance (with one person assist) in physical functioning that included: bed mobility, transfer, walking, locomotion on unit, locomotion off unit, dressing, eating, toilet use, personal hygiene, and bathing.
A review of the initial and quarterly Minimum Data Set assessment (a standardized assessment and care planning tool) dated 7/20/17 and 10/20/17, indicated Resident 2 had the ability in making self- understood and ability to understand others. A review of functional status for assistance of activities of daily living indicated Resident 2 required extensive assistance during transfer, locomotion on and off unit, dressing, toilet use, and personal hygiene.
A review of the Resident Care Plan, dated 10/3/17, indicated Resident 2 was at risk for falls/injuries, gait (manner of walking) imbalance, and needs assist extensive assistance with activities of daily living (ADLs). Resident 2 was also high risk for fractures (broken bones) due to osteoporosis (bones weaken and fracture [break] more easily), risk of unexplainable fracture and recent hospitalization. The care plan goals indicated will implement safety interventions to minimize injury potential. The care plan nursing approaches included to assess and observe level of awareness and judgment; maintain visual checks when up in a wheelchair and when in bed.
A review of the Licensed Nurses Notes indicated on 10/20/17 at 1 p.m., Resident 2 was found lying on the floor in a supine position (lying with the face upward). The licensed nurses notes also indicated the following: The physician examined the resident, had no new orders, resident able to recall and describe the incident, alert and oriented x 4 (a person's awareness of herself, those around her, her location and the date and time), with equal and strong bilateral (both) hand grip, able to move all extremities (hands and feet). The nurses notes also indicated that Resident 2 sustained a skin tear to the left side of forehead, 0.5 centimeters (cm) x 1 cm, with minimal bleeding and swelling noted with deep purple discoloration to surrounding skin, continue neurological checks (the assessment of motor responses, especially reflexes, to determine whether the nervous system is impaired) as ordered, no changes to baseline. The licensed nurses notes indicated that at 2 p.m., on the same date, Resident 2 was seen by the facility's wound consultant for the skin tear. Skin tear was noted with active bleeding and was cauterized (burn the skin or flesh of a wound) with a heated instrument or caustic substance) typically to stop bleeding or prevent the wound from becoming infected.
During an interview with the director of nursing (DON) on 10/26/17, at 6:30 p.m., she stated that Resident 2 fell in the bathroom. The DON stated that according to the certified nurse assistant (CNA) 1, she left Resident 2 in the bathroom unattended because CNA 1 forgot something, when CNA 1 came back she found the Resident 2 on the floor.
On 10/27/17, at 6 p.m., Resident 2 was observed lying in bed. Resident 2 had a dressing on her left forehead. During a concurrent interview, Resident 2 stated "the wheelchair threw me off when I was coming out of the bathroom." Resident 2 added that she did not know where the nurse went at that time.
During an interview on 10/27/17 at 7:20 p.m., the Director of Staff Developer (DSD) stated Resident 2 was assessed as needing extensive assistance in bed mobility and transfer. DSD stated CNAs are not to leave residents unattended at all times. DSD also stated that before the start of shifts, all staff meet for "huddles" (brief daily discussion) to keep them informed of the level of assistance each resident required. DSD stated she did not know why CNA 1 left Resident 2 unattended in the bathroom in the wheelchair. She also stated that extensive assistance means staff are not supposed to leave resident alone during ADL activities.
During an interview with the Director of Rehabilitation (DR) on 10/28/17, at 9 a.m., she stated that Resident 2 was not supposed to be left unattended, because "she needs extensive assistance with her ADLs." The DR added that Resident 2 cannot be left unattended while doing her ADLs.
A review of the facility IDT Accident/Incident Review, dated 10/20/17, indicated CNA 1 assisted the Resident 2 to the bathroom to brush her teeth and left the resident with instruction to call CNA 1 when she is finished (regular routine) but that day Resident 2 did not call. According to Resident 2, her wheelchair got stuck at the door on her way out, and she fell forward.
During a telephone interview with CNA 1 on 10/30/17, at 2:50 p.m., with the DSD as the interpreter, she stated that it had been the routine for her to set the resident in the bathroom on her wheelchair, so she can brush her teeth, then leave her while she makes the bed. CNA 1 stated that, "On 10/20 17, around 10 a.m., during the morning care, Resident 2's towel got wet and CNA 1 got out of the room to get Resident 2 a clean towel. I told resident to wait for me but, when I turned around, I saw her on the floor. It happened so fast." CNA 1 was asked if she was aware what level of care Resident 2 receives, CNA 1 stated extensive assistance because she provides perineal (region between the scrotum and the anus in males, and between the posterior vulva junction and the anus in females) care, combing hair, and dressing. CNA 1 also stated that she was not aware that she could not leave the resident alone in the bathroom.
The facility failed to ensure that Resident 2 received adequate supervision and assistance in accordance with the plan of care to prevent accidents by failing to implement a plan of care that addressed the prevention of falls and injury.
As a result, Resident 2 was left unattended on 10/20/17 on the wheelchair in the bathroom, fell and sustained swelling, bruising, and skin tear to the left forehead with active bleeding that needed to be cauterized to stop the bleeding.
This violation had a direct relationship to the health and safety or security of Resident 2. |
| 250001233 |
VERBENA HOUSE |
250013497 |
B |
5-Oct-17 |
JBHC11 |
5734 |
483.450 (b)(2) Interventions to manage inappropriate client behavior must be employed with sufficient safeguards and supervision to ensure that the safety, welfare and civil and human rights of clients are adequately protected.
On March 15, 2017, an unannounced visit was conducted to the facility to investigate a facility reported/ complaint incident of a fall when Client 1 sustained a laceration on the back of the head. It was determined that the facility failed to ensure Client 1 remained free from accident hazards to prevent further incidents of falls. This failure resulted in nine falls and seven head injuries.
Client 1 was admitted to the facility on November 11, 2011, with diagnoses that included seizure disorder, and epilepsy.
On March 15, 2017, at 10:45 a.m., Client 1 was observed sitting on the couch, wearing a hard helmet. Client 1 stood up, leaning forward with a unsteady gait. The Direct Care Staff (DCS) 1 assisted the client by holding the back of the client's pants while ambulating.
A concurrent interview was conducted with DCS 1. The DCS 1 stated Client 1, "always had unsteady gait ... always needs physical assistance when ambulating, and requires a helmet to wear at all times when awake."
Client 1's record indicated the following incidents:
1. February 1, 2016, fell out of bed, sustained laceration to the right eyebrow;
2. February 24, 2016, fell out of bed, right side of face swelling;
3. March 4, 2016, fell out of bed, sustained laceration to the right eyebrow;
4. March 11, 2016, fell on the left hand and wrist;
5. March 24, 2016, fell, sustained laceration to the left eyebrow;
6. January 17, 2017, fell to the ground, sustained laceration to the left eyelid;
7. January 25, 2017, fell while seated at the dining table, sustained laceration to the left eyelid;
8. February 6, 2017, fell while drinking water, sustained mouth bleeding;
9. February 27, 2017, fell while ambulating, sustained laceration to the left eyebrow; and
10. March 6, 2017, Client 1 hit head on the bed frame, sustained laceration on the back of the head.
Record reviews revealed seven of 10 incidents did not have documentation indicating Client 1 was wearing the hard helmet. Two of 10 incidents documented the client removed the helmet, and one incident documented the client refused to wear the helmet.
The physician order dated February 21, 2013, indicated "... HELMET WORN WHILE AWAKE ..."
The nursing care plan, dated, February 2, 2016, indicated "Staff to monitor client for unsteady gait ... ensure client is wearing helmet at all times while awake."
There were no additional interventions and evaluation on the nursing care plan for Client 1 on each episode of falls, to prevent and manage the client's falls.
The nursing care plan for, "at risk of injury due to unsteady gait," was not updated, revised, and re-evaluated, when Client 1 had multiple incidents of falls.
A review of the Physical Therapy evaluation note, dated May 11, 2016, indicated, "... Uses hardshell helmet for safety ... keep his helmet on while ambulating ..." There was no documentation indicating the physical therapist assessed or evaluated Client 1's falls.
On March 23, 2017, at 10:30 a.m., an interview was conducted with the Program Manager (PM). The PM indicated there were no physical therapy and occupational therapy assessments and there were no objectives related to the client's refusing to wear the protective helmet.
The PM also stated there were no meetings conducted to discuss the issues of Client's 1 history of multiple falls.
A review of Occupational Therapy notes, dated May 2016, indicated, "... equilibrium appears to be off and is gait is unsteady. He has recent history of falls ..."
There were no further assessments, evaluations, or recommendations by the Physical Therapist or Occupational Therapist to manage the client's falls.
A review of Psychiatry progress note, dated December 8, 2016, indicated, "... Recommend higher level of care due to DTO (danger to others) and extreme resistance then followed with aggression ..."
There was no documentation the facility attempted to place Client 1 to a higher level of care from December 2016 to January 27, 2017.
A review of the Qualified Intellectual Disability Professional (QIDP) notes from January 2016 through December 2016, revealed there were no behavior objectives to manage Client 1's refusal to wear the helmet or the falls.
The facility's policy and procedure titled, "FALLS," indicated, "... If the falls is a result of resistive or maladaptive behavior, the Behaviorist will be consulted for additional possible intervention appropriate to control/redirect the behavior ... the staff report form should include an assessment /investigation of the cause or likely cause of the fall and recommendations to ensure safety ..."
There was no documentation the Behaviorist was contacted until February 28, 2017.
A review of the staff report forms dated, February 24, 2016, January 17 and 25, 2017, revealed no investigation related to the cause of the client falls.
There were total of nine episodes of falls from February 2016 - February 2017 with seven episodes of head injury from the multiple falls.
On March 15, 2017, at 2:15 pm., the Registered Nurse consultant (RNC) was interviewed. She confirmed the Nursing Care Plan for the at risk of fall was not updated, revised, and re-evaluated.
Therefore the facility failed to ensure Client 1 remained free from injury resulting in seven head injuries with lacerations. The violation of the above regulation has a direct relationship to the health, safety, or security of the client. |
| 630014894 |
Veterans Home of California - Fresno |
150013170 |
A |
17-Nov-17 |
LOW511 |
4659 |
F323 483.25(d) (1)-(2) Free of Accident/Hazards/Supervision/Devices
(d)Accidents
The facility must ensure that -
(1) The resident environment remains as free from accident hazards as is possible; and
(2) Each resident receives adequate supervision and assistance devices to prevent accidents.
On 10/24/16 at 2:30 p.m., an onsite visit was conducted to investigate Entity Reported Incident (ERI) number CA00506968.
The facility failed to ensure each resident received adequate supervision to prevent accidents for one sampled resident (Resident 1), when Certified Nurse Assistant (CNA) 1 did not adequately supervise Resident 1 during personal care. This failure resulted in Resident 1 falling from bed and sustaining a Left Femur (hip) Fracture. This failure caused injury to Resident 1 and the potential for further health complications and subsequent death.
Resident 1's face sheet indicated he was a 94 year old male who was admitted to the facility on 2/11/16. Resident 1 had a diagnosis of unspecified dementia, major depressive disorder, age-related osteoporosis, and incontinence. Resident 1 has a history of poor safety awareness, combative/resistance to care, and agitation.
On 10/27/16 at 3:15 p.m., during an interview, CNA 1 stated on 10/11/16 at approximately 10:30 p.m., Resident 1 needed to have personal care provided. CNA 1 stated Resident 1 requires assistance from two CNAs to perform this task as Resident 1 has a history of aggressive behavior toward staff while they are performing care. CNA 1 stated, "Usually we have two people [to assist with personal care] but at that time he [Resident 1] was being pleasant and there wasn't anybody around to help, they were all busy," was the reason why she decided to perform the personal care without the assistance of a second CNA. CNA 1 stated she raised Resident 1's bed into high position, lowered the bed rails and asked Resident 1 to turn on his right side so she could perform personal care. CNA 1 stated Resident 1's back was toward her and his left arm was on top. CNA 1 stated as she was performing the personal care Resident 1 aggressively swung his left arm back over his body toward her and when she stepped back to dodge the blow, Resident 1 rolled out of bed and landed on the floor with his weight on his left knee.
Review of Resident 1's clinical record indicated Resident 1 was transferred to the emergency department where he was diagnosed with an acute left femur fracture.
Review of Resident 1's Interdisciplinary Team (IDT) meeting dated 10/11/16, indicated contributing factors prior to fall; combative/resists care, anxious, agitated.
Review of Resident 1's Care plan dated 8/18/16, updated 10/18/16, indicated Resident 1 was at risk for injury to self and others related to aggressive behavior and diagnosis of Alzheimers. Resident 1 has shown aggressive behavior such as hitting others.
Review of Resident 1's "Minimum Data Set" (MDS- assessment tool used to indicate what type of care a resident requires), dated 8/3/16, indicated Resident 1 required a two person physical assist for bed mobility.
Review of Resident 1's Activity of Daily Living (ADL) care plan dated 8/18/16, had no documented evidence the number of staff needed for assistance with bed mobility.
On 4/19/17 at 2:40 p.m., during an interview, CNA 2 stated it would not be safe to attempt providing a one person physical assist for personal care on a resident who was supposed to have a two person assist especially if they had a history of aggressive behavior. CNA 2 stated, "Don't risk it."
On 4/19/17 at 2:45 p.m., during an interview, CNA 3 stated it would place the resident at risk of falling if a one person assist is used when the resident needs a two person physical assist.
On 4/19/17 at 2:50 p.m., during an interview, CNA 4 stated if an aggressive resident requires a two person physical assist you would not want to do it on your own. CNA 4 stated two people should be used for safety so the patient does not fall.
Review of Resident 1's clinical record indicated, "Death Notification Form" dated 10/20/16 at 9:55 a.m., indicated, Death caused... Respiratory Failure... Due to, or as a consequence of, Pulmonary Embolism... Due to, or as consequence of Left Femoral Fracture...
The facility was not able to provide a policy and procedure for Accident/Hazard or Care Planning as requested by the end of the investigation.
This violation caused injury to Resident 1 and the potential for further health complications including subsequent death of Resident 1 and therefore constitutes a class "A" citation. |
| 630014895 |
Veterans Home of California - Redding |
150013628 |
A |
21-Nov-17 |
2UBD11 |
10816 |
PATIENT RIGHTS
CFR T42 483.12(b) (1)-(3) PROHIBIT MISTREATMENT/NEGLECT/ MISAPPROPRIATION
483.12 The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's symptoms.
483.12(b) The facility must develop and implement written policies and procedures that:
(b)(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property,
(b)(2) Establish policies and procedures to investigate any such allegations, and
(b)(3) Include training as required at paragraph 483.95
The facility failed to prevent 1 of 3 sampled residents from neglect when licensed staff (RN 3) failed to assess a resident (Resident A) during a change of condition (change in health status), failed to offer medication for nausea and vomiting, and failed to provide wound care. Unlicensed staff notified RN 3 that the Resident A was not feeling well and complained of symptoms that could have been cardiac related. The assigned licensed staff nurse (RN 3) failed to assess Resident A following notification of the change of condition and Resident A was subsequently discovered deceased during change of the shift.
On 7/28/17, an investigation was initiated regarding a complaint that Certified Nursing Assistants (CNA 5, CNA 6) had notified a registered nurse (RN 3) that Resident A needed attention. The resident was described as displaying symptoms, which could have been related to his known cardiac condition. The complainant reported that although RN 3 was notified, RN 3 did not assess the resident, have another RN assess the resident, did not provide wound care as ordered, or provide any other interventions. Resident A was found by staff deceased in his room at 6:35 a.m. on 6/18/17.
Resident A's medical record was reviewed on 8/29/17. The June 2017 Treatment-Wound Administration record for Resident A, dated 6/1/17 through 6/30/17 indicated the resident had four wounds, one skin tear above the left knee, one on the back of the left hand, a right wrist skin tear, and left gluteal fold (between leg and buttock) wound. Wound care treatment orders showed treatments were to be performed daily on the night (NOC) shift.
Further review of Resident A's medical record on 9/6/17, included the History and Physical (H&P), dated 1/4/16. The H&P indicated Resident A, age 81, had primary diagnoses including Coronary Artery Disease (reduce blood flow through the cardiac arteries), Cardiac Artery Bypass Surgery (Surgery performed to bypass occluded arteries), Gastro Esophageal Reflux Disease (Stomach contents leak backwards into the throat), Atrial Fibrillation (rapid, irregular beating of the upper chamber of the heart) and severe Peripheral Neuropathy (degeneration of nerves in extremities). Resident A's mental and behavioral status was documented as alert and "agreeable."
On 8/9/2017 at 2:30 p.m., when asked about the night of 6/17/17, CNA 8 stated a supervising registered nurse (SRN) had been working on the staff schedule for the 6/17/17 night shift. CNA 8 was taking Resident A's blood pressure when Resident A overheard the SRN mention that for the 6/17/17 night shift, RN 3 was to be assigned to care for Resident A. Resident A specifically told the SRN he did not want RN 3 to take care of him.
During interview with a supervising registered nurse (SRN 1), on 8/10/17 at 9:00 a.m., SRN 1 stated that although he had not worked the night of the event, he was aware Resident A and RN 3 had a relationship with conflict. SRN 1 characterized Resident A as having been very alert and an advocate for other residents at the facility. According to SRN 1, Resident A had asked for a change of nurses 3-4 weeks previously, not wanting RN 3 to provide care to him. SRN 1 had looked into making the change and informed Resident A that he would try to accommodate the resident's request. SRN 1 stated to accommodate the request, a resource nurse (a nurse available to assist with assessments, treatments and administration of medications) could do that resident's dressing changes or give his medications. SRN 1 stated during the 6/17/17 night shift, RN 3 should have traded assignments with a resource nurse to accommodate Resident A's request not to be cared for by RN3.
During interview with CNA 6, on 8/9/17, at 1:50 p.m., CNA 6 indicated she worked the 6/17/17 night shift (from 10 p.m. to 6:30 a.m.) and helped CNA 5 during the shift, assisting with the call lights and covering her for breaks that night. CNA 6 stated Resident A, complained of dry heaves, nausea, and did not feel well. CNA 6 stated Resident A was not the "same," with slow movements and speech. CNA 6 notified RN 3 several times during that night shift, that Resident A wanted medications for nausea. RN 3 stated, outside of Resident A's room, "He doesn't like my face; I can't go into that room." RN 3 did not go into the room per CNA 6. According to CNA 6, this event occurred around 4:00 a.m. or 5:00 a.m., toward the end of the shift.
During an interview on 8/10/17 at 10:00 a.m., CNA 5 stated she worked the 6/17/17 night (NOC) shift, as the direct care provider for Resident A. Resident A put on the call light and informed her that he wanted the head of the bed up and had "dry heaves." CNA 5 reported to RN 3 between 3-4 a.m., that Resident A looked sick and had dry heaves while she was getting a basin for the resident. CNA 5 stated she had not observed RN 3 check on Resident A and CNA 5 did not witness any refusal of care by the resident.
During an interview with RN 3 on 8/11/17 at 2:36 p.m., RN 3 stated she was notified of Resident A's condition at 1:00 a.m. and checked on him at that time. Resident A was watching TV, and refused wound care treatment. RN 3 stated Resident A did not like her. RN 3 stated she was "off the clock when patient was found dead."
Review of Resident A's Medication Administration Record (MAR) on 8/23/17, dated 6/1/2017 through 6/30/17, showed an order for Ondansetron HC (used for nausea and vomiting) 4 mg. (milligrams) - take 1 tab by mouth every 6 hours as needed. There was no documentation on the MAR showing that medication for nausea had been given, nor was there any documentation of refusal of antiemetic (to prevent/relieve nausea) medication on 6/17/17 or 6/18/17.
During an interview with RN 4, on 8/23/2017, at 3:28 p.m., RN 4 stated when she arrived to work on the a.m. shift, 6/18/2017, Resident A was found unresponsive by a CNA on day shift. There was no report from RN 3 regarding Resident A's change of condition, complaints or status, nothing mentioned during the change of shift report. The patient expired at 6:35 a.m. on 6/18/17.
During an interview with RN 7, on 8/29/17 at 10:10 a.m., RN 7 stated she had been a resource nurse on the 6/17/17 NOC shift. She indicated she worked the NOC shift on 6/17/17 on another unit, which was next to the unit where RN 3 was assigned. RN 7 stated she was aware of the relationship between Resident A and RN 3. The RN stated a resource nurse could work both units. If there was friction between the patient and the RN 3, RN 7 could have provided care to Resident A. RN 7 stated that RN 3 did not ask RN 7 to give Resident A's medication or provide wound care treatment to the resident that night.
On 8/29/2017, record review showed no written evidence that wound care had been provided on the 6/17/17 NOC shift. The Treatment-Wound Administration record for Resident A, dated 6/1/17 through 6/30/17 indicated the resident had four wounds with wound care treatment orders to be performed on the NOC shift. On the record where a signature would have indicated the treatment had been done, instead there was RN 3's signature circled, indicating the treatment was not performed. On the back of the wound care record, RN 3 documented, "All tx's (treatments) for NOC'S done by resource nurse." The resource nurse, during the 8/29/17, 10:10 a.m. interview, stated she did not provide wound care to Resident A and had not been asked to.
The medical record included a Gastric Care Plan, dated 3/21/16. Within the plan were instructions to notify a physician if the resident had signs/symptoms of GI distress. No record of physician notification was in the record.
Review of the vital signs record for Resident A for 6/17/17 or 6/18/17, indicated that there were no vital signs done for Resident A.
Review of the facility policy and procedure titled, "Notification of Physician, Resident, and Representative, dated 3/1/17, stated licensed staff of the Skilled Nursing Facility (SNF) must notify the resident, physician, and representative of significant or changes in the condition in the residents' condition."
During medical record review, the Interdisciplinary Progress notes for Resident A, showed no documentation for 6/17/17 NOC shift on that resident until after he was found deceased.
During an interview at 11:30 a.m. on 8/9/17, the Director of Nursing (DON) stated wound care was usually done on NOC shift. The DON stated if a resident had a request the facility was unable to accommodate, it should investigate the problem, and switch with another staff person to provide care for a resident if it was a staff-client conflict. She stated she knew of the relationship with Resident A and RN 3. The DON said the standard policy, if there was a change in condition of a resident, if reported, was that an assessment should be done, a physician called if needed, and vital signs should be reported to oncoming nurses.
During an interview with the Skilled Nursing Facility administrator, on 8/9/17, at 3:10 p.m., the administrator stated when there was a conflict between staff and residents, the procedure was to provide conflict resolution, assess the situation and resolve the issues. A resource nurse would provide care if a patient refused treatment from the main nurse.
The Certificate of Death for Resident A was reviewed on 9/1/17. The indicated time of death was 6/17/17 at 6:35 a.m. The immediate cause of death was Coronary Artery Disease and Atherosclerotic Cardiovascular Disease.
Failure to assess and provide care for Resident A following notification of a change of condition presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result. |