| 020000054 |
Willow Tree Nursing Center |
020009068 |
B |
02-Mar-12 |
K04O11 |
2678 |
Title 22 72520 (a) If a patient of a skilled nursing facility is transferred to a general acute care hospital as defined in Section 1250(a) of the Health and Safety Code, the skilled nursing facility shall afford the patient a bedhold of seven (7) days, which may be exercised by the patient or the patient's representative. ( c) A licensee who fails to meet these requirements shall offer to the patient the nxt available bed appropriate for the patient's needs. The facility violated the above regulations by failing to readmit Patient 1 when he was ready to return to the facility from the acute care hospital. On 2/8/11, record review showed that Patient 1 was admitted to the facility on 7/8/10 with diagnoses including Spina Bifida (birth defect that leaves the spinal column exposed), pressure sores and a colostomy (body waste is drained into bag attached to the abdominal wall).According to a physician order dated 1/6/11, Patient 1 was transferred to the hospital for treatment of nausea and vomiting and complaints of chest pain. A written bed hold notice was issued to Patient 1 at the time of transfer on 1/6/11. The bed hold period ended on 1/13/11. Review of the hospital record showed that on 1/11/11 the hospital discharge planner called the facility to arrange for Patient 1 to return after a minor surgical procedure on 1/12/11. The discharge planner documented "They are not willing to accept [patient] back."The hospital record contained a report dated 1/13/11 (day seven of the bed-hold) written by the physician indicating "Cleared for [discharge] to [skilled nursing facility]".Beginning on 1/11/11 until 2/22/11, the hospital discharge planner contacted the facility nine times asking to return the patient. The facility refused each time indicating that there was no bed available. The facility has a total of 82 beds and none of the beds were in suspension between 1/11/11 and 3/15/11 and at no time during this period were all the beds filled. During a meeting on 2/11/11 at 11 a.m., the Administrator and Director of Operations stated that they would not readmit Patient 1 under any circumstances because the Patient had an odor.During a telephone interview on 2/8/11 at 10:34 a.m. Patient 1 stated he had been at the facility for almost a year and wanted to return to it.On 3/15/11, the hospital discharged Patient 1 to a skilled nursing facility in another city.Therefore the facility failed to ensure that Patient 1 was readmitted when he was determined able to return to the facility. The above violation caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety or other emotional trauma to the patient. |
| 140000082 |
Windsor Rosewood Care Center |
020009798 |
B |
25-Apr-13 |
00JP11 |
7492 |
?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 ensure that Resident 1 was not discharged from the facility unless the reason for such action was 1) necessary for the welfare of the resident and the needs of the resident could not be met in the facility, 2) the health of the resident improved sufficient so that the resident no longer needed the services provided by the facility, 3) the safety of individuals in the facility was endangered, 4) the health of individuals in the facility would otherwise be endangered, 5) the resident failed, after reasonable and appropriate notice, to pay for a stay at the facility, or 6) the facility ceased to operate.For Resident 1 the facility did not identify any of these six specific regulatory reasons prior to and/or at the time of involuntary discharge of Resident 1 on 8/22/11. Failure to discharge Resident 1 for a lawful reason increased the risk of unmet needs, increased confusion, fear, anxiety and/or depression that would result in higher doses of psychotropic medications with potentially irreversible adverse side effects, and avoidable physical and/or mental decline. Record review conducted on 12/17/12 identified the following information. Resident 1 was admitted to the Secured Alzheimer's Unit of the facility on 5/7/09. Diagnoses included Alzheimer's disease, failure to thrive - adult, other altered consciousness, and debility. Resident 1 received Xanax 0.125 mg every-other-day for anxiety manifested by motor restlessness and Remeron 7.5 mg daily for depression as evidenced by weight loss. Review of the Minimum Data Sets (the facility's comprehensive assessment of the resident's status with quarterly reviews) dated 3/8/11 and 6/7/11 revealed that Resident 1 had long and short term memory problems, severely impaired cognitive skills for daily decision making, and that community placement was not appropriate. The MDS also indicated that Resident 1 had 1) physical behavior directed toward others up to three times weekly that put the resident and others at significant risk of physical injury and that interfered with care, 2) rejected care up to three days weekly, and 3) wandered daily, placing the resident at significant risk of an accidental injury, and significantly intruded on the privacy or activities others. At 8:40 p.m. on 8/19/11 the physician ordered, "Discharge to [skilled nursing facility with] meds on 8/20/11." A nursing note written at noon on 8/22/11 indicated, "...being [discharged to skilled nursing facility...11:30 a.m." No reason for the discharge was given in the physician orders or the nursing note. Further review of the clinical record showed no documented evidence of an acceptable reason for discharge from the facility. The clinical record contained copies of two letters that the administrator sent to a family member. None of the six specific regulatory reasons for an involuntary discharge of Resident 1 was described in either letter. 1) The first, a letter dated 7/18/11, contained the following statements: "...time to up-date our families, friends and conservators who have loved ones or clients who reside in our secure unit. We have received approval to proceed with opening our sub-acute unit... In the up-coming weeks we will be gathering information and working with families, friends and conservators to assist with the relocation of residents currently residing in our secure unit. Social Service is working with area facilities for bed availability and to arrange tours for families, friends and conservators." 2) The second, a letter dated 8/18/11, contained the following statements: "to up-date everyone on our on-going project to transition the secure unit to a sub-acute unit. The progression is slower than we had planned... The projection is now for mid November to early December before we will need to pursue relocation of our residents currently residing in our secure unit. Social Services will continue to work with area facilities on bed availability and to arrange tours for families, friends and Conservators." During an interview at 10:30 a.m. on 11/21/12, the Administrator stated that she was not the facility administrator at the time of this discharge action. She stated that the information found in the clinical record and what the Social Service Designee can recall is all that is available. During an interview at 11:30 a.m. on 12/27/12, the Social Service Designee (SSD) reported attending a meeting in April 2011 between the Medical Director of the Secured Alzheimer's Unit (SAU) and two or three family members. The SSD stated that during the meeting the Medical Director made statements to the family members indicating that there had been closures of dementia units in California. At the time, the facility was completing electrical work necessary for equipment needed for sub-acute patients in the resident rooms of the SAU. The Medical Director (MD) of the Secured Alzheimer's Unit (SAU) was a neurologist who specialized in Alzheimer's disease. During an interview at 2:37 p.m. on 12/31/12 the MD stated that he was never informed of the facility plans for closing the SAU by the facility administrator. He recalled speaking to "two or three" family members in April 2011. He stated that during the conversation he noted the closure of a number of secured units for residents with dementia in California and that he thought the facility would eventually phase out the SAU. During the interview on 12/31/12 the MD stated that "change causes enormous affect on each person with Alzheimer's disease (AD) and it takes about six weeks for the person [with AD] to adapt." During an interview at 11:33 a.m. on 1/30/13 the responsible party (RP) stated that the facility staff "told me that I had 30 days, not even that, to find a new placement for [Resident 1] because the Secured Alzheimer's Unit (SAU) was closing and reopening as a brain-damaged unit. When they told me they were discharging [Resident 1], I was upset. I left crying. It was devastating. I couldn't sleep [while] thinking, 'What am I going to do with [Resident 1]?'" The RP was unable to recall receiving any letters regarding the planned closure of the SAU. Therefore: The facility violated the above regulation when the facility involuntarily discharged Resident 1 to another facility on 8/22/11. The facility did not show that Resident 1 was suitable for discharge due to any of the six reasons stated in the regulation. These violations had a direct relationship to the health, safety, or security of Resident 1. |
| 140000082 |
Windsor Rosewood Care Center |
020009799 |
B |
25-Apr-13 |
00JP11 |
6988 |
?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 ensure that Resident 3 was not discharged from the facility unless the reason for such action was 1) necessary for the welfare of the resident and the needs of the resident could not be met in the facility, 2) the health of the resident improved sufficient so that the resident no longer needed the services provided by the facility, 3) the safety of individuals in the facility was endangered, 4) the health of individuals in the facility would otherwise be endangered, 5) the resident failed, after reasonable and appropriate notice, to pay for a stay at the facility, or 6) the facility ceased to operate.For Resident 3 the facility did not identify any of these six specific regulatory reasons prior to and/or at the time of the involuntary discharge of Resident 3 on 9/7/11. Failure to discharge Resident 3 for a lawful reason increased the risks of unmet needs, avoidable weight loss, physical altercations due to miscommunication, and increased doses of psychotropic medications with potentially irreversible adverse side effects to manage behavior. Record review conducted on 12/17/12 identified the following information: Resident 3 was admitted to the Secured Alzheimer's Unit of the facility on 9/9/10. Diagnoses included dementia with agitation, failure to thrive, and severe conductive hearing loss. Resident 3 received Depakote 125 mg twice daily for episodes of sudden angry outbursts; Seroquel 50 mg twice daily for episodes of striking out, throwing things and pushing others; and Remeron 7.5 mg at bed time for poor appetite. Review of the Minimum Data Sets (the facility's comprehensive assessment of the resident's status with quarterly reviews) dated 9/21/10 and 6/18/11 revealed that Resident 3 had long and short term memory loss, modified independence in cognitive skills for daily decision making, daily episodes of physical and verbal behavior, and that community placement was not appropriate. In an undated discharge plan a nurse documented, "Resident is hard of hearing...staff communicate by writing..." In another undated document staff wrote that Resident 3 was afraid of having personal items (books, etc) stolen and used an over-bed table to keep things within reach. Resident 3 sometimes threw books or magazines to keep others away and spat on the floor. On 9/6/11 the physician ordered, "Discharge to [skilled nursing facility with] meds when arrangements are made." A nursing note written at 10:40 a.m. on 9/7/11 indicated, "Discharged to [skilled nursing facility]..." No reason for the discharge was given in the physician orders or the nursing note. Further review of the clinical record showed no documented evidence of an acceptable reason for discharge from the facility. The clinical record contained copies of two letters sent to the responsible party by the facility administrator. None of the six specific regulatory reasons for an involuntary discharge of Resident 3 was described in either letter.1) The first, a letter dated 7/18/11, contained the following statements: "...time to up-date our families, friends and conservators who have loved ones or clients who reside in our secure unit. We have received approval to proceed with opening our sub-acute unit... In the up-coming weeks we will be gathering information and working with families, friends and conservators to assist with the relocation of residents currently residing in our secure unit. Social Service is working with area facilities for bed availability and to arrange tours for families, friends and conservators." 2) The second, a letter dated 8/18/11, contained the following statements: "...to up-date everyone on our on-going project to transition the secure unit to a sub-acute unit. The progression is slower than we had planned... The projection is now for mid November to early December before we will need to pursue relocation of our residents currently residing in our secure unit. Social Services will continue to work with area facilities on bed availability and to arrange tours for families, friends and Conservators." During an interview at 10:30 a.m. on 11/21/12, the Administrator stated that she was not the facility administrator at the time of this discharge action. She stated that the information found in the clinical record and what the Social Service Designee can recall is all that is available. During an interview at 11:30 a.m. on 12/27/12, the Social Service Designee (SSD) reported attending a meeting in April 2011 between the Medical Director of the Secured Alzheimer's Unit (SAU) and two or three family members. The SSD stated that during the meeting the Medical Director made statements to the family members indicating that there had been closures of dementia units in California. At the time, the facility was completing electrical work necessary for equipment needed for sub-acute patients in the resident rooms of the SAU. The Medical Director (MD) of the Secured Alzheimer's Unit (SAU) was a neurologist who specialized in Alzheimer's disease. During an interview at 2:37 p.m. on 12/31/12 the MD stated that he was never informed of the facility plans for closing the SAU by the facility administrator. He recalled speaking to "two or three" family members in April 2011. He stated that during the conversation he noted the closure of a number of secured units for residents with dementia in California and that he thought the facility would eventually phase out the SAU. During the interview on 12/31/12 the MD stated that "change causes enormous affect on each person with Alzheimer's disease (AD) and it takes about six weeks for the person [with AD] to adapt." Therefore: The facility violated the above regulation when the facility involuntarily discharged Resident 3 to another facility on 9/7/11. The facility did not show that Resident 3 was suitable for discharge due to any of the six reasons stated in the regulation. These violations had a direct relationship to the health, safety, or security of Resident 3. |
| 140000082 |
Windsor Rosewood Care Center |
020009800 |
B |
25-Apr-13 |
00JP11 |
7262 |
F201 ?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 ensure that Resident 4 was not discharged from the facility unless the reason for such action was 1) necessary for the welfare of the resident and the needs of the resident could not be met in the facility, 2) the health of the resident improved sufficient so that the resident no longer needed the services provided by the facility, 3) the safety of individuals in the facility was endangered, 4) the health of individuals in the facility would otherwise be endangered, 5) the resident failed, after reasonable and appropriate notice, to pay for a stay at the facility, or 6) the facility ceased to operate.For Resident 4 the facility did not identify any of these six specific regulatory reasons prior to and/or at the time of the involuntary discharge of Resident 4 on 9/30/11. Failure to discharge Resident 4 for a lawful reason increased the risk of unmet needs and the risk of confusion, fear, refusal to eat, premature decline, and increased use of psychotropic medications with potentially irreversible adverse side effects to manage increased inappropriate behavior after the discharge. Record review conducted on 12/17/12 identified the following information. Resident 4 was admitted to the Secured Alzheimer's Unit of the facility on 2/15/10. Diagnoses included Alzheimer's disease, degenerative osteoarthritis, and glaucoma. An undated discharge document indicated that Resident 4 did not speak English, engaged in pacing the hallways and occasionally entered the rooms of other residents and took their things without permission, and was argumentative at times. Review of the Minimum Data Sets (the facility's comprehensive assessment of the resident's status with quarterly reviews) dated 8/8/11 and 2/11/11 revealed that Resident 4 had long and short term memory problems, modified independence in cognitive skills for daily decision making, and that community placement was not appropriate. Resident 4 received Seroquel 25 mg twice daily for episodes of agitation noted as angry outbursts, Depakote 250 mg twice daily for mood swings, Celexa 10 mg daily for episodes of feelings hopelessness, and Ativan 1 mg every six hours as necessary for nervousness that causes extreme distress. On 9/30/11 the physician ordered, "Discharge to [skilled nursing facility with] meds on 9/30/11." A nursing note written at 2:40 p.m. on 9/30/11 indicated, "Discharged to [skilled nursing facility]..." No reason for the discharge was given in the physician orders or the nursing note. Further review of the clinical record showed no documented evidence of an acceptable reason for discharge from the facility. The clinical record contained copies of two letters sent to the responsible party by the facility administrator. None of the six specific regulatory reasons for involuntary discharge of Resident 4 was described in either letter. 1) The first, a letter dated 7/18/11, contained the following statements: "...time to up-date our families, friends and conservators who have loved ones or clients who reside in our secure unit. We have received approval to proceed with opening our sub-acute unit... In the up-coming weeks we will be gathering information and working with families, friends and conservators to assist with the relocation of residents currently residing in our secure unit. Social Service is working with area facilities for bed availability and to arrange tours for families, friends and conservators."2) The second, a letter dated 8/18/11, contained the following statements: "...to up-date everyone on our on-going project to transition the secure unit to a sub-acute unit. The progression is slower than we had planned... The projection is now for mid November to early December before we will need to pursue relocation of our residents currently residing in our secure unit. Social Services will continue to work with area facilities on bed availability and to arrange tours for families, friends and Conservators." During an interview at 10:30 a.m. on 11/21/12, the Administrator stated that she was not the facility administrator at the time of this discharge action. She stated that the information found in the clinical record and what the Social Service Designee can recall is all that is available. During an interview at 11:30 a.m. on 12/27/12, the Social Service Designee (SSD) reported attending a meeting in April 2011 between the Medical Director of the Secured Alzheimer's Unit (SAU) and two or three family members. The SSD stated that during the meeting the Medical Director made statements to the family members indicating that there had been closures of dementia units in California. At the time, the facility was completing electrical work necessary for equipment needed for sub-acute patients in the resident rooms of the SAU. The Medical Director (MD) of the Secured Alzheimer's Unit (SAU) was a neurologist who specialized in Alzheimer's disease. During an interview at 2:37 p.m. on 12/31/12 the MD stated that he was never informed of the facility plans for closing the SAU by the facility administrator. He recalled speaking to "two or three" family members in April 2011. He stated that during the conversation he noted the closure of a number of secured units for residents with dementia in California and that he thought the facility would eventually phase out the SAU. During the interview on 12/31/12 the MD stated that "change causes enormous affect on each person with Alzheimer's disease (AD) and it takes about six weeks for the person [with AD] to adapt." During an interview at 5:38 p.m. on 1/10/13 the responsible party (RP) stated that the only letter received from the facility was dated 8/18/11. The RP stated, "I sorta freaked out when I read the letter. Resident 4 was happy at the facility. I was scared and worried about what to do. I could not manage [Resident 4] at home. I was scared with such short notice, that I'd be able to find a placement and find a way to get [Resident 4] transferred to the new facility." Therefore: The facility violated the above regulation when the facility involuntarily discharged Resident 4 to another facility on 9/30/11. The facility did not show that Resident 4 was suitable for discharge due to any of the six reasons stated in the regulation. |
| 140000082 |
Windsor Rosewood Care Center |
020009802 |
B |
25-Apr-13 |
00JP11 |
7319 |
?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 ensure that Resident 5 was not discharged from the facility unless the reason for such action was 1) necessary for the welfare of the resident and the needs of the resident could not be met in the facility, 2) the health of the resident improved sufficient so that the resident no longer needed the services provided by the facility, 3) the safety of individuals in the facility was endangered, 4) the health of individuals in the facility would otherwise be endangered, 5) the resident failed, after reasonable and appropriate notice, to pay for a stay at the facility, or 6) the facility ceased to operate.For Resident 5 the facility did not identify any of these six specific regulatory reasons prior to and/or at the time of the involuntary discharge of Resident 5 on 8/12/11. Failure to discharge Resident 5 for a lawful reason increased the risk of unmet needs, increased confusion, mood and behavioral decline that would potentially lead to high doses of psychotropic medications and adverse side effects, and the risk of increased weight loss and premature general decline. Record review conducted on 12/17/12 identified the following information. Resident 5 was admitted to the Secured Alzheimer's Unit of the facility on 2/17/11. Diagnoses included dementia without behavioral disturbance, general muscle weakness, difficulty walking, memory loss, cognitive communication deficit, and failure to thrive-adult. Resident 5 received five psychotropic medications: Seroquel 25 mg twice daily for angry outbursts, Depakote 250 mg twice daily for mood swings, Ativan 1 mg every six hours as necessary for nervousness that causes extreme distress, Celexa 10 mg for expressing hopelessness, and Trazodone 25 mg at bed time for insomnia. Review of the Minimum Data Sets (the facility's comprehensive assessment of the resident's status with quarterly reviews) dated 2/24/11 and 8/8/11 revealed that Resident 5 had long and short term memory problems, moderately impaired skills for daily decision making, fluctuating inattention and disorganized thinking, and that community placement was not appropriate. On 8/11/11 the physician ordered, "[Discharge] to [skilled nursing facility with] medication when arrangements are ready." A nursing note written at 10:45 on 8/12/11indicated, "[Responsible Party] in facility to transport resident to [skilled nursing facility] in car... Escorted from facility by RP and staff [with] personal belongings." No reason for the discharge was given in the physician orders or the nursing note. Further review of the clinical record showed no documented evidence of an acceptable reason for discharge from the facility. The clinical record contained copies of two letters sent to the responsible party by the facility administrator. None of the six specific regulatory reasons for involuntary discharge of Resident 5 was described in either letter. 1) The first, a letter dated 7/18/11, contained the following statements: "...time to up-date our families, friends and conservators who have loved ones or clients who reside in our secure unit. We have received approval to proceed with opening our sub-acute unit... In the up-coming weeks we will be gathering information and working with families, friends and conservators to assist with the relocation of residents currently residing in our secure unit. Social Service is working with area facilities for bed availability and to arrange tours for families, friends and conservators."2) The second, a letter dated 8/18/11, contained the following statements: "...to up-date everyone on our on-going project to transition the secure unit to a sub-acute unit. The progression is slower than we had planned... The projection is now for mid November to early December before we will need to pursue relocation of our residents currently residing in our secure unit. Social Services will continue to work with area facilities on bed availability and to arrange tours for families, friends and Conservators." During an interview at 10:30 a.m. on 11/21/12, the Administrator stated that she was not the facility administrator at the time of this discharge action. She stated that the information found in the clinical record and what the Social Service Designee can recall is all that is available. During an interview at 11:30 a.m. on 12/27/12, the Social Service Designee (SSD) reported attending a meeting in April 2011 between the Medical Director of the Secured Alzheimer's Unit (SAU) and two or three family members. The SSD stated that during the meeting the Medical Director made statements to the family members indicating that there had been closures of dementia units in California. At the time, the facility was completing electrical work necessary for equipment needed for sub-acute patients in the resident rooms of the SAU. The Medical Director (MD) of the Secured Alzheimer's Unit (SAU) was a neurologist who specialized in Alzheimer's disease. During an interview at 2:37 p.m. on 12/31/12 the MD stated that he was never informed of the facility plans for closing the SAU by the facility administrator. He recalled speaking to "two or three" family members in April 2011. He stated that during the conversation he noted the closure of a number of secured units for residents with dementia in California and that he thought the facility would eventually phase out the SAU. During the interview on 12/31/12 the MD stated that "change causes enormous affect on each person with Alzheimer's disease (AD) and it takes about six weeks for the person [with AD] to adapt." During an interview at 2 p.m. on 1/8/13 the responsible party (RP) stated that the facility sent a letter indicating that the Secured Alzheimer's Unit (SAU) was closing and that it was necessary to discharge Resident 5. The RP stated, "Then they sorta put pressure on me. I started to panic, trying to find a good place. They (facility staff) said, 'If you can't make arrangements then we will.'"Therefore: The facility violated the above regulation when the facility involuntarily discharged Resident 5 to another facility on 8/12/11. The facility did not show that Resident 5 was suitable for discharge due to any of the six reasons stated in the regulation. These violations had a direct relationship to the health, safety, or security of Resident 5. |
| 140000082 |
Windsor Rosewood Care Center |
020009811 |
B |
25-Apr-13 |
00JP11 |
7593 |
F201 ?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 ensure that Resident 6 was not discharged from the facility unless the reason for such action was 1) necessary for the welfare of the resident and the needs of the resident could not be met in the facility, 2) the health of the resident improved sufficient so that the resident no longer needed the services provided by the facility, 3) the safety of individuals in the facility was endangered, 4) the health of individuals in the facility would otherwise be endangered, 5) the resident failed, after reasonable and appropriate notice, to pay for a stay at the facility, or 6) the facility ceased to operate.For Resident 6 the facility did not identify any of these six specific regulatory reasons prior to and/or at the time of the involuntary discharge of Resident 6 on 10/11/11. Failure to discharge Resident 6 for a lawful reason increased the risk of unmet needs, avoidable weight loss, increased anxiety, increased behavioral disturbance with potential for harm, and increased use of psychotropic medication with potentially irreversible adverse side effects if mood and/or behavioral problems increase after discharge. Record review conducted on 12/17/12 noted that Resident 6 was admitted to the Secured Alzheimer's Unit of the facility on 10/8/08. Diagnoses included anxiety, dementia with behavioral disturbance, and difficulty in walking. Resident 6 received five psychotropic medications as follows: Abilify 20 mg at bed time for a mood disorder manifested by hitting at others; Depakote Sprinkles 500 mg twice daily for a mood disorder with unspecified symptoms; Atarax 50 mg three times daily for anxiety and rash - expressed as restlessness; Remeron 7.5 mg at bed time for dementia with behavior expressed by eating less than 75% of each meal; and, Ativan 1 mg twice daily as necessary for anxiety expressed as constant pacing that could not be redirected. Review of the Minimum Data Sets (the facility's comprehensive assessment of the resident's status with quarterly reviews) dated 6/19/11 and 9/18/11 revealed that Resident 6 had long and short term memory problems, moderately impaired cognitive skills for daily decision making, and that community placement was not appropriate. The MDS also indicated that Resident 6 had physical and verbal behavior directed toward others up to three days weekly that placed the resident and/or others at significant risk of physical injury, and that significantly interfered with care, the privacy or activity of others, and the living environment. Resident 6 also had daily episodes of wandering that increased the risk of accidental injury and affected the privacy or activities of others. On 10/10/11 the physician ordered, "For discharge to [skilled nursing facility with] medications." A nursing note at 9:20 a.m. on 10/11/11 indicated, "Discharged to [skilled nursing facility..." No reason for the discharge was given in the physician orders or the nursing note. Further review of the clinical record showed no documented evidence of an acceptable reason for discharge from the facility. The clinical record contained copies of two letters sent to the responsible party by the facility administrator. None of the six specific regulatory reasons for involuntary discharge of Resident 6 was described in either letter. 1) The first, a letter dated 7/18/11, contained the following statements: "...time to up-date our families, friends and conservators who have loved ones or clients who reside in our secure unit. We have received approval to proceed with opening our sub-acute unit... In the up-coming weeks we will be gathering information and working with families, friends and conservators to assist with the relocation of residents currently residing in our secure unit. Social Service is working with area facilities for bed availability and to arrange tours for families, friends and conservators."2) The second, a letter dated 8/18/11, contained the following statements: "...to up-date everyone on our on-going project to transition the secure unit to a sub-acute unit. The progression is slower than we had planned... The projection is now for mid November to early December before we will need to pursue relocation of our residents currently residing in our secure unit. Social Services will continue to work with area facilities on bed availability and to arrange tours for families, friends and Conservators." During an interview at 10:30 a.m. on 11/21/12, the Administrator stated that she was not the facility administrator at the time of this discharge action. She stated that the information found in the clinical record and what the Social Service Designee can recall is all that is available. During an interview at 11:30 a.m. on 12/27/12, the Social Service Designee (SSD) reported attending a meeting in April 2011 between the Medical Director of the Secured Alzheimer's Unit (SAU) and two or three family members. The SSD stated that during the meeting the Medical Director made statements to the family members indicating that there had been closures of dementia units in California. At the time, the facility was completing electrical work necessary for equipment needed for sub-acute patients in the resident rooms of the SAU. The Medical Director (MD) of the Secured Alzheimer's Unit (SAU) was a neurologist who specialized in Alzheimer's disease. During an interview at 2:37 p.m. on 12/31/12 the MD stated that he was never informed of the facility plans for closing the SAU by the facility administrator. He recalled speaking to "two or three" family members in April 2011. He stated that during the conversation he noted the closure of a number of secured units for residents with dementia in California and that he thought the facility would eventually phase out the SAU. During the interview on 12/31/12 the MD stated that "change causes enormous affect on each person with Alzheimer's disease (AD) and it takes about six weeks for the person [with AD] to adapt." During an interview at 3:13 p.m. on 1/3/13 the responsible party (RP) stated that it was shocking to get the notice from the facility in August stating that [Resident 6] had to move by December 2011. At the time of discharge the facility did not return all of the blankets and clothing belonging to Resident 6 even though each item had been carefully marked.Therefore: The facility violated the above regulation when the facility involuntarily discharged Resident 6 to another facility on 10/11/11. The facility did not show that Resident 6 was suitable for discharge due to any of the six reasons stated in the regulation. |
| 140000082 |
Windsor Rosewood Care Center |
020009812 |
B |
25-Apr-13 |
00JP11 |
7237 |
?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 ensure that Resident 7 was not discharged from the facility unless the reason for such action was 1) necessary for the welfare of the resident and the needs of the resident could not be met in the facility, 2) the health of the resident improved sufficient so that the resident no longer needed the services provided by the facility, 3) the safety of individuals in the facility was endangered, 4) the health of individuals in the facility would otherwise be endangered, 5) the resident failed, after reasonable and appropriate notice, to pay for a stay at the facility, or 6) the facility ceased to operate.For Resident 7 the facility did not identify any of these six specific regulatory reasons prior to and/or at the time of the involuntary discharge of Resident 7 on 10/7/11. Failure to discharge Resident 7 for a lawful reason potentially disrupted important relationships and routines, increased the risks of unmet needs, confusion, agitation, and hallucinations, and the risk of increased doses of psychotropic medications with potentially irreversible adverse side effects if there is increased behavior after discharge. Record review conducted on 12/17/12 indicated that Resident 7 was admitted to the Secured Alzheimer's Unit of the facility on 10/20/10. Diagnoses included senile dementia and cognitive communication deficit. Resident 7 was prescribed Seroquel 50 mg orally twice daily for episodes of agitation and hallucinations. Review of the Minimum Data Sets (the facility's comprehensive assessment of the resident's status with quarterly reviews) dated 10/27/10 and 7/6/11 revealed that Resident 7 had long and short term memory problems, moderately impaired cognitive skills for daily decision making, fluctuating inattention and disorganized thinking, and that community placement was not appropriate. The MDS also indicated that Resident 7 had episodes of physical behavior directed toward others one to three times weekly, daily episodes of verbal behavior directed toward others, rejecting care, and wandering. On 10/4/11 the physician ordered, "May [discharge] to [skilled nursing facility with] medication when arrangements have been made." A nursing note written at 2:50 p.m. on 10/7/11 indicated, "Discharged to [skilled nursing facility]..." No reason for the discharge was given in the physician orders or the nursing note. Further review of the clinical record showed no documented evidence of an acceptable reason for discharge from the facility. The clinical record contained copies of two letters sent to the responsible party by the facility administrator. None of the six specific regulatory reasons for involuntary discharge of Resident 7 was described in either letter. 1) The first, a letter dated 7/18/11, contained the following statements: "...time to up-date our families, friends and conservators who have loved ones or clients who reside in our secure unit. We have received approval to proceed with opening our sub-acute unit... In the up-coming weeks we will be gathering information and working with families, friends and conservators to assist with the relocation of residents currently residing in our secure unit. Social Service is working with area facilities for bed availability and to arrange tours for families, friends and conservators."2) The second, a letter dated 8/18/11, contained the following statements: "...to up-date everyone on our on-going project to transition the secure unit to a sub-acute unit. The progression is slower than we had planned... The projection is now for mid November to early December before we will need to pursue relocation of our residents currently residing in our secure unit. Social Services will continue to work with area facilities on bed availability and to arrange tours for families, friends and Conservators." During an interview at 10:30 a.m. on 11/21/12, the Administrator stated that she was not the facility administrator at the time of this discharge action. She stated that the information found in the clinical record and what the Social Service Designee can recall is all that is available. During an interview at 11:30 a.m. on 12/27/12, the Social Service Designee (SSD) reported attending a meeting in April 2011 between the Medical Director of the Secured Alzheimer's Unit (SAU) and two or three family members. The SSD stated that during the meeting the Medical Director made statements to the family members indicating that there had been closures of dementia units in California. At the time, the facility was completing electrical work necessary for equipment needed for sub-acute patients in the resident rooms of the SAU. The Medical Director (MD) of the Secured Alzheimer's Unit (SAU) was a neurologist who specialized in Alzheimer's disease. During an interview at 2:37 p.m. on 12/31/12 the MD stated that he was never informed of the facility plans for closing the SAU by the facility administrator. He recalled speaking to "two or three" family members in April 2011. He stated that during the conversation he noted the closure of a number of secured units for residents with dementia in California and that he thought the facility would eventually phase out the SAU. During the interview on 12/31/12 the MD stated that "change causes enormous affect on each person with Alzheimer's disease (AD) and it takes about six weeks for the person [with AD] to adapt." During at interview at 4:07 p.m. on 1/3/13 the responsible party (RP) stated that the facility sent a letter stating that the facility was closing the Secured Alzheimer's Unit. Later, a facility staff member called to say that the facility had to discharge Resident 7 to another facility. The RP stated that she preferred to have Resident 7 stay where the resident had a familiar environment and routine rather than be discharged. The RP thought it would be less stressful to Resident 7. Therefore: The facility violated the above regulation when the facility involuntarily discharged Resident 7 to another facility on 10/7/11. The facility did not show that Resident 7 was suitable for discharge due to any of the six reasons stated in the regulation. These violations had a direct relationship to the health, safety, or security of Resident 7. |
| 140000082 |
Windsor Rosewood Care Center |
020009813 |
B |
25-Apr-13 |
00JP11 |
7567 |
?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 ensure that Resident 8 was not discharged from the facility unless the reason for such action was 1) necessary for the welfare of the resident and the needs of the resident could not be met in the facility, 2) the health of the resident improved sufficient so that the resident no longer needed the services provided by the facility, 3) the safety of individuals in the facility was endangered, 4) the health of individuals in the facility would otherwise be endangered, 5) the resident failed, after reasonable and appropriate notice, to pay for a stay at the facility, or 6) the facility ceased to operate.For Resident 8 the facility did not identify any of these six specific regulatory reasons prior to and/or at the time of the involuntary discharge of Resident 8 on 10/21/11. Failure to discharge Resident 8 for a lawful reason increased the risks of unmet needs, confusion that could potentially cause a sudden angry outburst or hitting others, loss of appetite, wandering from the facility without timely detection, and increased risk of higher doses of psychotropic medications with potentially irreversible adverse side effects if behavior worsens after discharge. Record review conducted on 12/17/12 identified the following information. Resident 8 was admitted to the Secured Alzheimer's Unit of the facility on 12/22/08. Diagnoses included senile dementia and Parkinson's disease. Resident 8 was prescribed two psychotropic medications for anger and anxiety and a medication for depression. Resident 8 was prescribed Depakote 750 mg with breakfast and 625 mg with dinner for sudden angry outbursts; Remeron 15 mg at bed time for depression due to poor motivation to eat at meal time; and Klonopin 0.5 mg twice daily for anxiety noted as constant pacing and 0.5 mg every eight hours as necessary for severe anxiety. Review of the Minimum Data Sets (the facility's comprehensive assessment of the resident's status with quarterly reviews) dated 12/24/10 and 9/11/11 revealed that Resident 8 had long and short term memory problems, severely impaired cognitive skills for daily decision making, fluctuating inattention and disorganized thinking, and that community placement was not appropriate. The MDS also indicated that Resident 8 had daily physical behavior directed toward others and pacing, and rejected care one to three days weekly. On 10/18/11 the physician ordered, "Discharge to [skilled nursing facility with] meds when arrangements are made." A nursing note written at 1:35 p.m. on 10/21/11 indicated, "...transfer of resident to [skilled nursing facility]." No reason for the discharge was given in the physician orders or the nursing note. Further review of the clinical record showed no documented evidence of an acceptable reason for discharge from the facility. The clinical record contained copies of two letters sent to the conservator by the facility administrator. None of the six specific regulatory reasons for involuntary discharge of Resident 8 was described in either letter. 1) The first, a letter dated 7/18/11, contained the following statements: "...time to up-date our families, friends and conservators who have loved ones or clients who reside in our secure unit. We have received approval to proceed with opening our sub-acute unit... In the up-coming weeks we will be gathering information and working with families, friends and conservators to assist with the relocation of residents currently residing in our secure unit. Social Service is working with area facilities for bed availability and to arrange tours for families, friends and conservators."2) The second, a letter dated 8/18/11, contained the following statements: "...to up-date everyone on our on-going project to transition the secure unit to a sub-acute unit. The progression is slower than we had planned... The projection is now for mid November to early December before we will need to pursue relocation of our residents currently residing in our secure unit. Social Services will continue to work with area facilities on bed availability and to arrange tours for families, friends and Conservators." During an interview at 10:30 a.m. on 11/21/12, the Administrator stated that she was not the facility administrator at the time of this discharge action. She stated that the information found in the clinical record and what the Social Service Designee can recall is all that is available. During an interview at 11:30 a.m. on 12/27/12, the Social Service Designee (SSD) reported attending a meeting in April 2011 between the Medical Director of the Secured Alzheimer's Unit (SAU) and two or three family members. The SSD stated that during the meeting the Medical Director made statements to the family members indicating that there had been closures of dementia units in California. At the time, the facility was completing electrical work necessary for equipment needed for sub-acute patients in the resident rooms of the SAU. The Medical Director (MD) of the Secured Alzheimer's Unit (SAU) was a neurologist who specialized in Alzheimer's disease. During an interview at 2:37 p.m. on 12/31/12 the MD stated that he was never informed of the facility plans for closing the SAU by the facility administrator. He recalled speaking to "two or three" family members in April 2011. He stated that during the conversation he noted the closure of a number of secured units for residents with dementia in California and that he thought the facility would eventually phase out the SAU. During the interview on 12/31/12 the MD stated that "change causes enormous affect on each person with Alzheimer's disease (AD) and it takes about six weeks for the person [with AD] to adapt." During an interview at 1:38 p.m. on 1/11/13 the conservator stated that he learned about the impending discharge from the letters dated 7/18/11 and 8/18/11. The conservator felt dismayed and annoyed. Resident 8 had a history of wandering away from facilities and needed a secure placement. The family had made a tremendous effort to settle Resident 8 into the secured unit. The conservator stated, "We really didn't want to move [Resident 8] but they told us they were shutting down a section of the facility." Therefore: The facility violated the above regulation when the facility involuntarily discharged Resident 8 to another facility on 10/21/11. The facility did not show that Resident 8 was suitable for discharge due to any of the six reasons stated in the regulation. These violations had a direct relationship to the health, safety, or security of Resident 8. |
| 140000082 |
Windsor Rosewood Care Center |
020009814 |
B |
25-Apr-13 |
00JP11 |
7471 |
?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 ensure that Resident 9 was not discharged from the facility unless the reason for such action was 1) necessary for the welfare of the resident and the needs of the resident could not be met in the facility, 2) the health of the resident improved sufficient so that the resident no longer needed the services provided by the facility, 3) the safety of individuals in the facility was endangered, 4) the health of individuals in the facility would otherwise be endangered, 5) the resident failed, after reasonable and appropriate notice, to pay for a stay at the facility, or 6) the facility ceased to operate.For Resident 9 the facility did not identify any of these six specific regulatory reasons prior to and/or at the time of the involuntary discharge of Resident 9 on 10/6/11. Failure to discharge Resident 9 for a lawful reason increased the risk of unmet needs, refusal of meals and care, increased fear of personal harm caused by others, increased anxiety, and potentially irreversible adverse side effects of psychotropic medications prescribed at higher dosages if behavior worsens after discharge. Record review conducted on 12/17/12 identified the following information. Resident 9 was admitted to the Secured Alzheimer's Unit of the facility on 6/13/05. Diagnoses included dementia with behavior and Alzheimer's disease. Resident 9 received psychotropic medications: a combined total of 250 mg of Seroquel daily for unreasonable fear of personal harm caused by others, Depakote DR 500 mg every morning for episodes of sudden angry outbursts, and Ativan 0.5 mg twice daily of episodes of purposeless pacing and an additional Ativan 0.5 mg twice daily as necessary, not to exceed a total of 2 mg daily. Review of the Minimum Data Sets (the facility's comprehensive assessment of the resident's status with quarterly reviews) dated 6/4/11 and 9/3/11 revealed that Resident 9 had long and short term memory problems, moderately impaired cognitive skills for daily decision making, and that community placement was not appropriate.On 10/4/11 the physician ordered, "May [discharge] to [skilled nursing facility] with medication when arrangements have been made." A nursing note written at 9:30 a.m. on 10/6/11 indicated, "Discharged to [skilled nursing facility]. No reason for the discharge was given in the physician orders or the nursing note. Further review of the clinical record showed no documented evidence of an acceptable reason for discharge from the facility. The clinical record contained copies of two letters sent to the responsible party by the facility administrator. None of the six specific regulatory reasons for involuntary discharge of Resident 9 was described in either letter. 1) The first, a letter dated 7/18/11, contained the following statements: "...time to up-date our families, friends and conservators who have loved ones or clients who reside in our secure unit. We have received approval to proceed with opening our sub-acute unit... In the up-coming weeks we will be gathering information and working with families, friends and conservators to assist with the relocation of residents currently residing in our secure unit. Social Service is working with area facilities for bed availability and to arrange tours for families, friends and conservators."2) The second, a letter dated 8/18/11, contained the following statements: "...to up-date everyone on our on-going project to transition the secure unit to a sub-acute unit. The progression is slower than we had planned... The projection is now for mid November to early December before we will need to pursue relocation of our residents currently residing in our secure unit. Social Services will continue to work with area facilities on bed availability and to arrange tours for families, friends and Conservators." During an interview at 10:30 a.m. on 11/21/12, the Administrator stated that she was not the facility administrator at the time of this discharge action. She stated that the information found in the clinical record and what the Social Service Designee can recall is all that is available. During an interview at 11:30 a.m. on 12/27/12, the Social Service Designee (SSD) reported attending a meeting in April 2011 between the Medical Director of the Secured Alzheimer's Unit (SAU) and two or three family members. The SSD stated that during the meeting the Medical Director made statements to the family members indicating that there had been closures of dementia units in California. At the time, the facility was completing electrical work necessary for equipment needed for sub-acute patients in the resident rooms of the SAU. The Medical Director (MD) of the Secured Alzheimer's Unit (SAU) was a neurologist who specialized in Alzheimer's disease. During an interview at 2:37 p.m. on 12/31/12 the MD stated that he was never informed of the facility plans for closing the SAU by the facility administrator. He recalled speaking to "two or three" family members in April 2011. He stated that during the conversation he noted the closure of a number of secured units for residents with dementia in California and that he thought the facility would eventually phase out the SAU. During the interview on 12/31/12 the MD stated that "change causes enormous affect on each person with Alzheimer's disease (AD) and it takes about six weeks for the person [with AD] to adapt." During interviews at 2:55 p.m. on 1/4/13 a family member (FM) stated that the facility sent letters regarding the planned closure of the Secured Alzheimer's Unit (SAU) and later called the responsible party (RP). During the call from the facility, staff stated that Resident 9 could not stay there any longer because "we are closing the unit." The RP stated, "They wanted [Resident 9] out." The FM stated, "We felt powerless." Both FM and RP stated that it was strange that the letters from the facility were so sudden and that it was a shock to learn that the SAU, where Resident 9 was comfortable, was closing. FM stated that Resident 9 historically became upset by changes and stopped eating, saying "no" to everything.Therefore: The facility violated the above regulation when the facility involuntarily discharged Resident 9 to another facility on 10/6/11. The facility did not show that Resident 9 was suitable for discharge due to any of the six reasons stated in the regulation. These violations had a direct relationship to the health, safety, or security of Resident 9. |
| 140000082 |
Windsor Rosewood Care Center |
020009815 |
B |
25-Apr-13 |
00JP11 |
7249 |
?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 ensure that Resident 11 was not discharged from the facility unless the reason for such action was 1) necessary for the welfare of the resident and the needs of the resident could not be met in the facility, 2) the health of the resident improved sufficient so that the resident no longer needed the services provided by the facility, 3) the safety of individuals in the facility was endangered, 4) the health of individuals in the facility would otherwise be endangered, 5) the resident failed, after reasonable and appropriate notice, to pay for a stay at the facility, or 6) the facility ceased to operate.For Resident 11 the facility did not identify any of these six specific regulatory reasons prior to and/or at the time of the involuntary discharge of Resident 11 on 9/26/11. Failure to discharge Resident 11 for a lawful reason increased the risk of unmet needs, increased confusion and irritability due to care givers that do not understand the needs and wishes of the resident, and increased risk of falls. Record review conducted on 12/17/12 identified the following information. Resident 11 was admitted to the Secured Alzheimer's Unit of the facility on 8/18/08. Diagnoses included vascular dementia and lack of coordination. An undated IDT Discharge/Transfer Planning document indicated that Resident 11 was "easily annoyed but manageable," "curt and grumpy," "dislikes long-winded explanations," and liked being alone. Review of the Minimum Data Sets (the facility's comprehensive assessment of the resident's status with quarterly reviews) dated 3/20/11 and 9/18/11 revealed that Resident 11 had long and short term memory problems, severely impaired cognitive skills for daily decision making, and fluctuating inattention and disorganized thinking. The MDS indicated that there were no plans to discharge Resident 11 to the community. On 9/23/11 the physician ordered, "Discharge to [skilled nursing facility with] meds on 9/26/11." A nursing note at 10:30 a.m. on 9/26/11 read, "Discharged to [skilled nursing home." No reason for the discharge was given in the physician orders or the nursing note. Further review of the clinical record showed no documented evidence of an acceptable reason for discharge from the facility. The clinical record contained copies of two letters sent to the Conservator by the facility administrator. None of the six specific regulatory reasons for involuntary discharge of Resident 11 was described in either letter. 1) The first, a letter dated 7/18/11, contained the following statements: "...time to up-date our families, friends and conservators who have loved ones or clients who reside in our secure unit. We have received approval to proceed with opening our sub-acute unit... In the up-coming weeks we will be gathering information and working with families, friends and conservators to assist with the relocation of residents currently residing in our secure unit. Social Service is working with area facilities for bed availability and to arrange tours for families, friends and conservators."2) The second, a letter dated 8/18/11, contained the following statements: "...to up-date everyone on our on-going project to transition the secure unit to a sub-acute unit. The progression is slower than we had planned... The projection is now for mid November to early December before we will need to pursue relocation of our residents currently residing in our secure unit. Social Services will continue to work with area facilities on bed availability and to arrange tours for families, friends and Conservators." During an interview at 10:30 a.m. on 11/21/12, the Administrator stated that she was not the facility administrator at the time of this discharge action. She stated that the information found in the clinical record and what the Social Service Designee can recall is all that is available. During an interview at 11:30 a.m. on 12/27/12, the Social Service Designee (SSD) reported attending a meeting in April 2011 between the Medical Director of the Secured Alzheimer's Unit (SAU) and two or three family members. The SSD stated that during the meeting the Medical Director made statements to the family members indicating that there had been closures of dementia units in California. At the time, the facility was completing electrical work necessary for equipment needed for sub-acute patients in the resident rooms of the SAU. The Medical Director (MD) of the Secured Alzheimer's Unit (SAU) was a neurologist who specialized in Alzheimer's disease. During an interview at 2:37 p.m. on 12/31/12 the MD stated that he was never informed of the facility plans for closing the SAU by the facility administrator. He recalled speaking to "two or three" family members in April 2011. He stated that during the conversation he noted the closure of a number of secured units for residents with dementia in California and that he thought the facility would eventually phase out the SAU. During the interview on 12/31/12 the MD stated that "change causes enormous affect on each person with Alzheimer's disease (AD) and it takes about six weeks for the person [with AD] to adapt." During an interview at 10:40 a.m. on 1/8/13 the Senior Case Manager in the Conservatorship Office stated that there were no plans to move Resident 11 to another facility prior to receiving letters from the facility on 7/18/11 and 8/18/11. At 3:29 p.m. on 1/9/13 the Co-Conservator-Finance (CCF) stated that it was a surprise to receive letters stating that Resident 11 had to move from the facility. The CCF stated that Resident 11 was really mad and upset about the move and refused to cooperate. The CCF thought the facility was trying to move Resident 11 because of falls and increased slowness. The CCF stated that a framed picture of herself and horse that Resident 11 loved, disappeared and was not found by the time of discharge. Therefore: The facility violated the above regulation when the facility involuntarily discharged Resident 11 to another facility on 9/26/11. The facility did not show that Resident 11 was suitable for discharge due to any of the six reasons stated in the regulation. These violations had a direct relationship to the health, safety, or security of Resident 11. |
| 140000082 |
Windsor Rosewood Care Center |
020009816 |
B |
25-Apr-13 |
00JP11 |
7149 |
?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 ensure that Resident 12 was not discharged from the facility unless the reason for such action was 1) necessary for the welfare of the resident and the needs of the resident could not be met in the facility, 2) the health of the resident improved sufficient so that the resident no longer needed the services provided by the facility, 3) the safety of individuals in the facility was endangered, 4) the health of individuals in the facility would otherwise be endangered, 5) the resident failed, after reasonable and appropriate notice, to pay for a stay at the facility, or 6) the facility ceased to operate.For Resident 12 the facility did not identify any of these six specific regulatory reasons prior to and/or at the time of the involuntary discharge of Resident 12 on 8/9/11. Failure to discharge Resident 12 for a lawful reason increased the risk of unmet needs, fear, and the risk of increased episodes of inappropriate behavior that would potentially require higher doses of psychotropic medication with potentially irreversible adverse side effects. Record review conducted on 12/17/12 identified the following information. Resident 12 was admitted to the Secured Alzheimer's Unit of the facility on 6/29/10. Diagnoses included dementia with behavior disturbance, senile dementia, Alzheimer's disease, and hearing loss. Resident 12 received Depakote 125 mg daily at bed time for sudden angry outbursts. Review of the Minimum Data Sets (the facility's comprehensive assessment of the resident's status with quarterly reviews) dated 3/24/11 and 6/23/11 revealed that Resident 12 had long and short term memory problems, moderately impaired cognitive skills for daily decision making, fluctuating disorganized thinking, and community placement was not appropriate. The 3/24/11 MDS indicated that Resident 12 had physical behavior directed toward others one to three days weekly, verbal behavior directed toward others up to six days weekly, and daily wandering. On 8/4/11 the physician ordered, "[Discharge] to [skilled nursing facility] when arrangements have been made. May [discharge with] meds." A nursing note written at 10:45 a.m. on 8/9/11 indicated, "Discharged to [skilled nursing facility]. No reason for the discharge was given in the physician orders or the nursing note. Further review of the clinical record showed no documented evidence of an acceptable reason for discharge from the facility. The clinical record contained copies of two letters sent to the responsible party by the facility administrator. None of the six specific regulatory reasons for involuntary discharge of Resident 12 was described in either letter. 1) The first, a letter dated 7/18/11, contained the following statements: "...time to up-date our families, friends and conservators who have loved ones or clients who reside in our secure unit. We have received approval to proceed with opening our sub-acute unit... In the up-coming weeks we will be gathering information and working with families, friends and conservators to assist with the relocation of residents currently residing in our secure unit. Social Service is working with area facilities for bed availability and to arrange tours for families, friends and conservators."2) The second, a letter dated 8/18/11, contained the following statements: "...to up-date everyone on our on-going project to transition the secure unit to a sub-acute unit. The progression is slower than we had planned... The projection is now for mid November to early December before we will need to pursue relocation of our residents currently residing in our secure unit. Social Services will continue to work with area facilities on bed availability and to arrange tours for families, friends and Conservators." During an interview at 10:30 a.m. on 11/21/12, the Administrator stated that she was not the facility administrator at the time of this discharge action. She stated that the information found in the clinical record and what the Social Service Designee can recall is all that is available. During an interview at 11:30 a.m. on 12/27/12, the Social Service Designee (SSD) reported attending a meeting in April 2011 between the Medical Director of the Secured Alzheimer's Unit (SAU) and two or three family members. The SSD stated that during the meeting the Medical Director made statements to the family members indicating that there had been closures of dementia units in California. At the time, the facility was completing electrical work necessary for equipment needed for sub-acute patients in the resident rooms of the SAU. The Medical Director (MD) of the Secured Alzheimer's Unit (SAU) was a neurologist who specialized in Alzheimer's disease. During an interview at 2:37 p.m. on 12/31/12 the MD stated that he was never informed of the facility plans for closing the SAU by the facility administrator. He recalled speaking to "two or three" family members in April 2011. He stated that during the conversation he noted the closure of a number of secured units for residents with dementia in California and that he thought the facility would eventually phase out the SAU. During the interview on 12/31/12 the MD stated that "change causes enormous affect on each person with Alzheimer's disease (AD) and it takes about six weeks for the person [with AD] to adapt." During an interview at 1:32 p.m. on 1/8/13 the responsible party (RP) stated that the facility sent letters stating that it was necessary to find a new placement for Resident 12. The RP was surprised and also concerned for Resident 12 who did not adjust well to changes and would like to move to another facility. The RP stated that the social worker called and said that in three months, all residents from the Secured Alzheimer's unit had to be discharged. Therefore: The facility violated the above regulation when the facility involuntarily discharged Resident 12 to another facility on 8/9/11. The facility did not show that Resident 12 was suitable for discharge due to any of the six reasons stated in the regulation. These violations had a direct relationship to the health, safety, or security of Resident 12. |
| 140000082 |
Windsor Rosewood Care Center |
020009817 |
B |
25-Apr-13 |
00JP11 |
6745 |
?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 ensure that Resident 14 was not discharged from the facility unless the reason for such action was 1) necessary for the welfare of the resident and the needs of the resident could not be met in the facility, 2) the health of the resident improved sufficient so that the resident no longer needed the services provided by the facility, 3) the safety of individuals in the facility was endangered, 4) the health of individuals in the facility would otherwise be endangered, 5) the resident failed, after reasonable and appropriate notice, to pay for a stay at the facility, or 6) the facility ceased to operate.For Resident 14 the facility did not identify any of these six specific regulatory reasons prior to and/or at the time of the involuntary discharge of Resident 14 on 8/2/11. Failure to discharge Resident 14 for a lawful reason increased the risk of unmet needs and the risk of fear and significant emotional trauma after living in the same place seven years. Record review conducted on 12/17/12 identified the following information. Resident 14 was admitted to the Secured Alzheimer's Unit of the facility on 3/9/04. Diagnoses included Alzheimer's disease and general weakness. Review of the Minimum Data Sets (the facility's comprehensive assessment of the resident's status with quarterly reviews) dated 3/10/11 and 6/9/11 revealed that Resident 14 had long and short term memory problems, severely impaired cognitive skills for daily decision making, and fluctuating inattention. The MDS indicated that there were no plans to discharge Resident 14 to the community. On 7/29/11 the physician ordered, "Discharge to [skilled nursing facility]." A nursing note written at 10 a.m. on 8/2/11 indicated, "Discharged to [skilled nursing facility.' No reason for the discharge was given in the physician orders or the nursing note. Further review of the clinical record showed no documented evidence of an acceptable reason for discharge from the facility. The clinical record contained copies of two letters sent to the responsible party by the facility administrator. None of the six specific regulatory reasons for involuntary discharge of Resident 14 was described in either letter. 1) The first, a letter dated 7/18/11, contained the following statements: "...time to up-date our families, friends and conservators who have loved ones or clients who reside in our secure unit. We have received approval to proceed with opening our sub-acute unit... In the up-coming weeks we will be gathering information and working with families, friends and conservators to assist with the relocation of residents currently residing in our secure unit. Social Service is working with area facilities for bed availability and to arrange tours for families, friends and conservators."2) The second, a letter dated 8/18/11, contained the following statements: "...to up-date everyone on our on-going project to transition the secure unit to a sub-acute unit. The progression is slower than we had planned... The projection is now for mid November to early December before we will need to pursue relocation of our residents currently residing in our secure unit. Social Services will continue to work with area facilities on bed availability and to arrange tours for families, friends and Conservators." During an interview at 10:30 a.m. on 11/21/12, the Administrator stated that she was not the facility administrator at the time of this discharge action. She stated that the information found in the clinical record and what the Social Service Designee can recall is all that is available. During an interview at 11:30 a.m. on 12/27/12, the Social Service Designee (SSD) reported attending a meeting in April 2011 between the Medical Director of the Secured Alzheimer's Unit (SAU) and two or three family members. The SSD stated that during the meeting the Medical Director made statements to the family members indicating that there had been closures of dementia units in California. At the time, the facility was completing electrical work necessary for equipment needed for sub-acute patients in the resident rooms of the SAU. The Medical Director (MD) of the Secured Alzheimer's Unit (SAU) was a neurologist who specialized in Alzheimer's disease. During an interview at 2:37 p.m. on 12/31/12 the MD stated that he was never informed of the facility plans for closing the SAU by the facility administrator. He recalled speaking to "two or three" family members in April 2011. He stated that during the conversation he noted the closure of a number of secured units for residents with dementia in California and that he thought the facility would eventually phase out the SAU. During the interview on 12/31/12 the MD stated that "change causes enormous affect on each person with Alzheimer's disease (AD) and it takes about six weeks for the person [with AD] to adapt." During an interview at 5:40 p.m. on 1/11/13 the responsible party (RP) stated that the facility sent letters stating that the Secured Alzheimer's Unit (SAU) was being closed and that the residents living there would be discharged. The RP stated that the family was shocked and did not want Resident 14 to be moved from the SAU, that it would be very traumatic for someone in that state of health and mentation. The RP stated that Resident 14 was shaking upon leaving the SAU environment on the day of discharge Therefore: The facility violated the above regulation when the facility involuntarily discharged Resident 14 to another facility on 8/2/11. The facility did not show that Resident 14 was suitable for discharge due to any of the six reasons stated in the regulation. These violations had a direct relationship to the health, safety, or security of Resident 14. |
| 140000082 |
Windsor Rosewood Care Center |
020009818 |
B |
25-Apr-13 |
00JP11 |
6600 |
?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 ensure that Resident 15 was not discharged from the facility unless the reason for such action was 1) necessary for the welfare of the resident and the needs of the resident could not be met in the facility, 2) the health of the resident improved sufficient so that the resident no longer needed the services provided by the facility, 3) the safety of individuals in the facility was endangered, 4) the health of individuals in the facility would otherwise be endangered, 5) the resident failed, after reasonable and appropriate notice, to pay for a stay at the facility, or 6) the facility ceased to operate.For Resident 15 the facility did not identify any of these six specific regulatory reasons prior to and/or at the time of the involuntary discharge of Resident 15 on 10/10/11. Failure to discharge Resident 15 for a lawful reason increased the risk of unmet needs and the risks of confusion, fear, and episodes of maladaptive behavior that may require higher doses of psychotropic medication and increased risk of irreversible adverse side effects if behavior worsened after discharge. Record review conducted on 12/17/12 identified the following information. Resident 15 was admitted to the Secured Alzheimer's Unit of the facility on 10/17/10. Diagnoses included senile dementia and general muscle weakness. Resident 15 received Seroquel 75 mg twice daily for threatening behavior towards others, Valproic Acid 250 mg at bed time for episodes of sudden angry outbursts, and Haldol 1 mg every hour hours as necessary for extreme agitation. Review of the Minimum Data Sets (the facility's comprehensive assessment of the resident's status with quarterly reviews) dated 6/25/11 and 9/24/11 revealed that Resident 15 had long and short term memory problems and moderately impaired cognitive skills for daily decision making. The MDS indicated that there were no plans to discharge Resident 15 to the community. On 10/10/11 the physician ordered, "Discharge to [skilled nursing facility with] medications." A nursing note written at 9:15 a.m. on 10/10/11 indicated, "Discharged to [skilled nursing facility...]" No reason for the discharge was given in the physician orders or the nursing note. Further review of the clinical record showed no documented evidence of an acceptable reason for discharge from the facility. The clinical record contained copies of two letters sent to the responsible party by the facility administrator. None of the six specific regulatory reasons for involuntary discharge of Resident 15 was described in either letter. 1) The first, a letter dated 7/18/11, contained the following statements: "...time to up-date our families, friends and conservators who have loved ones or clients who reside in our secure unit. We have received approval to proceed with opening our sub-acute unit... In the up-coming weeks we will be gathering information and working with families, friends and conservators to assist with the relocation of residents currently residing in our secure unit. Social Service is working with area facilities for bed availability and to arrange tours for families, friends and conservators."2) The second, a letter dated 8/18/11, contained the following statements: "...to up-date everyone on our on-going project to transition the secure unit to a sub-acute unit. The progression is slower than we had planned... The projection is now for mid November to early December before we will need to pursue relocation of our residents currently residing in our secure unit. Social Services will continue to work with area facilities on bed availability and to arrange tours for families, friends and Conservators." During an interview at 10:30 a.m. on 11/21/12, the Administrator stated that she was not the facility administrator at the time of this discharge action. She stated that the information found in the clinical record and what the Social Service Designee can recall is all that is available. During an interview at 11:30 a.m. on 12/27/12, the Social Service Designee (SSD) reported attending a meeting in April 2011 between the Medical Director of the Secured Alzheimer's Unit (SAU) and two or three family members. The SSD stated that during the meeting the Medical Director made statements to the family members indicating that there had been closures of dementia units in California. At the time, the facility was completing electrical work necessary for equipment needed for sub-acute patients in the resident rooms of the SAU. The Medical Director (MD) of the Secured Alzheimer's Unit (SAU) was a neurologist who specialized in Alzheimer's disease. During an interview at 2:37 p.m. on 12/31/12 the MD stated that he was never informed of the facility plans for closing the SAU by the facility administrator. He recalled speaking to "two or three" family members in April 2011. He stated that during the conversation he noted the closure of a number of secured units for residents with dementia in California and that he thought the facility would eventually phase out the SAU. During the interview on 12/31/12 the MD stated that "change causes enormous affect on each person with Alzheimer's disease (AD) and it takes about six weeks for the person [with AD] to adapt." Therefore: The facility violated the above regulation when the facility involuntarily discharged Resident 15 to another facility on 10/10/11. The facility did not show that Resident 15 was suitable for discharge due to any of the six reasons stated in the regulation. These violations had a direct relationship to the health, safety, or security of Resident 15. |
| 140000082 |
Windsor Rosewood Care Center |
020009819 |
B |
25-Apr-13 |
00JP11 |
7655 |
?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 ensure that Resident 16 was not discharged from the facility unless the reason for such action was 1) necessary for the welfare of the resident and the needs of the resident could not be met in the facility, 2) the health of the resident improved sufficient so that the resident no longer needed the services provided by the facility, 3) the safety of individuals in the facility was endangered, 4) the health of individuals in the facility would otherwise be endangered, 5) the resident failed, after reasonable and appropriate notice, to pay for a stay at the facility, or 6) the facility ceased to operate.For Resident 16 the facility did not identify any of these six specific regulatory reasons prior to and/or at the time of the involuntary discharge of Resident 16 on 10/5/11. Failure to discharge Resident 16 for a lawful reason increased the risk of unmet needs, increased anxiety, placement at a greater distance from family members, and the risk of harm if able to leave the facility undetected. In addition, the loss of familiar staff and setting increased the risk that higher doses of psychotropic medication with potentially irreversible adverse side effects would be necessary in there is increased behavior after the discharge. Record review conducted on 12/17/12 identified the following information. Resident 16 was admitted to the Secured Alzheimer's Unit of the facility on 11/3/10. Diagnoses included advanced dementia. Resident 16 received Abilify 7.5 mg twice daily, for episodes of "easily irritable, angry outbursts"; and Ativan 0.5 mg daily as necessary, for episodes of "obsessive concern over clothing and room." The Minimum Data Sets (the facility's comprehensive assessment of the resident's status with quarterly reviews) dated 11/10/10 and 8/7/11 indicated that Resident 16 had no cognitive deficits and that community placement was not appropriate. An undated document entitled, "[Interdisciplinary Team Discharge/Transfer Planning," indicated that Resident 16 was "very territorial", became upset if roommates were very confused, noisy and/or intrusive, and sometimes had angry outbursts. On 10/4/11 the physician ordered, "May [discharge] to facility responsible party choice(sic) with medications when arrangement(sic) have been made." A nursing note written at 1 p.m. on 10/5/11 indicated, "Discharged to [skilled nursing facility] in a private car." No reason for the discharge was given in the physician orders or the nursing note. Further review of the clinical record showed no documented evidence of an acceptable reason for discharge from the facility. The clinical record contained copies of two letters sent to the responsible party by the facility administrator. None of the six specific regulatory reasons for involuntary discharge of Resident 16 was described in either letter. 1) The first, a letter dated 7/18/11, contained the following statements: "...time to up-date our families, friends and conservators who have loved ones or clients who reside in our secure unit. We have received approval to proceed with opening our sub-acute unit... In the up-coming weeks we will be gathering information and working with families, friends and conservators to assist with the relocation of residents currently residing in our secure unit. Social Service is working with area facilities for bed availability and to arrange tours for families, friends and conservators."2) The second, a letter dated 8/18/11, contained the following statements: "...to up-date everyone on our on-going project to transition the secure unit to a sub-acute unit. The progression is slower than we had planned... The projection is now for mid November to early December before we will need to pursue relocation of our residents currently residing in our secure unit. Social Services will continue to work with area facilities on bed availability and to arrange tours for families, friends and Conservators." During an interview at 10:30 a.m. on 11/21/12, the Administrator stated that she was not the facility administrator at the time of this discharge action. She stated that the information found in the clinical record and what the Social Service Designee can recall is all that is available. During an interview at 11:30 a.m. on 12/27/12, the Social Service Designee (SSD) reported attending a meeting in April 2011 between the Medical Director of the Secured Alzheimer's Unit (SAU) and two or three family members. The SSD stated that during the meeting the Medical Director made statements to the family members indicating that there had been closures of dementia units in California. At the time, the facility was completing electrical work necessary for equipment needed for sub-acute patients in the resident rooms of the SAU. The Medical Director (MD) of the Secured Alzheimer's Unit (SAU) was a neurologist who specialized in Alzheimer's disease. During an interview at 2:37 p.m. on 12/31/12 the MD stated that he was never informed of the facility plans for closing the SAU by the facility administrator. He recalled speaking to "two or three" family members in April 2011. He stated that during the conversation he noted the closure of a number of secured units for residents with dementia in California and that he thought the facility would eventually phase out the SAU. During the interview on 12/31/12 the MD stated that "change causes enormous affect on each person with Alzheimer's disease (AD) and it takes about six weeks for the person [with AD] to adapt." During an interview at 3:40 p.m. on 1/4/13 the responsible party (RP) stated that she learned of the plan to discharge Resident 16 from the social worker during a visit to the facility. The RP stated that she was informed that if she did not move Resident 16, the facility would move Resident 16 to a facility in Sacramento. The RP stated that Resident 16 required a secured environment due to a history of leaving home/facility without the ability to return in a timely and safe manner. Resident 16 was upset, unable to understand why the discharge to another facility was necessary and made many calls to the RP for reassurance. The RP stated that it was very unkind of the social worker to do that to Resident 16. The RP stated that there was pressure to identify a new placement. Therefore: The facility violated the above regulation when the facility involuntarily discharged Resident 16 to another facility on 10/5/11. The facility did not show that Resident 16 was suitable for discharge due to any of the six reasons stated in the regulation. These violations had a direct relationship to the health, safety, or security of Resident 16. |
| 140000082 |
Windsor Rosewood Care Center |
020009820 |
B |
25-Apr-13 |
00JP11 |
7325 |
?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 ensure that Resident 17 was not discharged from the facility unless the reason for such action was 1) necessary for the welfare of the resident and the needs of the resident could not be met in the facility, 2) the health of the resident improved sufficient so that the resident no longer needed the services provided by the facility, 3) the safety of individuals in the facility was endangered, 4) the health of individuals in the facility would otherwise be endangered, 5) the resident failed, after reasonable and appropriate notice, to pay for a stay at the facility, or 6) the facility ceased to operate.For Resident 17 the facility did not identify any of these six specific regulatory reasons prior to and/or at the time of the involuntary discharge of Resident 17 on 10/6/11. Failure to discharge Resident 17 for a lawful reason increased the risk of unmet needs, the risks of avoidable decline due to changes in the daily routine and the loss of familiar staff and environment, recurrence of currently suppressed inappropriate behaviors, and potentially irreversible side effects of psychotropic medications that may be increased if behavior worsens after discharge. Record review conducted on 12/17/12 identified the following information. Resident 17 was admitted to the Secured Alzheimer's Unit of the facility on 7/23/10. Diagnoses included dementia and Alzheimer's disease. Resident 17 was prescribed Risperidal 0.5 mg orally twice daily for dementia with behavior disturbance as evidenced by "episodes of pacing constantly difficult to redirect." Review of the Minimum Data Sets (the facility's comprehensive assessment of the resident's status with quarterly reviews) dated 4/27/11 and 7/26/11 revealed that Resident 17 had long and short term memory problems, moderately impaired cognitive skills for daily decision making, and that community placement was not appropriate. On 10/5/11 the physician ordered, "For [discharge] to [skilled nursing facility with] medication when arrangements made." A nursing note written at 6:30 p.m. on 10/6/11 indicated, "[Family member] came and picked up... endorsed belongings and medication... Left [with family member] in fair condition." No reason for the discharge was given in the physician orders or the nursing note. Further review of the clinical record showed no documented evidence of an acceptable reason for discharge from the facility. The clinical record contained copies of two letters sent to the responsible party by the facility administrator. None of the six specific regulatory reasons for involuntary discharge of Resident 17 was described in either letter. 1) The first, a letter dated 7/18/11, contained the following statements: "...time to up-date our families, friends and conservators who have loved ones or clients who reside in our secure unit. We have received approval to proceed with opening our sub-acute unit... In the up-coming weeks we will be gathering information and working with families, friends and conservators to assist with the relocation of residents currently residing in our secure unit. Social Service is working with area facilities for bed availability and to arrange tours for families, friends and conservators."2) The second, a letter dated 8/18/11, contained the following statements: "...to up-date everyone on our on-going project to transition the secure unit to a sub-acute unit. The progression is slower than we had planned... The projection is now for mid November to early December before we will need to pursue relocation of our residents currently residing in our secure unit. Social Services will continue to work with area facilities on bed availability and to arrange tours for families, friends and Conservators." During an interview at 10:30 a.m. on 11/21/12, the Administrator stated that she was not the facility administrator at the time of this discharge action. She stated that the information found in the clinical record and what the Social Service Designee can recall is all that is available. During an interview at 11:30 a.m. on 12/27/12, the Social Service Designee (SSD) reported attending a meeting in April 2011 between the Medical Director of the Secured Alzheimer's Unit (SAU) and two or three family members. The SSD stated that during the meeting the Medical Director made statements to the family members indicating that there had been closures of dementia units in California. At the time, the facility was completing electrical work necessary for equipment needed for sub-acute patients in the resident rooms of the SAU. The Medical Director (MD) of the Secured Alzheimer's Unit (SAU) was a neurologist who specialized in Alzheimer's disease. During an interview at 2:37 p.m. on 12/31/12 the MD stated that he was never informed of the facility plans for closing the SAU by the facility administrator. He recalled speaking to "two or three" family members in April 2011. He stated that during the conversation he noted the closure of a number of secured units for residents with dementia in California and that he thought the facility would eventually phase out the SAU. During the interview on 12/31/12 the MD stated that "change causes enormous affect on each person with Alzheimer's disease (AD) and it takes about six weeks for the person [with AD] to adapt." During an interview at 3:45 p.m. on 1/3/13 the responsible party (RP) stated that the facility sent a letter indicating that the Secured Alzheimer's Unit would be closing at the end of November 2011. The RP stated that the pressure from the facility staff to find a new placement was stressful due to the concern that the facility would not find a placement near the family. The RP was unhappy when a month after the discharge, after all the difficulty in finding a suitable placement, and the confusion and disruption in daily routines and relationships that it caused Resident 17, the facility sent a letter stating that Resident 17 could return. Therefore: The facility violated the above regulation when the facility involuntarily discharged Resident 17 to another facility on 10/6/11. The facility did not show that Resident 17 was suitable for discharge due to any of the six reasons stated in the regulation. These violations had a direct relationship to the health, safety, or security of Resident 17. |
| 140000082 |
Windsor Rosewood Care Center |
020009821 |
B |
25-Apr-13 |
00JP11 |
7494 |
?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 ensure that Resident 18 was not discharged from the facility unless the reason for such action was 1) necessary for the welfare of the resident and the needs of the resident could not be met in the facility, 2) the health of the resident improved sufficient so that the resident no longer needed the services provided by the facility, 3) the safety of individuals in the facility was endangered, 4) the health of individuals in the facility would otherwise be endangered, 5) the resident failed, after reasonable and appropriate notice, to pay for a stay at the facility, or 6) the facility ceased to operate.For Resident 18 the facility did not identify any of these six specific regulatory reasons prior to and/or at the time of the involuntary discharge of Resident 18 on 10/8/11. Failure to discharge Resident 18 for a lawful reason increased the risks of unmet needs, premature and/or a more rapid decline due to the significant change in staff, daily routine, and the environment, currently controlled behaviors reemerging after discharge, and potentially result in use of higher doses of psychotropic medications with potentially irreversible side effects to manage these behaviors. Record review conducted on 12/17/12 identified the following information. Resident 18 was admitted to the Secured Alzheimer's Unit of the facility on 2/7/09. Diagnoses included senile dementia. Resident 18 received an antidepressant, Celexa 10 mg orally daily to decrease sexual libido manifested by touching and undressing residents. Review of the Minimum Data Sets (the facility's comprehensive assessment of the resident's status with quarterly reviews) dated 2/4/11 and 8/2/11 revealed that Resident 18 had long and short term memory problems, severely impaired cognitive skills for daily decision making, and that community placement was not appropriate. The 8/2/11 MDS also indicated that Resident 18 displayed behavior not directed toward others as often as three days weekly. On 10/7/11 the physician ordered, "May discharge to facility family (sic) of choice when the arrangement (sic) have been made [with] medications." A nursing note at 10 a.m. on 10/8/11 indicated, "Discharged to [skilled nursing facility]." No reason for the discharge was given in the physician orders or the nursing note. Further review of the clinical record showed no documented evidence of an acceptable reason for discharge from the facility. The clinical record contained copies of two letters sent to the responsible party by the facility administrator. None of the six specific regulatory reasons for involuntary discharge of Resident 18 was described in either letter. 1) The first, a letter dated 7/18/11, contained the following statements: "...time to up-date our families, friends and conservators who have loved ones or clients who reside in our secure unit. We have received approval to proceed with opening our sub-acute unit... In the up-coming weeks we will be gathering information and working with families, friends and conservators to assist with the relocation of residents currently residing in our secure unit. Social Service is working with area facilities for bed availability and to arrange tours for families, friends and conservators."2) The second, a letter dated 8/18/11, contained the following statements: "...to up-date everyone on our on-going project to transition the secure unit to a sub-acute unit. The progression is slower than we had planned... The projection is now for mid November to early December before we will need to pursue relocation of our residents currently residing in our secure unit. Social Services will continue to work with area facilities on bed availability and to arrange tours for families, friends and Conservators." During an interview at 10:30 a.m. on 11/21/12, the Administrator stated that she was not the facility administrator at the time of this discharge action. She stated that the information found in the clinical record and what the Social Service Designee can recall is all that is available. During an interview at 11:30 a.m. on 12/27/12, the Social Service Designee (SSD) reported attending a meeting in April 2011 between the Medical Director of the Secured Alzheimer's Unit (SAU) and two or three family members. The SSD stated that during the meeting the Medical Director made statements to the family members indicating that there had been closures of dementia units in California. At the time, the facility was completing electrical work necessary for equipment needed for sub-acute patients in the resident rooms of the SAU. The Medical Director (MD) of the Secured Alzheimer's Unit (SAU) was a neurologist who specialized in Alzheimer's disease. During an interview at 2:37 p.m. on 12/31/12 the MD stated that he was never informed of the facility plans for closing the SAU by the facility administrator. He recalled speaking to "two or three" family members in April 2011. He stated that during the conversation he noted the closure of a number of secured units for residents with dementia in California and that he thought the facility would eventually phase out the SAU. During the interview on 12/31/12 the MD stated that "change causes enormous affect on each person with Alzheimer's disease (AD) and it takes about six weeks for the person [with AD] to adapt." During an interview at 4:20 p.m. on 1/3/13 the responsible party (RP) stated that Resident 18 did not like changes in the daily routine and environment. The RP stated, "We were given no choice. We were told that the unit (Secured Alzheimer's Unit - SAU) was shutting down." The RP stated that at that time there were few places that would accept Resident 18 due to behavior and this caused the family anxiety for the continued welfare of the resident. During an interview at 3:45 p.m. on 1/7/13 a family friend (FF), helping as translator, called and stated that the social worker informed the family that the SAU was closing and that Resident 18 must be moved. FF stated that it seemed best to make the move rather than leave Resident 18 in limbo but that distance would be a problem for visiting. Therefore: The facility violated the above regulation when the facility involuntarily discharged Resident 18 to another facility on 10/8/11. The facility did not show that Resident 18 was suitable for discharge due to any of the six reasons stated in the regulation. These violations had a direct relationship to the health, safety, or security of Resident 18. |
| 140000082 |
Windsor Rosewood Care Center |
020009822 |
B |
25-Apr-13 |
00JP11 |
7461 |
?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 ensure that Resident 19 was not discharged from the facility unless the reason for such action was 1) necessary for the welfare of the resident and the needs of the resident could not be met in the facility, 2) the health of the resident improved sufficient so that the resident no longer needed the services provided by the facility, 3) the safety of individuals in the facility was endangered, 4) the health of individuals in the facility would otherwise be endangered, 5) the resident failed, after reasonable and appropriate notice, to pay for a stay at the facility, or 6) the facility ceased to operate.For Resident 19 the facility did not identify any of these six specific regulatory reasons prior to and/or at the time of the involuntary discharge of Resident 19 on 10/18/11. Failure to discharge Resident 19 for a lawful reason increased the risk of unmet needs, increased confusion, loss of comfort from relationships with family, friends, and staff, increased rate of decline, and potentially irreversible adverse side effects of psychotropic medications that may be increased if behavior worsens after discharge. Record review conducted on 12/17/12 identified the following information. Resident 19 was admitted to the Secured Alzheimer's Unit of the facility on 9/15/11. Diagnoses included senile dementia and anxiety. Resident 19 was prescribed Seroquel 300 mg twice daily for episodes of striking at others and Ativan 0.5 mg every six hours as necessary for anxiety as evidenced by episodes of constantly banging doors. An undated Transfer Report indicated that Resident 19 did not speak English, wandered from the facility, and resisted care. Resident 19 received Seroquel 300 mg twice daily for striking out at others and Ativan 0.5 mg every six hours as necessary for constant banging on doors despite redirection. Review of the Minimum Data Sets (the facility's comprehensive assessment of the resident's status with quarterly reviews) dated 6/12/11 and 9/11/11 revealed that Resident 19 had long and short term memory problems, moderately impaired cognitive skills for daily decision making, and that community placement was not appropriate. The MDS also indicated that Resident 19 had physical behavior directed toward others daily and both rejected care and wandered daily. On 10/19/11 the physician ordered, "Discharge to [skilled nursing facility with] meds on 10/18/11(sic)." A nursing note written at 10:15 a.m. on 10/18/11 indicated, "Discharged to [skilled nursing facility] accompanied by two staff." No reason for the discharge was given in the physician orders or the nursing note. Further review of the clinical record showed no documented evidence of an acceptable reason for discharge from the facility. The clinical record contained copies of two letters sent to the son by the facility administrator. None of the six specific regulatory reasons for involuntary discharge of Resident 19 was described in either letter. 1) The first, a letter dated 7/18/11, contained the following statements: "...time to up-date our families, friends and conservators who have loved ones or clients who reside in our secure unit. We have received approval to proceed with opening our sub-acute unit... In the up-coming weeks we will be gathering information and working with families, friends and conservators to assist with the relocation of residents currently residing in our secure unit. Social Service is working with area facilities for bed availability and to arrange tours for families, friends and conservators."2) The second, a letter dated 8/18/11, contained the following statements: "...to up-date everyone on our on-going project to transition the secure unit to a sub-acute unit. The progression is slower than we had planned... The projection is now for mid November to early December before we will need to pursue relocation of our residents currently residing in our secure unit. Social Services will continue to work with area facilities on bed availability and to arrange tours for families, friends and Conservators." During an interview at 10:30 a.m. on 11/21/12, the Administrator stated that she was not the facility administrator at the time of this discharge action. She stated that the information found in the clinical record and what the Social Service Designee can recall is all that is available. During an interview at 11:30 a.m. on 12/27/12, the Social Service Designee (SSD) reported attending a meeting in April 2011 between the Medical Director of the Secured Alzheimer's Unit (SAU) and two or three family members. The SSD stated that during the meeting the Medical Director made statements to the family members indicating that there had been closures of dementia units in California. At the time, the facility was completing electrical work necessary for equipment needed for sub-acute patients in the resident rooms of the SAU. The Medical Director (MD) of the Secured Alzheimer's Unit (SAU) was a neurologist who specialized in Alzheimer's disease. During an interview at 2:37 p.m. on 12/31/12 the MD stated that he was never informed of the facility plans for closing the SAU by the facility administrator. He recalled speaking to "two or three" family members in April 2011. He stated that during the conversation he noted the closure of a number of secured units for residents with dementia in California and that he thought the facility would eventually phase out the SAU. During the interview on 12/31/12 the MD stated that "change causes enormous affect on each person with Alzheimer's disease (AD) and it takes about six weeks for the person [with AD] to adapt." During an interview at 2:20 p.m. on 1/14/13 the responsible party (RP) stated that the facility sent a letter regarding the closure of the Secured Alzheimer's Unit and that Resident 19 would be discharged. The RP stated that the social worker told him to find a new facility for Resident 19 or the resident would be discharged to a facility in Stockton. The RP stated that Resident 19 had family and friends in San Francisco and that Stockton was too far away. Therefore: The facility violated the above regulation when the facility involuntarily discharged Resident 19 to another facility on 10/18/11. The facility did not show that Resident 19 was suitable for discharge due to any of the six reasons stated in the regulation. These violations had a direct relationship to the health, safety, or security of Resident 19. |
| 140000082 |
Windsor Rosewood Care Center |
020009823 |
B |
25-Apr-13 |
00JP11 |
7748 |
?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 ensure that Resident 20 was not discharged from the facility unless the reason for such action was 1) necessary for the welfare of the resident and the needs of the resident could not be met in the facility, 2) the health of the resident improved sufficient so that the resident no longer needed the services provided by the facility, 3) the safety of individuals in the facility was endangered, 4) the health of individuals in the facility would otherwise be endangered, 5) the resident failed, after reasonable and appropriate notice, to pay for a stay at the facility, or 6) the facility ceased to operate.For Resident 20 the facility did not identify any of these six specific regulatory reasons prior to and/or at the time of the involuntary discharge of Resident 20 on 9/28/11. Failure to discharge Resident 20 for a lawful reason increased the risk of unmet needs, significant confusion, fear, and anxiety as a result of the discharge, and potentially irreversible adverse side effects of psychotropic medication at higher doses to treat increased behavior and/or anxiety that may occur as a result of the discharge. Record review conducted on 12/17/12 identified the following information. Resident 20 was admitted to the Secured Alzheimer's Unit of the facility on 1/8/09. Diagnoses included dementia with behavioral disturbance, general muscle weakness, difficulty walking, and anxiety. Resident 20 received Depakote 125 mg at bed time for combative behavior during care and Ativan 0.5 mg every eight hours as necessary for anxiety. Review of the Minimum Data Sets (the facility's comprehensive assessment of the resident's status with quarterly reviews) dated 1/14/11 and 7/12/11 revealed that Resident 20 had community placement was not appropriate. The MDS indicated that Resident 20 1) often had physical behavior directed toward others that put the resident and others at significant risk for physical injury, and that significantly interfered with care, activities or social interaction, 2) often rejected care, and 3) had wandering behavior that increased the risk of accidental injury. Additionally, Resident 20 did not speak English. On 9/23/11 the physician ordered, "Discharge resident to [skilled nursing facility with] medications on 9/27/11." A nursing note written at 10 a.m. on 9/28/11 indicated, "Transfer to [skilled nursing facility]." No reason for the discharge was given in the physician orders or the nursing note. Further review of the clinical record showed no documented evidence of an acceptable reason for discharge from the facility. The clinical record contained copies of two letters sent to the spouse by the facility administrator. None of the six specific regulatory reasons for involuntary discharge of Resident 20 was described in either letter. 1) The first, a letter dated 7/18/11, contained the following statements: "...time to up-date our families, friends and conservators who have loved ones or clients who reside in our secure unit. We have received approval to proceed with opening our sub-acute unit... In the up-coming weeks we will be gathering information and working with families, friends and conservators to assist with the relocation of residents currently residing in our secure unit. Social Service is working with area facilities for bed availability and to arrange tours for families, friends and conservators."2) The second, a letter dated 8/18/11, contained the following statements: "...to up-date everyone on our on-going project to transition the secure unit to a sub-acute unit. The progression is slower than we had planned... The projection is now for mid November to early December before we will need to pursue relocation of our residents currently residing in our secure unit. Social Services will continue to work with area facilities on bed availability and to arrange tours for families, friends and Conservators." During an interview at 10:30 a.m. on 11/21/12, the Administrator stated that she was not the facility administrator at the time of this discharge action. She stated that the information found in the clinical record and what the Social Service Designee can recall is all that is available. During an interview at 11:30 a.m. on 12/27/12, the Social Service Designee (SSD) reported attending a meeting in April 2011 between the Medical Director of the Secured Alzheimer's Unit (SAU) and two or three family members. The SSD stated that during the meeting the Medical Director made statements to the family members indicating that there had been closures of dementia units in California. At the time, the facility was completing electrical work necessary for equipment needed for sub-acute patients in the resident rooms of the SAU. The Medical Director (MD) of the Secured Alzheimer's Unit (SAU) was a neurologist who specialized in Alzheimer's disease. During an interview at 2:37 p.m. on 12/31/12 the MD stated that he was never informed of the facility plans for closing the SAU by the facility administrator. He recalled speaking to "two or three" family members in April 2011. He stated that during the conversation he noted the closure of a number of secured units for residents with dementia in California and that he thought the facility would eventually phase out the SAU. During the interview on 12/31/12 the MD stated that "change causes enormous affect on each person with Alzheimer's disease (AD) and it takes about six weeks for the person [with AD] to adapt." During an interview at 9:30 a.m. on 1/16/13 the responsible party (RP) stated the facility sent letters and met with family members about the closure of the Secured Alzheimer's Unit (SAU). The RP stated that the facility began to leave the hall doors to the SAU unlocked, reducing the safety of Resident 20. The RP stated that if the families did not like what the facility was doing, then they could move their relatives. The facility offered to place Resident 20 in Sacramento, too far for the RP to visit regularly. Instead, the facility discharged Resident 20 to a facility without a secured unit, placing Resident 20 at high risk of wandering into a dangerous place. The RP was troubled by the facility decision to discharge Resident 20, the process of finding a secured placement, and the plan to discharge Resident 20 to an unsecured facility where wandering behavior placed the resident at risk of harm. Therefore: The facility violated the above regulation when the facility involuntarily discharged Resident 20 to another facility on 9/28/11. The facility did not show that Resident 20 was suitable for discharge due to any of the six reasons stated in the regulation. These violations had a direct relationship to the health, safety, or security of Resident 20. |
| 140000082 |
Windsor Rosewood Care Center |
020009854 |
B |
25-Apr-13 |
00JP11 |
7643 |
?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 ensure that Resident 2 was not discharged from the facility unless the reason for such action was 1) necessary for the welfare of the resident and the needs of the resident could not be met in the facility, 2) the health of the resident improved sufficient so that the resident no longer needed the services provided by the facility, 3) the safety of individuals in the facility was endangered, 4) the health of individuals in the facility would otherwise be endangered, 5) the resident failed, after reasonable and appropriate notice, to pay for a stay at the facility, or 6) the facility ceased to operate.For Resident 2 the facility did not identify any of these six specific regulatory reasons prior to and/or at the time of the involuntary discharge of Resident 2 on 11/4/11. Failure to discharge Resident 2 for a lawful reason increased the risks of 1) injury due to inadequate supervision to ensure the safety of the resident with a history of unauthorized absence, 2) a severe aggressive altercation resulting in harm, 3) increased confusion and anxiety, and 4) use of higher doses of psychotropic medications with potentially irreversible adverse side effects if mood and behavior increased after discharge. Record review conducted on 11/21/11 identified the following information: Resident 2 was admitted to the Secured Alzheimer's Unit of the facility on 8/18/10 with a diagnosis of dementia with behavior disturbance. Resident 2 received a total of 1.5 mg of Risperidal daily for delusions of going to work; a total of 150 mg of Depakote Sprinkles daily for sudden angry outbursts; and Ativan 0.5 mg every four hours as needed for severe anxiety. Review of the Minimum Data Sets (the facility's comprehensive assessment of the resident's status with quarterly reviews) dated 5/27/11 and 8/26/11 indicated that Resident 2 had short and long term memory problems, moderately impaired cognitive skills for daily decision making, and that community placement was not appropriate. Resident 2 wandered most days increasing the risk of accidental injury. On 11/1/11 the physician ordered, "Ok to transfer resident to [skilled nursing facility with] meds when arrangements are made." A nursing note at 9:40 a.m. on 11/4/11 indicated, "Discharged resident [with] all the medication..." The Face Sheet in the clinical record also indicated that Resident 2 was "discharged." No reason for the discharge was given in the physician orders or the nursing note. Further review of the clinical record showed no documented evidence of an acceptable reason for discharge from the facility. The clinical record contained copies of two letters sent to the responsible party by the facility administrator. None of the six specific regulatory reasons for discharge of Resident 2 was described as the reason for discharge in either letter. 1) The first, a letter dated 7/18/11, contained the following statements: "...time to up-date our families, friends and conservators who have loved ones or clients who reside in our secure unit. We have received approval to proceed with opening our sub-acute unit... In the up-coming weeks we will be gathering information and working with families, friends and conservators to assist with the relocation of residents currently residing in our secure unit. Social Service is working with area facilities for bed availability and to arrange tours for families, friends and conservators." 2) The second, a letter dated 8/18/11, contained the following statements: "...to up-date everyone on our on-going project to transition the secure unit to a sub-acute unit. The progression is slower than we had planned... The projection is now for mid November to early December before we will need to pursue relocation of our residents currently residing in our secure unit. Social Services will continue to work with area facilities on bed availability and to arrange tours for families, friends and Conservators." During an interview at 10:30 a.m. on 11/21/12, the Administrator stated that she was not the facility administrator at the time of this discharge action. She stated that the information found in the clinical record and what the Social Service Designee can recall is all that is available. During an interview at 11:30 a.m. on 12/27/12, the Social Service Designee (SSD) reported attending a meeting in April 2011 between the Medical Director of the Secured Alzheimer's Unit (SAU) and two or three family members. The SSD stated that during the meeting the Medical Director made statements to the family members indicating that there had been closures of dementia units in California. At the time, the facility was completing electrical work necessary for equipment needed for sub-acute patients in the resident rooms of the SAU. The Medical Director (MD) of the Secured Alzheimer's Unit (SAU) was a neurologist who specialized in Alzheimer's disease. During an interview at 2:37 p.m. on 12/31/12 the MD stated that he was never informed of the facility plans for closing the SAU by the facility administrator. He recalled speaking to "two or three" family members in April 2011. He stated that during the conversation he noted the closure of a number of secured units for residents with dementia in California and that he thought the facility would eventually phase out the SAU. During the interview on 12/31/12 the MD stated that "change causes enormous affect on each person with Alzheimer's disease (AD) and it takes about six weeks for the person [with AD] to adapt." During an interview at 10:46 a.m. on 1/10/13, the responsible party (RP) stated that in the spring of 2011, Resident 2 had increased confusion when moved to new bed rooms during remodeling of the Secured Alzheimer's Unit (SAU). The RP was "quite upset" upon receipt of a letter dated 8/18/11 and after informally learning that the facility was planning to replace the SAU "with a more profitable population." The RP stated that it was difficult to find a secure placement for Resident 2 who had "severe sundowner syndrome" with increased aggression later in the day and a prior history of elopement. The RP stated that the family was concerned that discharge to a new facility would again cause increased confusion leading to a severe aggressive altercation causing harm. Therefore: The facility violated the above regulation when the facility involuntarily discharged Resident 2 to another facility on 11/4/11. The facility did not show that Resident 2 was suitable for discharge due to any of the six reasons stated in the regulation. These violations had a direct relationship to the health, safety, or security of Resident 2. |
| 140000082 |
Windsor Rosewood Care Center |
020010062 |
B |
13-Aug-13 |
00JP11 |
4410 |
The facility failed to issue a proper written discharge notice prior to the discharge of Resident 1 to another facility and to document this action in the clinical record. The facility failed to inform Resident 1 of the reason for the discharge in writing in a discharge notice and document the reason in the clinical record. The facility did not inform Resident 1 in writing of the date of discharge and the location of discharge. The facility did not inform Resident 1 in writing of the right to appeal the discharge nor provide written contact information for the Ombudsman or other advocacy groups. The facility did not provide Resident 1 a written notice of discharge 30 days in advance of the intended discharge date. Failure to properly notify Resident 1, in accordance with regulatory requirements regarding discharge, resulted in violations of Resident 1's rights. Review of the closed clinical record on 12/17/12 showed that the facility admitted Resident 1 to the Secured Alzheimer's Unit of the facility on 5/7/09. Resident 1's diagnoses included Alzheimer's disease and failure to thrive.Minimum Data Sets (the facility's comprehensive assessment of the resident's condition with quarterly reviews and updates), dated 3/8/11 and 6/7/11, indicated that Resident 1 had long and short term memory problems. Resident 1 was severely impaired for the ability to reason and make decisions about daily living. Resident 1 could not live independently in the community. The MDS also indicated that Resident 1 had physical behavior that was directed toward others frequently. The behavior interfered with care and Resident 1 rejected care. Resident 1 wandered within the facility daily. The closed record contained copies of letters sent by the facility to the responsible party (RP) on 7/18/11 and 8/18/11. 1) The July 2011 letter contained these statements from the administrator: "In the up-coming weeks we will be gathering information and working with families, friends and conservators to assist with the relocation of residents currently residing in our secure unit. Social Service is working with area facilities for bed availability and to arrange tours for families, friends and conservators." 2) The August 2011 letter contained the following statements from the administrator: "I wanted to up-date everyone on our on-going project to transition the secure unit to a sub-acute unit. The progression is slower than we had planned which allows us more time to continue giving care to our residents on the unit. The projection is now for mid-November to early December before we will need to pursue relocation of our residents currently residing in our secure unit." There was no documented evidence in the clinical record that Resident 1 was given a written discharge notice at any time prior to the date of discharge. At 8:40 p.m. on 8/19/11 the physician ordered, "Discharge to [skilled nursing facility with] meds on 8/20/11." A nursing note written at noon on 8/22/11 indicated, "...being [discharged to skilled nursing facility...11:30 a.m." There was no documented evidence in the clinical record that Resident 1 was given a written discharge notice 30 days prior to the date of discharge. During an interview at 2 p.m. on 11/21/12 the Administrator stated that no written discharge notice was issued to Resident 1 in accordance with the applicable regulatory requirements prior to discharge on 8/22/11. During an interview at 11:30 a.m. on 1/30/13 the responsible party stated that the facility did not issue a written discharge notice including a statement of the right to appeal the discharge prior to the date of discharge. Therefore: The above regulations were violated when the facility failed to ensure that Resident 1 was provided a written notice of discharge that contained information to ensure an orderly transfer (including the date and location) and to document this action in the clinical record, failed to document the reason for the discharge in both a discharge notice and the clinical record, failed to inform Resident 1 in writing of the right to appeal the discharge, failed to provide Resident 1 with written contact information for the Ombudsman and consultation with advocacy groups, and failed to issue a written discharge notice 30 days prior to the intended discharge date. These violations had a direct relationship to the health, safety, or security of Resident 1. |
| 140000082 |
Windsor Rosewood Care Center |
020010065 |
B |
13-Aug-13 |
00JP11 |
6498 |
?483.12(a)(4)(5)(6) NOTICE REQUIREMENTS BEFORE TRANSFER OR DISCHARGE Before a facility transfers or discharges a resident, the facility must (a)(4)(i) notify the resident and, if known, a family member or legal representative of the resident of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand; (a)(4)(ii) record the reasons in the resident's clinical record; (a)(4)(iii) and include in the notice the items described in paragraph (a)(6) of this section. Except when specified in paragraph (a)(5)(ii) of this section, the notice of transfer or discharge required under paragraph (a)(4) of this section must be made by the facility at least 30 days before the resident is transferred or discharged. (a)(6) The written notice specified in paragraph (a)(4) of this section must include (a)(4)(i) the reason for transfer or discharge; (a)(4)(ii) the effective date of transfer or discharge; (a)(4)(iii) the location to which the resident is transferred or discharged; (a)(4)(iv) a statement that the resident has the right to appeal the action to the State; (a)(4)(v) the name, address and telephone number of the State long term care ombudsman; and (a)(4)(vi) for nursing facility residents who are mentally ill, the mailing address and telephone number of the agency responsible for the protection and advocacy of mentally ill individuals established under the Protection and Advocacy for Mentally Ill Individuals Act. The facility failed to ensure a proper written notice of discharge prior to the discharge of Resident 2 to another facility. The facility did not inform Resident 2 of the reason for the discharge and document this action in a discharge notice and in the clinical record. The facility did not inform Resident 2 in writing of the date of discharge or the location of discharge. The facility did not inform Resident 2 of the right to appeal the discharge and did not provide contact information for the Ombudsman or other advocacy groups. The facility did not provide Resident 2 a written notice of discharge 30 days in advance of the intended discharge date. Failure to properly notify Resident 2, in accordance with regulatory requirements regarding discharge, resulted in violations of Resident 2's rights. Review of the closed clinical records on 12/17/11 showed that the facility admitted Resident 2 to the Secured Alzheimer's Unit (SAU) of the facility on 8/18/10. Resident 2 had diagnoses that included dementia with behavior disturbance.Review of the Minimum Data Sets (the facility's comprehensive assessment of the resident's condition with quarterly reviews and updates), dated 5/27/11 and 8/26/11 indicated that Resident 2 had short and long term memory problems. Resident 2 was moderately impaired for reasoning in order to make decisions about daily life. Resident 2 could not live independently in the community. Resident 2 wandered about the facility.The closed record contained copies of letters sent by the facility to the responsible party (RP) on 7/18/11, 8/18/11, and 11/4/11. 1) The July 2011 letter contained these statements from the administrator: "In the up-coming weeks we will be gathering information and working with families, friends and conservators to assist with the relocation of residents currently residing in our secure unit. Social Service is working with area facilities for bed availability and to arrange tours for families, friends and conservators." 2) The August 2011 letter contained the following statements from the administrator: "I wanted to up-date everyone on our on-going project to transition the secure unit to a sub-acute unit. The progression is slower than we had planned which allows us more time to continue giving care to our residents on the unit. The projection is now for mid-November to early December before we will need to pursue relocation of our residents currently residing in our secure unit." 3) The November 2011 letter contained these statements from the administrator: "In July and August you received a letter from our facility that was intended ONLY to be an informative letter communicating our plans to convert the Dementia wing of our facility into a Sub Acute Unit. We have become aware that this may have been misinterpreted as a notice of transfer and discharge." There was no documented evidence in the clinical record that Resident 2 was given a written discharge notice at any time prior to the date of discharge. On 11/1/11 the physician ordered, "Ok to transfer resident to [skilled nursing facility with] meds when arrangements are made." A nursing note at 9:40 a.m. on 11/4/11 indicated, "Discharged resident [with] all the medication..." The Face Sheet in the clinical record also indicated that Resident 2 was "discharged." There was no recorded reason for discharge in physician's orders or nurses' notes. There was no documented evidence in the clinical record that Resident 2 and/or the responsible party were given a written discharge notice 30 days prior to the date of discharge. During an interview at 2 p.m. on 11/21/12 the Administrator stated that no discharge notice was issued for Resident 2 in accordance with the applicable regulatory requirements prior to discharge on 9/30/11. During an interview at 10:46 a.m. on 1/10/13 the responsible party (RP) stated that she heard that the facility was discharging residents from the SAU in order to change to a population that would make them more money. RP had learned this during informal conversations with nursing staff. The RP stated that she did not receive a letter from the facility in July and was "quite upset" upon receipt of the 8/18/11 letter from the facility indicating that the SAU was closing and that residents would be relocated. Therefore: The above regulations were violated when the facility failed to issue Resident 2 a written notice of discharge that contained information to ensure an orderly transfer (including the date and location) and to document this action in the clinical record, failed to document the reason for discharge in both a discharge notice and the clinical record, failed to inform Resident 2 in writing of the right to appeal the discharge, failed to provide Resident 2 with written contact information for consultation with advocacy groups, and failed to issue a written discharge notice 30 days prior to the intended discharge date. These violations had a direct relationship to the health, safety, or security of Resident 2. |
| 140000082 |
Windsor Rosewood Care Center |
020010066 |
B |
13-Aug-13 |
00JP11 |
5579 |
?483.12(a)(4)(5)(6) NOTICE REQUIREMENTS BEFORE TRANSFER OR DISCHARGE Before a facility transfers or discharges a resident, the facility must (a)(4)(i) notify the resident and, if known, a family member or legal representative of the resident of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand; (a)(4)(ii) record the reasons in the resident's clinical record; (a)(4)(iii) and include in the notice the items described in paragraph (a)(6) of this section. Except when specified in paragraph (a)(5)(ii) of this section, the notice of transfer or discharge required under paragraph (a)(4) of this section must be made by the facility at least 30 days before the resident is transferred or discharged. (a)(6) The written notice specified in paragraph (a)(4) of this section must include (a)(4)(i) the reason for transfer or discharge; (a)(4)(ii) the effective date of transfer or discharge; (a)(4)(iii) the location to which the resident is transferred or discharged; (a)(4)(iv) a statement that the resident has the right to appeal the action to the State; (a)(4)(v) the name, address and telephone number of the State long term care ombudsman; and (a)(4)(vi) for nursing facility residents who are mentally ill, the mailing address and telephone number of the agency responsible for the protection and advocacy of mentally ill individuals established under the Protection and Advocacy for Mentally Ill Individuals Act. The facility failed to issue a proper written discharge notice prior to the discharge of Resident 3 to another facility and to document this action in the clinical record. The facility did not inform Resident 3 of the reason for the discharge in writing in a discharge notice and document the reason in the clinical record. The facility did not inform Resident 3 in writing of the date of discharge and the location of discharge. The facility did not inform Resident 3 in writing of the right to appeal the discharge and did not provide contact information for the Ombudsman or other advocacy groups. The facility did not provide Resident 3 a written notice of discharge 30 days in advance of the intended discharge date. Failure to properly notify Resident 3, in accordance with regulatory requirements regarding discharge, resulted in violations of Resident 3's rights. Review of the closed clinical record on 12/17/12 showed that the facility admitted Resident 3 to the Secured Alzheimer's Unit of the facility on 9/9/10. Resident 3 had diagnoses that included dementia with agitation, failure to thrive, and severe conductive hearing loss.Minimum Data Sets (the facility's comprehensive assessment of the resident's condition, with quarterly reviews and updates), dated 9/21/10 and 6/18/11, indicated that Resident 3 had long and short term memory loss. Resident 3 needed assistance to make decisions regarding daily life, and Resident 3 had daily episodes of physical and verbal behaviors toward others. Community placement was not appropriate.The closed record contained copies of letters sent by the facility to the responsible party (RP) on 7/18/11 and 8/18/11. 1) The July 2011 letter contained these statements from the administrator: "In the up-coming weeks we will be gathering information and working with families, friends and conservators to assist with the relocation of residents currently residing in our secure unit. Social Service is working with area facilities for bed availability and to arrange tours for families, friends and conservators." 2) The August 2011 letter contained the following statements from the administrator: "I wanted to up-date everyone on our on-going project to transition the secure unit to a sub-acute unit. The progression is slower than we had planned which allows us more time to continue giving care to our residents on the unit. The projection is now for mid-November to early December before we will need to pursue relocation of our residents currently residing in our secure unit." There was no documented evidence in the clinical record that Resident 3 was given a written discharge notice at any time prior to the date of discharge.On 9/6/11 the physician ordered, "Discharge to [skilled nursing facility with] meds when arrangements are made." A nursing note written at 10:40 a.m. on 9/7/11 indicated, "Discharged to [skilled nursing facility]..." There was no reason for discharge recorded in physician orders or in nurses' notes. There was no documented evidence in the clinical record that Resident 3 or a responsible party was given a written discharge notice 30 days prior to the date of discharge. During an interview at 2 p.m. on 11/21/12 the Administrator stated that no written discharge notice was issued to Resident 3 in accordance with the applicable regulatory requirements prior to discharge. Therefore: The above regulations were violated when the facility failed to issue Resident 3 a written notice of discharge that contained information to ensure an orderly transfer (including the date and location) and to document this action in the clinical record, failed to document the reason for the discharge in both a discharge notice and the clinical record, failed to inform Resident 3 of the right to appeal the discharge, failed to provide Resident 3 with written contact information for the Ombudsman and consultation with advocacy groups, and failed to issue a written discharge notice 30 days prior to the intended discharge date. These violations had a direct relationship to the health, safety, or security of Resident 3. |
| 140000082 |
Windsor Rosewood Care Center |
020010067 |
B |
13-Aug-13 |
00JP11 |
5664 |
?483.12(a)(4)(5)(6) NOTICE REQUIREMENTS BEFORE TRANSFER OR DISCHARGE Before a facility transfers or discharges a resident, the facility must (a)(4)(i) notify the resident and, if known, a family member or legal representative of the resident of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand; (a)(4)(ii) record the reasons in the resident's clinical record; (a)(4)(iii) and include in the notice the items described in paragraph (a)(6) of this section. Except when specified in paragraph (a)(5)(ii) of this section, the notice of transfer or discharge required under paragraph (a)(4) of this section must be made by the facility at least 30 days before the resident is transferred or discharged. (a)(6) The written notice specified in paragraph (a)(4) of this section must include (a)(4)(i) the reason for transfer or discharge; (a)(4)(ii) the effective date of transfer or discharge; (a)(4)(iii) the location to which the resident is transferred or discharged; (a)(4)(iv) a statement that the resident has the right to appeal the action to the State; (a)(4)(v) the name, address and telephone number of the State long term care ombudsman; and (a)(4)(vi) for nursing facility residents who are mentally ill, the mailing address and telephone number of the agency responsible for the protection and advocacy of mentally ill individuals established under the Protection and Advocacy for Mentally Ill Individuals Act. The facility failed to issue a proper written notice of discharge prior to the discharge of Resident 4 to another facility and document this action in the clinical record. The facility did not inform Resident 4 of reason for the discharge in writing in a discharge notice and document the reason in the clinical record. The facility did not inform Resident 4 in writing of the date of discharge and the location of discharge. The facility did not inform Resident 4 in writing of the right to appeal the discharge and provide written information for contacting the Ombudsman or other advocacy groups. The facility did not provide Resident 4 a written notice of discharge 30 days in advance of the intended discharge date. Failure to properly notify Resident 4, in accordance with regulatory requirements regarding discharge, resulted in violations of Resident 4's rights. Review of the closed clinical record on 12/17/12 showed that the facility admitted Resident 4 to the Secured Alzheimer's Unit of the facility on 2/15/10.Resident 4's diagnoses included Alzheimer's disease. Resident 4 did not speak English, paced in the hallways and occasionally entered the rooms of other residents and took their things without permission. At times, Resident 4 was argumentative.Minimum Data Sets (the facility's comprehensive assessment of the resident's condition with quarterly reviews and updates), dated 8/8/11 and 2/11/11, indicated that Resident 4 had long and short term memory problems. Resident 4 needed assistance to make decisions about daily life. Community placement was not appropriate.The closed record contained copies of letters sent by the facility to the responsible party (RP) on 7/18/11 and 8/18/11. 1) The July 2011 letter contained these statements from the administrator: "In the up-coming weeks we will be gathering information and working with families, friends and conservators to assist with the relocation of residents currently residing in our secure unit. Social Service is working with area facilities for bed availability and to arrange tours for families, friends and conservators." 2) The August 2011 letter contained the following statements from the administrator: "I wanted to up-date everyone on our on-going project to transition the secure unit to a sub-acute unit. The progression is slower than we had planned which allows us more time to continue giving care to our residents on the unit. The projection is now for mid-November to early December before we will need to pursue relocation of our residents currently residing in our secure unit." There was no documented evidence in the clinical record that Resident 4 was given a written discharge notice at any time prior to the date of discharge. On 9/30/11 the physician ordered, "Discharge to [skilled nursing facility with] meds on 9/30/11." A nursing note written at 2:40 p.m. on 9/30/11 indicated, "Discharged to [skilled nursing facility]..." No reason for the discharge was given in the physician's orders or the nurse's note. During an interview at 2 p.m. on 11/21/12 the Administrator stated that no written discharge notice was issued to Resident 4 in accordance with the applicable regulatory requirements prior to discharge on 9/7/11. During an interview at 11:35 a.m. on 2/11/13 the responsible party stated that the facility did not issue a discharge notice including a statement of the right to appeal the discharge prior to the discharge. Therefore: The above regulations were violated when the facility failed to issue Resident 4 a written notice of discharge that contained information to ensure an orderly transfer (including the date and location) and to document this action in the clinical record, failed to document the reason for the discharge in both a discharge notice and the clinical record, failed to inform Resident 4 in writing of the right to appeal the discharge, failed to provide Resident 4 with written contact information for the Ombudsman and consultation with advocacy groups, and failed to issue a written discharge notice 30 days prior to the intended discharge date. These violations had a direct relationship to the health, safety, or security of Resident 4. |
| 140000082 |
Windsor Rosewood Care Center |
020010069 |
B |
13-Aug-13 |
00JP11 |
5607 |
?483.12(a)(4)(5)(6) NOTICE REQUIREMENTS BEFORE TRANSFER OR DISCHARGE Before a facility transfers or discharges a resident, the facility must (a)(4)(i) notify the resident and, if known, a family member or legal representative of the resident of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand; (a)(4)(ii) record the reasons in the resident's clinical record; (a)(4)(iii) and include in the notice the items described in paragraph (a)(6) of this section. Except when specified in paragraph (a)(5)(ii) of this section, the notice of transfer or discharge required under paragraph (a)(4) of this section must be made by the facility at least 30 days before the resident is transferred or discharged. (a)(6) The written notice specified in paragraph (a)(4) of this section must include (a)(4)(i) the reason for transfer or discharge; (a)(4)(ii) the effective date of transfer or discharge; (a)(4)(iii) the location to which the resident is transferred or discharged; (a)(4)(iv) a statement that the resident has the right to appeal the action to the State; (a)(4)(v) the name, address and telephone number of the State long term care ombudsman; and (a)(4)(vi) for nursing facility residents who are mentally ill, the mailing address and telephone number of the agency responsible for the protection and advocacy of mentally ill individuals established under the Protection and Advocacy for Mentally Ill Individuals Act. The facility failed to issue a proper notice of discharge prior to the discharge of Resident 5 to another facility and to document this action in the clinical record. The facility did not inform Resident 5 of the reason for the discharge in writing in a discharge notice and document the reason in the clinical record. The facility did not inform Resident 5 in writing of the date of discharge and the location of discharge. The facility did not inform Resident 5 in writing of the right to appeal the discharge nor provide contact information for the Ombudsman or other advocacy groups. The facility did not provide Resident 5 a written notice of discharge 30 days in advance of the intended discharge date. Failure to properly notify Resident 5, in accordance with regulatory requirements regarding discharge, resulted in violations of Resident 5's rights. Review of the closed clinical record on 12/17/12 showed that the facility admitted Resident 5 to the Secured Alzheimer's Unit of the facility on 2/17/11. Resident 5's diagnoses included dementia without behavioral disturbance, memory loss, cognitive communication deficit, and failure to thrive.Minimum Data Sets (the facility's comprehensive assessment of the resident's condition with quarterly reviews), dated 2/24/11 and 8/8/11, revealed that Resident 5 had long and short term memory problems. Resident 5 required assistance to make decisions about daily living. Resident 5's attention span fluctuated and thinking was disorganized. Community placement was not appropriate. The closed record contained a copy of a letter sent by the facility to the responsible party (RP) on 7/18/11.The July 2011 letter contained these statements from the administrator: "In the up-coming weeks we will be gathering information and working with families, friends and conservators to assist with the relocation of residents currently residing in our secure unit. Social Service is working with area facilities for bed availability and to arrange tours for families, friends and conservators." There was no documented evidence in the clinical record that Resident 5 was given a written discharge notice at any time prior to the date of discharge. On 8/11/11 the physician ordered, "[Discharge] to [skilled nursing facility with] medication when arrangements are ready." A nursing note written at 10:45 a.m. on 8/12/11 indicated, "[Responsible Party] in facility to transport resident to [skilled nursing facility] in car... Escorted from facility by RP and staff [with] personal belongings." There was no documented evidence in the clinical record that Resident 6 was given a written discharge notice 30 days prior to the intended date of discharge.During an interview at 2 p.m. on 11/21/12 the Administrator stated that no written discharge notice was issued for Resident 5 in accordance with the applicable regulatory requirements prior to discharge on 8/12/11. During an interview, at 12:03 p.m. on 2/11/13, the responsible party stated that he did not recall ever receiving a discharge notice from the facility that included a statement of the right to appeal the discharge. He could only recall receiving the letter that said the facility was closing the SAU and that Resident 5 had to go to another facility. The RP also recalled that staff said that if he did not find a placement for Resident 5, they would find one. Therefore: The above regulations were violated when the facility failed to ensure that Resident 5 was provided written notice of discharge that contained information to ensure an orderly transfer (including the date and location) and to document this action in the clinical record, failed to document the reason for the discharge in a discharge notice and in the clinical record, failed to inform Resident 5 of the right to appeal the discharge, the facility failed to provide Resident 5 with contact information for the Ombudsman and consultation with advocacy groups, and failed to issue the written discharge notice 30 days prior to the intended discharge date. These violations had a direct relationship to the health, safety, or security of Resident 5. |
| 140000082 |
Windsor Rosewood Care Center |
020010070 |
B |
13-Aug-13 |
00JP11 |
5989 |
?483.12(a)(4)(5)(6) NOTICE REQUIREMENTS BEFORE TRANSFER OR DISCHARGE Before a facility transfers or discharges a resident, the facility must (a)(4)(i) notify the resident and, if known, a family member or legal representative of the resident of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand; (a)(4)(ii) record the reasons in the resident's clinical record; (a)(4)(iii) and include in the notice the items described in paragraph (a)(6) of this section. Except when specified in paragraph (a)(5)(ii) of this section, the notice of transfer or discharge required under paragraph (a)(4) of this section must be made by the facility at least 30 days before the resident is transferred or discharged. (a)(6) The written notice specified in paragraph (a)(4) of this section must include (a)(4)(i) the reason for transfer or discharge; (a)(4)(ii) the effective date of transfer or discharge; (a)(4)(iii) the location to which the resident is transferred or discharged; (a)(4)(iv) a statement that the resident has the right to appeal the action to the State; (a)(4)(v) the name, address and telephone number of the State long term care ombudsman; and (a)(4)(vi) for nursing facility residents who are mentally ill, the mailing address and telephone number of the agency responsible for the protection and advocacy of mentally ill individuals established under the Protection and Advocacy for Mentally Ill Individuals Act. The facility failed to issue a proper written notice of discharge prior to the discharge of Resident 6 to another facility and to document this action in the clinical record. The facility did not inform Resident 6 of the reason for the discharge in a discharge notice and document the reason in the clinical record. The facility did not inform Resident 6 in writing of the date of discharge and the location of discharge. The facility did not inform Resident 6 in writing of the right to appeal the discharge and did not provide contact information for the Ombudsman or other advocacy groups. The facility did not provide Resident 6 a written notice of discharge 30 days in advance of the intended discharge date. Failure to properly notify Resident 6, in accordance with regulatory requirements regarding discharge, resulted in violations of Resident 6's rights. Review of the closed clinical record on 12/17/12 showed that the facility admitted Resident 6 to the Secured Alzheimer's Unit (SAU) of the facility on 10/8/08. Resident 6's diagnoses included anxiety and dementia with behavioral disturbance.Review of the Minimum Data Sets (the facility's comprehensive assessment of the resident's condition with quarterly reviews and updates), dated 6/19/11 and 9/18/11, indicated that Resident 6 had long and short term memory problems. Resident 6 was moderately impaired for reasoning and the ability to make decisions about daily living. Community placement was not appropriate. The MDS also indicated that Resident 6 had frequent physical and verbal behavior directed toward others. Resident 6 rejected care and wandered about the facility. The closed record contained copies of letters sent by the facility to the responsible party (RP) on 7/18/11 and 8/18/11. 1) The July 2011 letter contained these statements from the administrator: "In the up-coming weeks we will be gathering information and working with families, friends and conservators to assist with the relocation of residents currently residing in our secure unit. Social Service is working with area facilities for bed availability and to arrange tours for families, friends and conservators." 2) The August 2011 letter contained the following statements from the administrator: "I wanted to up-date everyone on our on-going project to transition the secure unit to a sub-acute unit. The progression is slower than we had planned which allows us more time to continue giving care to our residents on the unit. The projection is now for mid-November to early December before we will need to pursue relocation of our residents currently residing in our secure unit." There was no documented evidence in the clinical record that Resident 6 was given a written discharge notice at any time prior to the date of discharge. On 10/10/11 the physician ordered, "For discharge to [skilled nursing facility with] medications." A nursing note at 9:20 a.m. on 10/11/11 indicated, "Discharged to [skilled nursing facility..." There was no reason for discharge recorded in physician's orders or in nurse's notes. There was no documented evidence in the clinical record that Resident 6 was given a written discharge notice 30 days prior to the intended date of discharge. During an interview at 2 p.m. on 11/21/12 the Administrator stated that no written discharge notice was issued for Resident 6 in accordance with the applicable regulatory requirements prior to discharge on 10/11/11. During an interview, at 4 p.m. on 2/11/13, the responsible party stated that the facility did not issue a discharge notice including a statement of the right to appeal the discharge prior to the discharge. The RP stated, "We only received the letters saying that the [SAU] was closing and that we had to move [Resident 6]." Therefore: The above regulations were violated when the facility failed to issue Resident 6 a written notice of discharge that contained information to ensure an orderly transfer (including the date and location) and to document this action in the clinical record, failed to document the reason for the discharge in both a discharge notice and the clinical record, failed to inform Resident 6 in writing of the right to appeal the discharge, failed to provide Resident 6 with written contact information for the Ombudsman and consultation with advocacy groups, and failed to issue a written discharge notice 30 days prior to the intended discharge date. These violations had a direct relationship to the health, safety, or security of Resident 6. |
| 140000082 |
Windsor Rosewood Care Center |
020010071 |
B |
13-Aug-13 |
00JP11 |
6326 |
?483.12(a)(4)(5)(6) NOTICE REQUIREMENTS BEFORE TRANSFER OR DISCHARGE Before a facility transfers or discharges a resident, the facility must (a)(4)(i) notify the resident and, if known, a family member or legal representative of the resident of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand; (a)(4)(ii) record the reasons in the resident's clinical record; (a)(4)(iii) and include in the notice the items described in paragraph (a)(6) of this section. Except when specified in paragraph (a)(5)(ii) of this section, the notice of transfer or discharge required under paragraph (a)(4) of this section must be made by the facility at least 30 days before the resident is transferred or discharged. (a)(6) The written notice specified in paragraph (a)(4) of this section must include (a)(4)(i) the reason for transfer or discharge; (a)(4)(ii) the effective date of transfer or discharge; (a)(4)(iii) the location to which the resident is transferred or discharged; (a)(4)(iv) a statement that the resident has the right to appeal the action to the State; (a)(4)(v) the name, address and telephone number of the State long term care ombudsman; and (a)(4)(vi) for nursing facility residents who are mentally ill, the mailing address and telephone number of the agency responsible for the protection and advocacy of mentally ill individuals established under the Protection and Advocacy for Mentally Ill Individuals Act. The facility failed to issue a proper written notice of discharge and to document this action in the clinical record prior to the discharge of Resident 7 to another facility. The facility did not inform Resident 7 of the reason for the discharge in writing in a discharge notice and document the reason in the clinical record. The facility did not inform Resident 7 in writing of the date of discharge and the location of discharge. The facility did not inform Resident 7 in writing of the right to appeal the discharge and contact information for the Ombudsman or other advocacy groups. The facility did not provide Resident 7 a written notice of discharge 30 days in advance of the intended discharge date. Failure to properly notify Resident 7, in accordance with regulatory requirements regarding discharge, resulted in violations of Resident 7's rights. Review of the closed clinical record, on 12/17/12, showed that the facility admitted Resident 7 to the Secured Alzheimer's Unit (SAU) on 10/20/10. Resident 7's diagnoses included senile dementia and cognitive communication deficit.Minimum Data Sets (the facility's comprehensive assessment of the resident's condition with quarterly reviews and updates), dated 10/27/10 and 7/6/11, indicated that Resident 7 had long and short term memory problems. Resident 7 was moderately impaired for the ability to reason and make decisions about daily life. Resident 7's attention span fluctuated and thinking was disorganized. Resident 7 could not live independently in the community. The MDS also indicated that Resident 7 had frequent episodes of striking others and daily episodes of verbally abusive behaviors directed toward others. Resident 7 rejected care, and Resident 7 wandered about in the facility.The closed record contained copies of letters sent by the facility to the responsible party (RP) on 7/18/11 and 8/18/11. 1) The July 2011 letter contained these statements from the administrator: "In the up-coming weeks we will be gathering information and working with families, friends and conservators to assist with the relocation of residents currently residing in our secure unit. Social Service is working with area facilities for bed availability and to arrange tours for families, friends and conservators." 2) The August 2011 letter contained the following statements from the administrator: "I wanted to up-date everyone on our on-going project to transition the secure unit to a sub-acute unit. The progression is slower than we had planned which allows us more time to continue giving care to our residents on the unit. The projection is now for mid-November to early December before we will need to pursue relocation of our residents currently residing in our secure unit." Resident 7's clinical record contained no documented evidence of a written discharge notice that met State requirements. On 10/4/11 the physician ordered, "May [discharge] to [skilled nursing facility with] medication when arrangements have been made." A nurse's note, written at 2:50 p.m. on 10/7/11, recorded, "Discharged to [skilled nursing facility]..." No reason for the discharge was recorded in the physician's orders or in the nurse's note. There was no documented evidence in the clinical record that Resident 7 was given a written discharge notice 30 days prior to the date of discharge. During an interview at 2 p.m. on 11/21/12 the Administrator stated that no written discharge notice was issued for Resident 7 in accordance with the applicable regulatory requirements prior to discharge on 10/7/11. During an interview at 4:07 p.m. on 1/3/13 the responsible party (RP) stated that the facility did not provide a discharge notice that included a statement of the right to appeal the discharge. The RP stated that the way she learned that the facility was going to discharge Resident 7 was, "by letter," that said the SAU was being closed. The RP stated, "They (facility) also called to say that [Resident 7] had to be moved." When asked if she knew that Resident 7 had the right to appeal the discharge the RP stated, "No." Therefore: The above regulations were violated when the facility failed to ensure that Resident 7 was provided written notice of discharge that contained information to ensure an orderly transfer (including the date and location) and to document this action in the clinical record, failed to document the reason for the discharge in both a discharge notice and the clinical record, failed to inform Resident 7 in writing of the right to appeal the discharge, failed to provide Resident 7 with written contact information for the Ombudsman and consultation with advocacy groups, and failed to issue a written discharge notice 30 days prior to the intended discharge date. These violations had a direct relationship to the health, safety, or security of Resident 7. |
| 140000082 |
Windsor Rosewood Care Center |
020010073 |
B |
13-Aug-13 |
00JP11 |
5921 |
?483.12(a)(4)(5)(6) NOTICE REQUIREMENTS BEFORE TRANSFER OR DISCHARGE Before a facility transfers or discharges a resident, the facility must (a)(4)(i) notify the resident and, if known, a family member or legal representative of the resident of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand; (a)(4)(ii) record the reasons in the resident's clinical record; (a)(4)(iii) and include in the notice the items described in paragraph (a)(6) of this section. Except when specified in paragraph (a)(5)(ii) of this section, the notice of transfer or discharge required under paragraph (a)(4) of this section must be made by the facility at least 30 days before the resident is transferred or discharged. (a)(6) The written notice specified in paragraph (a)(4) of this section must include (a)(4)(i) the reason for transfer or discharge; (a)(4)(ii) the effective date of transfer or discharge; (a)(4)(iii) the location to which the resident is transferred or discharged; (a)(4)(iv) a statement that the resident has the right to appeal the action to the State; (a)(4)(v) the name, address and telephone number of the State long term care ombudsman; and (a)(4)(vi) for nursing facility residents who are mentally ill, the mailing address and telephone number of the agency responsible for the protection and advocacy of mentally ill individuals established under the Protection and Advocacy for Mentally Ill Individuals Act. The facility failed to issue a proper written notice of discharge and to document this action in the clinical record prior to the discharge of Resident 8 to another facility. The facility did not inform Resident 8 of the reason for the discharge in writing in a discharge notice and document the reason in the clinical record. The facility did not inform Resident 8 in writing of the date of discharge and the location of discharge. The facility did not inform Resident 8 in writing of the right to appeal the discharge and the contact information for the Ombudsman or other advocacy groups. The facility did not provide Resident 8 a written notice of discharge 30 days in advance of the intended discharge date. Failure to properly notify Resident 8 in accordance with regulatory requirements regarding discharge resulted in violations of Resident 8's rights. Closed clinical record review, on 12/17/12, showed that the facility admitted Resident 8 to the facility's Secured Alzheimer's Unit (SAU) on 12/22/08. Resident 8 had diagnoses that included senile dementia.Minimum Data Sets (the facility's comprehensive assessment of the resident's condition with quarterly reviews and updates), dated 12/24/10 and 9/11/11, indicated that Resident 8 had long and short term memory problems. Resident 8 was severely impaired in his ability to reason and make decisions about daily life. His attention span fluctuated and his thinking was disorganized. Resident 8 could not live independently in the community. The MDS also indicated that Resident 8 struck out at others every day, he paced and he frequently rejected care.The closed record contained copies of letters sent by the facility to the responsible party (RP) on 7/18/11 and 8/18/11. 1) The July 2011 letter contained these statements from the administrator: "In the up-coming weeks we will be gathering information and working with families, friends and conservators to assist with the relocation of residents currently residing in our secure unit. Social Service is working with area facilities for bed availability and to arrange tours for families, friends and conservators." 2) The August 2011 letter contained the following statements from the administrator: "I wanted to up-date everyone on our on-going project to transition the secure unit to a sub-acute unit. The progression is slower than we had planned which allows us more time to continue giving care to our residents on the unit. The projection is now for mid-November to early December before we will need to pursue relocation of our residents currently residing in our secure unit." Resident 8's clinical record contained no documented evidence of a written discharge notice that met State requirements. On 10/18/11 the physician ordered, "Discharge to [skilled nursing facility with medications] when arrangements are made." A nurse's note written at 1:35 p.m. on 10/21/11 recorded, "...transfer of resident to [skilled nursing facility]." No reason for discharge was recorded in the physician's orders or the nurse's notes.There was no documented evidence in the clinical record that Resident 8 was given a written discharge notice 30 days prior to the date of discharge. During an interview at 2 p.m. on 11/21/12 the Administrator stated that no written discharge notice was issued for Resident 8 in accordance with the applicable regulatory requirements prior to discharge on 10/21/11. During an interview at 1:38 p.m. on 1/11/13 the responsible party (RP) stated he learned that the SAU was closing from letters sent by the facility. The RP stated, "We really did not want to move [Resident 8] but they told us that they were shutting down that section of the facility."Therefore: The above regulations were violated when the facility failed to issue Resident 8 a written notice of discharge that contained information to ensure an orderly transfer (including the date and location) and to document this action in the clinical record, failed to document the reason for the discharge in both a discharge notice and the clinical record, failed to inform Resident 8 in writing of the right to appeal the discharge, failed to provide Resident 8 with written contact information for the Ombudsman and consultation with advocacy groups, and failed to issue a written discharge notice 30 days prior to the intended discharge date. These violations had a direct relationship to the health, safety, or security of Resident 8. |
| 140000082 |
Windsor Rosewood Care Center |
020010075 |
B |
13-Aug-13 |
00JP11 |
5916 |
?483.12(a)(4)(5)(6) NOTICE REQUIREMENTS BEFORE TRANSFER OR DISCHARGE Before a facility transfers or discharges a resident, the facility must (a)(4)(i) notify the resident and, if known, a family member or legal representative of the resident of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand; (a)(4)(ii) record the reasons in the resident's clinical record; (a)(4)(iii) and include in the notice the items described in paragraph (a)(6) of this section. Except when specified in paragraph (a)(5)(ii) of this section, the notice of transfer or discharge required under paragraph (a)(4) of this section must be made by the facility at least 30 days before the resident is transferred or discharged. (a)(6) The written notice specified in paragraph (a)(4) of this section must include (a)(4)(i) the reason for transfer or discharge; (a)(4)(ii) the effective date of transfer or discharge; (a)(4)(iii) the location to which the resident is transferred or discharged; (a)(4)(iv) a statement that the resident has the right to appeal the action to the State; (a)(4)(v) the name, address and telephone number of the State long term care ombudsman; and (a)(4)(vi) for nursing facility residents who are mentally ill, the mailing address and telephone number of the agency responsible for the protection and advocacy of mentally ill individuals established under the Protection and Advocacy for Mentally Ill Individuals Act. The facility failed to issue a proper written notice of discharge and to document this action in the clinical record prior to the discharge of Resident 9 to another facility. The facility did not inform Resident 9 of the reason for the discharge in writing in a discharge notice and document it in clinical record. The facility did not inform Resident 9 in writing of the date of discharge and the location of discharge. The facility did not inform Resident 9 in writing of the right to appeal the discharge and the contact information for the Ombudsman or other advocacy groups. The facility did not provide Resident 9 a notice of discharge 30 days in advance of the intended discharge date.Failure to properly notify Resident 9, in accordance with regulatory requirements regarding discharge, resulted in violations of Resident 9's rights. Review of the closed clinical record on 12/17/12 identified the following information. Resident 9 was admitted to the Secured Alzheimer's Unit (SAU) of the facility on 6/13/05. Diagnoses included dementia with behaviors and Alzheimer's disease.Minimum Data Sets (the facility's comprehensive assessment of the resident's condition with quarterly reviews and updates), dated 6/4/11 and 9/3/11, indicated that Resident 9 had long and short term memory problems. Resident 9 was moderately impaired in ability to reason and make decisions about daily living. Resident 9 could not live independently in the community. Closed record review on 12/17/12 showed copies of letters sent by the facility to the responsible party (RP) on 7/18/11 and 8/18/11. 1) The July 2011 letter contained these statements from the administrator: "In the up-coming weeks we will be gathering information and working with families, friends and conservators to assist with the relocation of residents currently residing in our secure unit. Social Service is working with area facilities for bed availability and to arrange tours for families, friends and conservators." 2) The August 2011 letter contained the following statements from the administrator: "I wanted to up-date everyone on our on-going project to transition the secure unit to a sub-acute unit. The progression is slower than we had planned which allows us more time to continue giving care to our residents on the unit. The projection is now for mid-November to early December before we will need to pursue relocation of our residents currently residing in our secure unit." There was no documented evidence in the clinical record that Resident 9 was given a written discharge notice at any time prior to the date of discharge. On 10/4/11 the physician ordered, "May [discharge] to [skilled nursing facility] with medication when arrangements have been made." A nursing note written at 9:30 a.m. on 10/6/11 indicated, "Discharged to [skilled nursing facility]." Physician's orders and nurse's notes did not contain a reason for discharge.There was no documented evidence in the clinical record that Resident 9 was given a written discharge notice 30 days prior to the date of discharge. During an interview at 2 p.m. on 11/21/12 the Administrator stated that no written discharge notice was issued for Resident 9 in accordance with the applicable regulatory requirements prior to discharge on 10/6/11. During an interview at 2:55 p.m. on 1/4/13 a family member stated that the family learned that the facility planned to discharge Resident 9 from facility letters and later, a phone call from a facility family member who said, "[Resident 9] can't stay here. We're closing the [SAU]." At 3 p.m. on 1/4/13 the responsible party stated that he learned of the plan to discharge Resident 9 from facility letters. Therefore: The above regulations were violated when the facility failed to issue Resident 9 a written notice of discharge that contained information to ensure an orderly transfer (including the date and location) and to document this action in the clinical record, failed to document the reason for the discharge in both the discharge notice and the clinical record, failed to inform Resident 9 in writing of the right to appeal the discharge, failed to provide Resident 9 with written contact information for the Ombudsman and consultation with advocacy groups, and failed to issue a written discharge notice 30 days prior to the intended discharge date. These violations had a direct relationship to the health, safety, or security of Resident 9. |
| 140000082 |
Windsor Rosewood Care Center |
020010076 |
B |
13-Aug-13 |
00JP11 |
5180 |
?483.12(b)(1)(2) Notice of Bed-Hold Policy and Readmission (b)(1) Notice before transfer. Before a nursing facility transfers a resident to a hospital or allows a resident to go on therapeutic leave, the nursing facility must provide written information to the resident and a family member or legal representative that specifies. (i) The duration of the bed-hold policy under the State plan, if any, during which the resident is permitted to return and resume residence in the nursing facility; and(b)(2) Bed-hold notice upon transfer. At the time of transfer of a resident for hospitalization or therapeutic leave, a nursing facility must provide to the resident and a family member or legal representative written notice which specifies the duration of the bed-hold policy described in paragraph (b)(1) of this section.The facility failed to issue a bedhold notice to Resident 10 and a family member/ responsible party (RP) at the time of transfer for hospitalization that specified the duration of the bed hold during which the resident is permitted to return and resume residence in the facility. Failure to issue a bedhold notice to Resident 10 and RP violated the resident's right to return to the facility after a hospitalization. Record review, conducted on 12/17/12, showed that the facility admitted Resident 10 to the Secured Alzheimer's Unit of the facility on 3/3/10. Resident 10's diagnoses included Alzheimer's disease and dementia with behavioral disturbance.An undated document entitled, "IDT (interdisciplinary team) Discharge/Transfer Planning" indicated that Resident 10 had limited ability to communicate because English was a second language. Resident 10 showed increased agitation in the afternoons and ability to walk independently. Due to poor vision, Resident 10 was at high risk for falls. On 9/16/11 the facility transferred Resident 10 to the hospital to diagnose and repair a hip fracture after a fall in the facility's patio area. The clinical record contained no documented evidence that Resident 10 was 1) issued a bed hold notice at the time of transfer for hospitalization and 2) lawfully refused readmission during the seven day bed hold period. At 10 a.m. on 9/19/11, three days after Resident 10's hospitalization, a hospital discharge planner (planner) documented a call from the facility social worker. The hospital discharge planner documented; "They (the facility) are closing the unit where this patient was..." The planner documented that because the facility would not readmit Resident 10, plans were made to discharge Resident 10 to a facility near the RP.Resident 10 was not allowed to exercise the right to return to the facility within the seven day bedhold period.At 4:48 p.m. on 9/19/11 an entry in the physician orders read, "[Patient] may [discharge] to [Skilled Nursing Facility] from ortho view once cleared by hospitalist." A Social Service Progress Note dated 9/20/11 noted that Resident 10 was not readmitted to the facility due to "[RPs] wish for [Resident 10] to be closer to [the RPs home, cultural environment of the proposed new facility], and the closing of the secure unit at [the facility]." This entry was inaccurate for the wishes of the RP. During an interview, at 8:55 a.m. on 1/30/13, the RP stated there were staff rumors for some time that the facility was closing the SAU and opening a subacute unit in its place. Later, the facility sent letters to tell residents and families of the planned change. RP had no plans to remove Resident 10 from the facility. Resident 10 was transferred for hospitalization on 9/16/11 to diagnose and repair a hip fracture. After Resident 10 stabilized from the hip surgery, the hospital informed RP that Resident 10 could not be readmitted to the facility due to the closure of the SAU. The RP could not recall receiving a bed hold notice at the time Resident 10 was transferred for hospitalization on 9/16/11.A copy of the facility bed hold policy was reviewed and found to lack a statement consistent with 483.12(b)(2) that required the facility provide the resident and the RP a written notice that specified the duration of the bed hold period at the time a resident is transferred for hospitalization. The facility provided the Standard State Admission Contract (5/11) for review. The contract included the statement, "...VII. Bed Holds and Readmission. If you must be transferred to an acute hospital for seven days or less, we will notify you or your representative that we are willing to hold you bed. You or your representative have 24 hours after receiving this notice to let us know whether you want us to hold your bed for you." The facility did not uphold the admission contract agreement for notice of a bedhold and readmission to the facility after hospitalization.Therefore: The facility violated the above regulations that required the facility failed to issue a seven day bed hold notice at the time Resident 10 was transferred for hospitalization (9/16/11) and refused to readmit Resident 10 once stabilized after surgical repair of the hip fracture (9/20/11). These violations had a direct relationship to the health, safety, or security of Resident 10. |
| 140000082 |
Windsor Rosewood Care Center |
020010077 |
B |
13-Aug-13 |
00JP11 |
6059 |
?483.12(a)(4)(5)(6) NOTICE REQUIREMENTS BEFORE TRANSFER OR DISCHARGE Before a facility transfers or discharges a resident, the facility must (a)(4)(i) notify the resident and, if known, a family member or legal representative of the resident of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand; (a)(4)(ii) record the reasons in the resident's clinical record; (a)(4)(iii) and include in the notice the items described in paragraph (a)(6) of this section. Except when specified in paragraph (a)(5)(ii) of this section, the notice of transfer or discharge required under paragraph (a)(4) of this section must be made by the facility at least 30 days before the resident is transferred or discharged. (a)(6) The written notice specified in paragraph (a)(4) of this section must include (a)(4)(i) the reason for transfer or discharge; (a)(4)(ii) the effective date of transfer or discharge; (a)(4)(iii) the location to which the resident is transferred or discharged; (a)(4)(iv) a statement that the resident has the right to appeal the action to the State; (a)(4)(v) the name, address and telephone number of the State long term care ombudsman; and (a)(4)(vi) for nursing facility residents who are mentally ill, the mailing address and telephone number of the agency responsible for the protection and advocacy of mentally ill individuals established under the Protection and Advocacy for Mentally Ill Individuals Act. The facility failed to issue a proper written notice of discharge and to document this action in the clinical record prior to the discharge of Resident 11 to another facility. The facility failed to inform Resident 11 of the reason for the discharge in writing in a discharge notice and to document it in clinical record. The facility did not inform Resident 11 in writing of the date of discharge and the location of discharge. The facility did not inform Resident 11 in writing of the right to appeal the discharge and the contact information for the Ombudsman or other advocacy groups. The facility did not provide Resident 11 a notice of discharge 30 days in advance of the intended discharge date. Failure to properly notify Resident 11, in accordance with regulatory requirements regarding discharge, resulted in violations of Resident 11's rights. Review of the closed clinical record on 12/17/12 showed that the facility admitted Resident 11 the Secured Alzheimer's Unit (SAU) of the facility on 8/18/08. Diagnoses included vascular dementia and lack of coordination. An undated Interdisciplinary Team Discharge/ Transfer Planning document recorded that Resident 11 was, "easily annoyed but manageable," "curt and grumpy," "dislikes long-winded explanations," and liked being alone.Minimum Data Sets (the facility's comprehensive assessment of the resident's condition with quarterly reviews and updates), dated 3/20/11 and 9/18/11, indicated that Resident 11 had long and short term memory problems. Resident 11 was severely impaired for the ability to make decisions about daily life. Resident 11 had a fluctuating attention span and disorganized thinking. The MDS indicated that there were no plans to discharge Resident 11 to the community. During the closed record review on 12/17/12 copies of letters sent by the facility to the Responsible Party (RP) on 7/18/11 and 8/18/11 were noted. 1) The July 2011 letter contained these statements from the administrator: "In the up-coming weeks we will be gathering information and working with families, friends and conservators to assist with the relocation of residents currently residing in our secure unit. Social Service is working with area facilities for bed availability and to arrange tours for families, friends and conservators." 2) The August 2011 letter contained the following statements from the administrator: "I wanted to up-date everyone on our on-going project to transition the secure unit to a sub-acute unit. The progression is slower than we had planned which allows us more time to continue giving care to our residents on the unit. The projection is now for mid-November to early December before we will need to pursue relocation of our residents currently residing in our secure unit." There was no documented evidence in the clinical record that Resident 11 was given a written discharge notice at any time prior to the date of discharge. On 9/23/11 the physician ordered, "Discharge to [skilled nursing facility with] meds on 9/26/11." A nursing note at 10:30 a.m. on 9/26/11 read, "Discharged to [skilled nursing home." Physician's orders and nurse's notes did not contain a reason for discharge. There was no documented evidence in the clinical record that Resident 11 was given a written discharge notice 30 days prior to the date of discharge. During an interview at 2 p.m. on 11/21/12 the Administrator stated that no written discharge notice was issued for Resident 11 in accordance with the applicable regulatory requirements prior to discharge on 9/26/11. During an interview at 3:15 p.m. on 1/8/13 the Co-Conservator - Contra Costa County, stated that she learned of the pending closure of the SAU and discharge of Resident 11 from letters sent by the facility. She did not recall receiving notice of the right to appeal the discharge.Therefore: The above regulations were violated when the facility failed to issue Resident 11 a written notice of discharge that contained information to ensure an orderly transfer (including the date and location) and to document this action in the clinical record, failed to document the reason for the discharge in both the discharge notice and the clinical record, failed to inform Resident 11 in writing of the right to appeal the discharge, failed to provide Resident 11 with written contact information for the Ombudsman and consultation with advocacy groups, and failed to issue a written discharge notice 30 days prior to the intended discharge date. These violations had a direct relationship to the health, safety, or security of Resident 11. |
| 140000082 |
Windsor Rosewood Care Center |
020010078 |
B |
13-Aug-13 |
00JP11 |
5549 |
?483.12(a)(4)(5)(6) NOTICE REQUIREMENTS BEFORE TRANSFER OR DISCHARGE Before a facility transfers or discharges a resident, the facility must (a)(4)(i) notify the resident and, if known, a family member or legal representative of the resident of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand; (a)(4)(ii) record the reasons in the resident's clinical record; (a)(4)(iii) and include in the notice the items described in paragraph (a)(6) of this section. Except when specified in paragraph (a)(5)(ii) of this section, the notice of transfer or discharge required under paragraph (a)(4) of this section must be made by the facility at least 30 days before the resident is transferred or discharged. (a)(6) The written notice specified in paragraph (a)(4) of this section must include (a)(4)(i) the reason for transfer or discharge; (a)(4)(ii) the effective date of transfer or discharge; (a)(4)(iii) the location to which the resident is transferred or discharged; (a)(4)(iv) a statement that the resident has the right to appeal the action to the State; (a)(4)(v) the name, address and telephone number of the State long term care ombudsman; and (a)(4)(vi) for nursing facility residents who are mentally ill, the mailing address and telephone number of the agency responsible for the protection and advocacy of mentally ill individuals established under the Protection and Advocacy for Mentally Ill Individuals Act. The facility failed to issue a proper written notice of discharge and to document this action in the clinical record prior to the discharge of Resident 12 to another facility. The facility did not inform Resident 12 of the reason for the discharge in writing in a discharge notice and document the reason in the clinical record. The facility did not inform Resident 12 in writing of the date of discharge and the location of discharge. The facility did not inform Resident 12 in writing of the right to appeal the discharge and the contact information for the Ombudsman or other advocacy groups. The facility did not provide Resident 12 a written notice of discharge 30 days in advance of the intended discharge date. Failure to properly notify Resident 12, in accordance with regulatory requirements regarding discharge, resulted in violations of Resident 12's rights. Review of the closed clinical record on 12/17/12 showed that the facility admitted Resident 12 to the Secured Alzheimer's Unit (SAU) of the facility on 6/29/10. Diagnoses included dementia with behavior disturbance, senile dementia, Alzheimer's disease, and hearing loss.Minimum Data Sets (the facility's comprehensive assessment of the resident's condition with quarterly reviews and updates), dated 3/24/11 and 6/23/11, indicated that Resident 12 had long and short term memory problems. Resident 12 was moderately impaired for the ability to reason and make decisions about daily life. Resident 12 had a fluctuating attention span and disorganized thinking. Resident 12 could not live independently in the community. Resident 12 struck out at others frequently, had verbal behaviors directed toward others frequently and Resident 12 wandered about. During the closed record review on 12/17/12 a copy of a letter sent by the facility to the responsible party (RP) on 7/18/11 was noted. The July 2011 letter contained these statements from the administrator: "In the up-coming weeks we will be gathering information and working with families, friends and conservators to assist with the relocation of residents currently residing in our secure unit. Social Service is working with area facilities for bed availability and to arrange tours for families, friends and conservators." There was no documented evidence in the clinical record that Resident 12 was given a written discharge notice at any time prior to the date of discharge. On 8/4/11 the physician ordered, "[Discharge] to [skilled nursing facility] when arrangements have been made. May [discharge with] meds." A nursing note written at 10:45 a.m. on 8/9/11 indicated, "Discharged to [skilled nursing facility]. There was no documented reason for Resident 12's discharge in physician orders or in nurse's notes. During an interview at 2 p.m. on 11/21/12 the Administrator stated that no written discharge notice was issued for Resident 12 in accordance with the applicable regulatory requirements prior to discharge on 8/9/11. During an interview at 1:32 p.m. on 1/8/13 the responsible party (RP) stated that he learned that the SAU was closing from letters sent by the administrator and from the social worker. The RP stated, "They told me [Resident 12] had to move within three months." The RP stated, "No," when asked if the facility informed him of the right to appeal the discharge. Therefore: The above regulations were violated when the facility failed to issue Resident 12 a written notice of discharge that contained information to ensure an orderly transfer (including the date and location) and to document this action in the clinical record, failed to document the reason for the discharge in both a discharge notice and the clinical record, failed to inform Resident 12 in writing of the right to appeal the discharge, failed to provide Resident 12 with written contact information for the Ombudsman and consultation with advocacy groups, and failed to issue a written discharge notice 30 days prior to the intended discharge date. These violations had a direct relationship to the health, safety, or security of Resident 12. |
| 140000082 |
Windsor Rosewood Care Center |
020010079 |
B |
13-Aug-13 |
00JP11 |
5239 |
?483.12(a)(4)(5)(6) NOTICE REQUIREMENTS BEFORE TRANSFER OR DISCHARGE Before a facility transfers or discharges a resident, the facility must (a)(4)(i) notify the resident and, if known, a family member or legal representative of the resident of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand; (a)(4)(ii) record the reasons in the resident's clinical record; (a)(4)(iii) and include in the notice the items described in paragraph (a)(6) of this section. Except when specified in paragraph (a)(5)(ii) of this section, the notice of transfer or discharge required under paragraph (a)(4) of this section must be made by the facility at least 30 days before the resident is transferred or discharged. (a)(6) The written notice specified in paragraph (a)(4) of this section must include (a)(4)(i) the reason for transfer or discharge; (a)(4)(ii) the effective date of transfer or discharge; (a)(4)(iii) the location to which the resident is transferred or discharged; (a)(4)(iv) a statement that the resident has the right to appeal the action to the State; (a)(4)(v) the name, address and telephone number of the State long term care ombudsman; and (a)(4)(vi) for nursing facility residents who are mentally ill, the mailing address and telephone number of the agency responsible for the protection and advocacy of mentally ill individuals established under the Protection and Advocacy for Mentally Ill Individuals Act. The facility failed to issue a proper written notice of discharge and to document this action in the clinical record prior to the discharge of Resident 14 to another facility. The facility did not inform Resident 14 of the reason for the discharge in writing in a discharge notice and document the reason in the clinical record. The facility did not inform Resident 14 in writing of the date of discharge and the location of discharge. The facility did not inform Resident 14 in writing of the right to appeal the discharge and the contact information for the Ombudsman or other advocacy groups. The facility did not provide Resident 14 a written notice of discharge 30 days in advance of the intended discharge date. Failure to properly notify Resident 14, in accordance with regulatory requirements regarding discharge, resulted in violations of Resident 14's rights. Review of the closed clinical record on 12/17/12 showed that Resident 14 was a long term resident of the facility. The facility admitted Resident 14 to the Secured Alzheimer's Unit (SAU) on 3/9/04. Resident 14's diagnoses included Alzheimer's disease and general weakness.Minimum Data Sets (the facility's comprehensive assessment of the resident's condition with quarterly reviews and updates), dated 3/10/11 and 6/9/11, indicated that Resident 14 had long and short term memory problems. Resident 14 was severely impaired in ability to reason and make decisions about daily life. Resident 14 had a fluctuating attention span. The MDS indicated that there were no plans to discharge Resident 14 to the community. During the closed record review on 12/17/12 a copy of a letter sent by the facility to the responsible party (RP) on 7/18/11 was noted. The July 2011 letter contained these statements from the administrator: "In the up-coming weeks we will be gathering information and working with families, friends and conservators to assist with the relocation of residents currently residing in our secure unit. Social Service is working with area facilities for bed availability and to arrange tours for families, friends and conservators." There was no documented evidence in the clinical record that Resident 14 was given a written discharge notice at any time prior to the date of discharge. On 7/29/11 the physician ordered, "Discharge to [skilled nursing facility]." A nursing note written at 10 a.m. on 8/2/11 indicated, "Discharged to [skilled nursing facility.' Physician orders and nurses' notes did not record a reason for the discharge. During an interview at 2 p.m. on 11/21/12 the Administrator stated that no written discharge notice was issued for Resident 14 in accordance with the applicable regulatory requirements prior to discharge on 8/2/11. During an interview at 5:40 p.m. on 1/11/13 the responsible party (RP) stated that the learned of the facility plan to close the SAU and discharge Resident 14 in a letter from the facility. The RP stated that the family was not informed of the right to appeal the discharge. Therefore: The above regulations were violated when the facility failed to issue Resident 14 a written notice of discharge that contained information to ensure an orderly transfer (including the date and location) and to document this action in the clinical record, failed to document the reason for the discharge in both a discharge notice and the clinical record, failed to inform Resident 14 in writing of the right to appeal the discharge, failed to provide Resident 14 with written contact information for the Ombudsman and consultation with advocacy groups, and failed to issue a written discharge notice 30 days prior to the intended discharge date. These violations had a direct relationship to the health, safety, or security of Resident 14. |
| 140000082 |
Windsor Rosewood Care Center |
020010080 |
B |
13-Aug-13 |
00JP11 |
5989 |
?483.12(a)(4)(5)(6) NOTICE REQUIREMENTS BEFORE TRANSFER OR DISCHARGE Before a facility transfers or discharges a resident, the facility must (a)(4)(i) notify the resident and, if known, a family member or legal representative of the resident of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand; (a)(4)(ii) record the reasons in the resident's clinical record; (a)(4)(iii) and include in the notice the items described in paragraph (a)(6) of this section. Except when specified in paragraph (a)(5)(ii) of this section, the notice of transfer or discharge required under paragraph (a)(4) of this section must be made by the facility at least 30 days before the resident is transferred or discharged. (a)(6) The written notice specified in paragraph (a)(4) of this section must include (a)(4)(i) the reason for transfer or discharge; (a)(4)(ii) the effective date of transfer or discharge; (a)(4)(iii) the location to which the resident is transferred or discharged; (a)(4)(iv) a statement that the resident has the right to appeal the action to the State; (a)(4)(v) the name, address and telephone number of the State long term care ombudsman; and (a)(4)(vi) for nursing facility residents who are mentally ill, the mailing address and telephone number of the agency responsible for the protection and advocacy of mentally ill individuals established under the Protection and Advocacy for Mentally Ill Individuals Act. The facility failed to issue a proper written notice of discharge prior to the discharge of Resident 6 to another facility and to document this action in the clinical record. The facility did not inform Resident 6 of the reason for the discharge in a discharge notice and document the reason in the clinical record. The facility did not inform Resident 6 in writing of the date of discharge and the location of discharge. The facility did not inform Resident 6 in writing of the right to appeal the discharge and did not provide contact information for the Ombudsman or other advocacy groups. The facility did not provide Resident 6 a written notice of discharge 30 days in advance of the intended discharge date. Failure to properly notify Resident 6, in accordance with regulatory requirements regarding discharge, resulted in violations of Resident 6's rights. Review of the closed clinical record on 12/17/12 showed that the facility admitted Resident 6 to the Secured Alzheimer's Unit (SAU) of the facility on 10/8/08. Resident 6's diagnoses included anxiety and dementia with behavioral disturbance.Review of the Minimum Data Sets (the facility's comprehensive assessment of the resident's condition with quarterly reviews and updates), dated 6/19/11 and 9/18/11, indicated that Resident 6 had long and short term memory problems. Resident 6 was moderately impaired for reasoning and the ability to make decisions about daily living. Community placement was not appropriate. The MDS also indicated that Resident 6 had frequent physical and verbal behavior directed toward others. Resident 6 rejected care and wandered about the facility. The closed record contained copies of letters sent by the facility to the responsible party (RP) on 7/18/11 and 8/18/11. 1) The July 2011 letter contained these statements from the administrator: "In the up-coming weeks we will be gathering information and working with families, friends and conservators to assist with the relocation of residents currently residing in our secure unit. Social Service is working with area facilities for bed availability and to arrange tours for families, friends and conservators." 2) The August 2011 letter contained the following statements from the administrator: "I wanted to up-date everyone on our on-going project to transition the secure unit to a sub-acute unit. The progression is slower than we had planned which allows us more time to continue giving care to our residents on the unit. The projection is now for mid-November to early December before we will need to pursue relocation of our residents currently residing in our secure unit." There was no documented evidence in the clinical record that Resident 6 was given a written discharge notice at any time prior to the date of discharge. On 10/10/11 the physician ordered, "For discharge to [skilled nursing facility with] medications." A nursing note at 9:20 a.m. on 10/11/11 indicated, "Discharged to [skilled nursing facility..." There was no reason for discharge recorded in physician's orders or in nurse's notes. There was no documented evidence in the clinical record that Resident 6 was given a written discharge notice 30 days prior to the intended date of discharge. During an interview at 2 p.m. on 11/21/12 the Administrator stated that no written discharge notice was issued for Resident 6 in accordance with the applicable regulatory requirements prior to discharge on 10/11/11. During an interview, at 4 p.m. on 2/11/13, the responsible party stated that the facility did not issue a discharge notice including a statement of the right to appeal the discharge prior to the discharge. The RP stated, "We only received the letters saying that the [SAU] was closing and that we had to move [Resident 6]." Therefore: The above regulations were violated when the facility failed to issue Resident 6 a written notice of discharge that contained information to ensure an orderly transfer (including the date and location) and to document this action in the clinical record, failed to document the reason for the discharge in both a discharge notice and the clinical record, failed to inform Resident 6 in writing of the right to appeal the discharge, failed to provide Resident 6 with written contact information for the Ombudsman and consultation with advocacy groups, and failed to issue a written discharge notice 30 days prior to the intended discharge date. These violations had a direct relationship to the health, safety, or security of Resident 6. |
| 140000082 |
Windsor Rosewood Care Center |
020010081 |
B |
13-Aug-13 |
00JP11 |
6358 |
?483.12(a)(4)(5)(6) NOTICE REQUIREMENTS BEFORE TRANSFER OR DISCHARGE Before a facility transfers or discharges a resident, the facility must (a)(4)(i) notify the resident and, if known, a family member or legal representative of the resident of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand; (a)(4)(ii) record the reasons in the resident's clinical record; (a)(4)(iii) and include in the notice the items described in paragraph (a)(6) of this section. Except when specified in paragraph (a)(5)(ii) of this section, the notice of transfer or discharge required under paragraph (a)(4) of this section must be made by the facility at least 30 days before the resident is transferred or discharged. (a)(6) The written notice specified in paragraph (a)(4) of this section must include (a)(4)(i) the reason for transfer or discharge; (a)(4)(ii) the effective date of transfer or discharge; (a)(4)(iii) the location to which the resident is transferred or discharged; (a)(4)(iv) a statement that the resident has the right to appeal the action to the State; (a)(4)(v) the name, address and telephone number of the State long term care ombudsman; and (a)(4)(vi) for nursing facility residents who are mentally ill, the mailing address and telephone number of the agency responsible for the protection and advocacy of mentally ill individuals established under the Protection and Advocacy for Mentally Ill Individuals Act. The facility failed to issue a proper written notice of discharge and to document this action in the clinical record prior to the discharge of Resident 16 to another facility. The facility did not inform Resident 16 of the reason for the discharge in writing in a discharge notice and document the reason in the clinical record. The facility did not inform Resident 16 in writing of the date of discharge and the location of discharge. The facility did not inform Resident 16 in writing of the right to appeal the discharge and the contact information for the Ombudsman or other advocacy groups. The facility did not provide Resident 16 a written notice of discharge 30 days in advance of the intended discharge date. Failure to properly notify Resident 16, in accordance with regulatory requirements regarding discharge, resulted in violations of Resident 16's rights. Record review conducted on 12/17/12 showed that the facility admitted Resident 16 to the Secured Alzheimer's Unit (SAU) of the facility on 11/3/10. Resident 16's diagnoses included advanced dementia.Minimum Data Sets (the facility's comprehensive assessment of the resident's condition with quarterly reviews and updates), dated 11/10/10 and 8/7/11, indicated that Resident 16 was able to make decisions about daily life but that community placement was not appropriate. An undated document entitled, "[Interdisciplinary Team Discharge/Transfer Planning," recorded that Resident 16 was "very territorial" in behavior, and became upset if roommates were very confused, noisy and/or intrusive, and sometimes had angry outbursts. During the closed record review on 12/17/12 copies of letters sent by the facility to the responsible party (RP) on 7/18/11 and 8/18/11 were noted. 1) The July 2011 letter contained these statements from the administrator: "In the up-coming weeks we will be gathering information and working with families, friends and conservators to assist with the relocation of residents currently residing in our secure unit. Social Service is working with area facilities for bed availability and to arrange tours for families, friends and conservators." 2) The August 2011 letter contained the following statements from the administrator: "I wanted to up-date everyone on our on-going project to transition the secure unit to a sub-acute unit. The progression is slower than we had planned which allows us more time to continue giving care to our residents on the unit. The projection is now for mid-November to early December before we will need to pursue relocation of our residents currently residing in our secure unit." There was no documented evidence in the clinical record that Resident 16 was given a written discharge notice at any time prior to the date of discharge. On 10/4/11 the physician ordered, "May [discharge] to facility responsible party choice (sic) with medications when arrangement(sic) have been made." A nursing note written at 1 p.m. on 10/5/11 indicated, "Discharged to [skilled nursing facility] in a private car." There was no documented evidence in the clinical record that Resident 16 was given a written discharge notice 30 days prior to the date of discharge. During an interview at 2 p.m. on 11/21/12 the Administrator stated that no written discharge notice was issued for Resident 16 in accordance with the applicable regulatory requirements prior to discharge on 10/5/11. During an interview at 3:40 p.m. on 1/4/13 the responsible party (RP) stated that she first learned of the facility plan to close the SAU and discharge the residents from Resident 16. The RP stated that the social worker told Resident 16 of the planned discharge. The RP stated that Resident 16 did not understand any of this and called repeatedly due to the upset the news caused. The RP stated, "I found out about this from the social worker who spoke with me one day when I was in the facility. She told me that the [SAU] was closing and that if I did not move [Resident 16], they would - to a facility in Sacramento." The facility did not issue a discharge notice and, "did not inform me of the right to appeal the discharge." Therefore: The above regulations were violated when the facility failed to issue Resident 16 a written notice of discharge that contained information to ensure an orderly transfer (including the date and location) and to document this action in the clinical record, failed to document the reason for the discharge in both a discharge notice and the clinical record, failed to inform Resident 16 in writing of the right to appeal the discharge, failed to provide Resident 16 with written contact information for the Ombudsman and consultation with advocacy groups, and failed to issue a written discharge notice 30 days prior to the intended discharge date. These violations had a direct relationship to the health, safety, or security of Resident 16. |
| 140000082 |
Windsor Rosewood Care Center |
020010082 |
B |
13-Aug-13 |
00JP11 |
5875 |
?483.12(a)(4)(5)(6) NOTICE REQUIREMENTS BEFORE TRANSFER OR DISCHARGE Before a facility transfers or discharges a resident, the facility must (a)(4)(i) notify the resident and, if known, a family member or legal representative of the resident of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand; (a)(4)(ii) record the reasons in the resident's clinical record; (a)(4)(iii) and include in the notice the items described in paragraph (a)(6) of this section. Except when specified in paragraph (a)(5)(ii) of this section, the notice of transfer or discharge required under paragraph (a)(4) of this section must be made by the facility at least 30 days before the resident is transferred or discharged. (a)(6) The written notice specified in paragraph (a)(4) of this section must include (a)(4)(i) the reason for transfer or discharge; (a)(4)(ii) the effective date of transfer or discharge; (a)(4)(iii) the location to which the resident is transferred or discharged; (a)(4)(iv) a statement that the resident has the right to appeal the action to the State; (a)(4)(v) the name, address and telephone number of the State long term care ombudsman; and (a)(4)(vi) for nursing facility residents who are mentally ill, the mailing address and telephone number of the agency responsible for the protection and advocacy of mentally ill individuals established under the Protection and Advocacy for Mentally Ill Individuals Act. The facility failed to issue a proper written notice of discharge and to document this action in the clinical record prior to the discharge of Resident 17 to another facility. The facility did not inform Resident 17 of the reason for the discharge in writing in a discharge notice and document the reason in the clinical record. The facility did not inform Resident 17 in writing of the date of discharge and the location of discharge. The facility did not inform Resident 17 in writing of the right to appeal the discharge and the contact information for the Ombudsman or other advocacy groups. The facility did not provide Resident 17 a written notice of discharge 30 days in advance of the intended discharge date. Failure to properly notify Resident 17, in accordance with regulatory requirements regarding discharge, resulted in violations of Resident 17's rights. Review of the closed clinical record on 12/17/12 showed that the facility admitted Resident 17 to the Secured Alzheimer's Unit (SAU) of the facility on 7/23/10. Resident 17's diagnoses included dementia and Alzheimer's disease.Minimum Data Sets (the facility's comprehensive assessment of the resident's condition with quarterly reviews and updates), dated 4/27/11 and 7/26/11, revealed that Resident 17 had long and short term memory problems. Resident 17 needed help to make decisions about daily life. According to the assessment, community placement was not appropriate. The closed record contained copies of letters sent by the facility to the responsible party (RP) on 7/18/1 and, 8/18/11. 1) The July 2011 letter contained these statements from the administrator: "In the up-coming weeks we will be gathering information and working with families, friends and conservators to assist with the relocation of residents currently residing in our secure unit. Social Service is working with area facilities for bed availability and to arrange tours for families, friends and conservators." 2) The August 2011 letter contained the following statements from the administrator: "I wanted to up-date everyone on our on-going project to transition the secure unit to a sub-acute unit. The progression is slower than we had planned which allows us more time to continue giving care to our residents on the unit. The projection is now for mid-November to early December before we will need to pursue relocation of our residents currently residing in our secure unit." There was no documented evidence in the clinical record that Resident 17 was given a written discharge notice at any time prior to the date of discharge. On 10/5/11 the physician ordered, "For [discharge] to [skilled nursing facility with] medication when arrangements made." A nursing note at on indicated, " A nursing note written at 6:30 p.m. on 10/6/11 indicated, "[Family member] came and picked up... endorsed belongings and medication... Left [with family member] in fair condition." There was no documented evidence in the clinical record that Resident 17 was given a written discharge notice 30 days prior to the date of discharge During an interview at 2 p.m. on 11/21/12 the Administrator stated that no written discharge notice was issued for Resident 17 in accordance with the applicable regulatory requirements prior to discharge on 10/6/11. During an interview at 3:45 p.m. on 1/3/13 the responsible party (RP) stated that he learned that the [SAU] was closing and that Resident 17 would be discharged from the letters sent by the facility. The RP stated, "They told me that [Resident 17] had to leave the facility..." The RP stated that he was never informed of the right to appeal the discharge. Therefore: The above regulations were violated when the facility failed to issue Resident 17 a written notice of discharge that contained information to ensure an orderly transfer (including the date and location) and to document this action in the clinical record, failed to document the reason for the discharge in both a discharge notice and the clinical record, failed to inform Resident 17 in writing of the right to appeal the discharge, failed to provide Resident 17 with written contact information for the Ombudsman and consultation with advocacy groups, and failed to issue a written discharge notice 30 days prior to the intended discharge date. These violations had a direct relationship to the health, safety, or security of Resident 17. |
| 140000082 |
Windsor Rosewood Care Center |
020010084 |
B |
13-Aug-13 |
00JP11 |
6188 |
?483.12(a)(4)(5)(6) NOTICE REQUIREMENTS BEFORE TRANSFER OR DISCHARGE Before a facility transfers or discharges a resident, the facility must (a)(4)(i) notify the resident and, if known, a family member or legal representative of the resident of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand; (a)(4)(ii) record the reasons in the resident's clinical record; (a)(4)(iii) and include in the notice the items described in paragraph (a)(6) of this section. Except when specified in paragraph (a)(5)(ii) of this section, the notice of transfer or discharge required under paragraph (a)(4) of this section must be made by the facility at least 30 days before the resident is transferred or discharged. (a)(6) The written notice specified in paragraph (a)(4) of this section must include (a)(4)(i) the reason for transfer or discharge; (a)(4)(ii) the effective date of transfer or discharge; (a)(4)(iii) the location to which the resident is transferred or discharged; (a)(4)(iv) a statement that the resident has the right to appeal the action to the State; (a)(4)(v) the name, address and telephone number of the State long term care ombudsman; and (a)(4)(vi) for nursing facility residents who are mentally ill, the mailing address and telephone number of the agency responsible for the protection and advocacy of mentally ill individuals established under the Protection and Advocacy for Mentally Ill Individuals Act. The facility failed to issue a proper written notice of discharge and to document this action in the clinical record prior to the discharge of Resident 18 to another facility. The facility did not inform Resident 18 of the reason for the discharge in writing in a discharge notice and document the reason in clinical record. The facility did not inform Resident 18 in writing of the date of discharge and the location of discharge. The facility did not inform Resident 18 in writing of the right to appeal the discharge and the contact information for the Ombudsman or other advocacy groups. The facility did not provide Resident 18 a written notice of discharge 30 days in advance of the intended discharge date. Failure to properly notify Resident 18, in accordance with regulatory requirements regarding discharge, resulted in violations of Resident 18's rights. Review of the closed clinical record on 12/17/12 showed that the facility admitted Resident 18 to the Secured Alzheimer's Unit (SAU) of the facility on 2/7/09. Resident 18's diagnoses included senile dementia. There was no documented evidence in the clinical record that Resident 18 was given a written discharge notice 30 days prior to the date of discharge. Minimum Data Sets (the facility's comprehensive assessment of the resident's condition with quarterly reviews and updates), dated 2/4/11 and 8/2/11, indicated that Resident 18 had long and short term memory problems. Resident 18 was severely impaired for the ability to reason and make decisions about daily life. Community placement was not appropriate. Resident 18 had behaviors that were not socially appropriate.The closed record contained copies of letters sent by the facility to the responsible party (RP) on 7/18/11 and 8/18/11. 1) The July 2011 letter contained these statements from the administrator: "In the up-coming weeks we will be gathering information and working with families, friends and conservators to assist with the relocation of residents currently residing in our secure unit. Social Service is working with area facilities for bed availability and to arrange tours for families, friends and conservators." 2) The August 2011 letter contained the following statements from the administrator: "I wanted to up-date everyone on our on-going project to transition the secure unit to a sub-acute unit. The progression is slower than we had planned which allows us more time to continue giving care to our residents on the unit. The projection is now for mid-November to early December before we will need to pursue relocation of our residents currently residing in our secure unit." There was no documented evidence in the clinical record that Resident 18 was given a written discharge notice at any time prior to the date of discharge. On 10/7/11 the physician ordered, "May discharge to facility family (sic) of choice when the arrangement (sic) have been made [with] medications." A nursing note at 10 a.m. on 10/8/11 indicated, "Discharged to [skilled nursing facility]." There was no documented evidence in the clinical record that Resident 18 was given a written discharge notice 30 days prior to the date of discharge.During an interview at 2 p.m. on 11/21/12 the Administrator stated that no written discharge notice was issued for Resident 18 in accordance with the applicable regulatory requirements prior to discharge on 10/8/11. During an interview at 4:20 p.m. on 1/3/13 the responsible party (RP) stated that she learned about the facility plan to close the SAU and discharge Resident 18 from letters sent by the facility. The RP stated, "We were given no choice. We were told that the [SAU] was closing. The RP asked a friend to translate. During an interview on 1/7/13 the friend stated, "We were told that the [SAU] was closing and that we must move [Resident 18] by the social worker who arranged discharge to [a Sacramento, CA facility]. We were not told of the right to appeal the discharge."Therefore: The above regulations were violated when the facility failed to issue Resident 18 a written notice of discharge that contained information to ensure an orderly transfer (including the date and location) and to document this action in the clinical record, failed to document the reason for the discharge in both a discharge notice and the clinical record, failed to inform Resident 18 in writing of the right to appeal the discharge, failed to provide Resident 18 with written contact information for the Ombudsman and consultation with advocacy groups, and failed to issue a written discharge notice 30 days prior to the intended discharge date. These violations had a direct relationship to the health, safety, or security of Resident 18. |
| 140000082 |
Windsor Rosewood Care Center |
020010085 |
B |
13-Aug-13 |
00JP11 |
5829 |
?483.12(a)(4)(5)(6) NOTICE REQUIREMENTS BEFORE TRANSFER OR DISCHARGE Before a facility transfers or discharges a resident, the facility must (a)(4)(i) notify the resident and, if known, a family member or legal representative of the resident of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand; (a)(4)(ii) record the reasons in the resident's clinical record; (a)(4)(iii) and include in the notice the items described in paragraph (a)(6) of this section. Except when specified in paragraph (a)(5)(ii) of this section, the notice of transfer or discharge required under paragraph (a)(4) of this section must be made by the facility at least 30 days before the resident is transferred or discharged. (a)(6) The written notice specified in paragraph (a)(4) of this section must include (a)(4)(i) the reason for transfer or discharge; (a)(4)(ii) the effective date of transfer or discharge; (a)(4)(iii) the location to which the resident is transferred or discharged; (a)(4)(iv) a statement that the resident has the right to appeal the action to the State; (a)(4)(v) the name, address and telephone number of the State long term care ombudsman; and (a)(4)(vi) for nursing facility residents who are mentally ill, the mailing address and telephone number of the agency responsible for the protection and advocacy of mentally ill individuals established under the Protection and Advocacy for Mentally Ill Individuals Act. The facility failed to issue a proper written notice of discharge and to document this action in the clinical record prior to the discharge of Resident 19 to another facility. The facility did not inform Resident 19 of the reason for the discharge in writing in a discharge notice and document the reason in clinical record. The facility did not inform Resident 19 in writing of the date of discharge and the location of discharge. The facility did not inform Resident 19 in writing of the right to appeal the discharge and the contact information for the Ombudsman or other advocacy groups. The facility did not provide Resident 19 a written notice of discharge 30 days in advance of the intended discharge date. Failure to properly notify Resident 19, in accordance with regulatory requirements regarding discharge, resulted in violations of Resident 19's rights. Record review conducted on 12/17/12 showed that the facility admitted Resident 19 to the Secured Alzheimer's Unit (SAU) of the facility on 9/15/11. Resident 19's diagnoses included senile dementia and anxiety.Minimum Data Sets (MDS, the facility's comprehensive assessment of the resident's condition with quarterly reviews and updates), dated 6/12/11 and 9/11/11, revealed that Resident 19 had long and short term memory problems, moderately impaired cognitive skills for daily decision making, and that community placement was not appropriate. The MDS also indicated that Resident 19 had frequent physical behaviors that were directed toward others. Resident 19 rejected care and wandered daily. The closed record contained copies of letters sent by the facility to the responsible party (RP) on 7/18/11 and 8/18/11. 1) The July 2011 letter contained these statements from the administrator: "In the up-coming weeks we will be gathering information and working with families, friends and conservators to assist with the relocation of residents currently residing in our secure unit. Social Service is working with area facilities for bed availability and to arrange tours for families, friends and conservators." 2) The August 2011 letter contained the following statements from the administrator: "I wanted to up-date everyone on our on-going project to transition the secure unit to a sub-acute unit. The progression is slower than we had planned which allows us more time to continue giving care to our residents on the unit. The projection is now for mid-November to early December before we will need to pursue relocation of our residents currently residing in our secure unit." There was no documented evidence in the clinical record that Resident 19 was given a written discharge notice at any time prior to the date of discharge. On 10/19/11 the physician ordered, "Discharge to [skilled nursing facility with] meds on 10/18/11(sic)." A nursing note written at 10:15 a.m. on 10/18/11 indicated, "Discharged to [skilled nursing facility] accompanied by two staff."During an interview at 2 p.m. on 11/21/12 the Administrator stated that no written discharge notice was issued for Resident 19 in accordance with the applicable regulatory requirements prior to discharge on 10/18/11. During an interview at 2:20 p.m. on 1/14/13 the responsible party (RP) stated that he learned that the facility was closing the [SAU] from letters that indicated the SAU would be closed and Resident 19 would be discharged. The RP stated, "I was told to find a placement for [Resident 19] or the facility would place [Resident 19] in a Stockton facility." The RP also stated that he did not recall being told that he could appeal the discharge. Therefore: The above regulations were violated when the facility failed to issue Resident 19 a written notice of discharge that contained information to ensure an orderly transfer (including the date and location) and to document this action in the clinical record, failed to document the reason for the discharge in both a discharge notice and the clinical record, failed to inform Resident 19 in writing of the right to appeal the discharge, failed to provide Resident 19 with written contact information for the Ombudsman and consultation with advocacy groups, and failed to issue a written discharge notice 30 days prior to the intended discharge date. These violations had a direct relationship to the health, safety, or security of Resident 19. |
| 140000082 |
Windsor Rosewood Care Center |
020010086 |
B |
14-Aug-13 |
00JP11 |
6893 |
?483.12(a)(4)(5)(6) NOTICE REQUIREMENTS BEFORE TRANSFER OR DISCHARGE Before a facility transfers or discharges a resident, the facility must (a)(4)(i) notify the resident and, if known, a family member or legal representative of the resident of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand; (a)(4)(ii) record the reasons in the resident's clinical record; (a)(4)(iii) and include in the notice the items described in paragraph (a)(6) of this section. Except when specified in paragraph (a)(5)(ii) of this section, the notice of transfer or discharge required under paragraph (a)(4) of this section must be made by the facility at least 30 days before the resident is transferred or discharged. (a)(6) The written notice specified in paragraph (a)(4) of this section must include (a)(4)(i) the reason for transfer or discharge; (a)(4)(ii) the effective date of transfer or discharge; (a)(4)(iii) the location to which the resident is transferred or discharged; (a)(4)(iv) a statement that the resident has the right to appeal the action to the State; (a)(4)(v) the name, address and telephone number of the State long term care ombudsman; and (a)(4)(vi) for nursing facility residents who are mentally ill, the mailing address and telephone number of the agency responsible for the protection and advocacy of mentally ill individuals established under the Protection and Advocacy for Mentally Ill Individuals Act. The facility failed to issue a proper written notice of discharge and to document this action in the clinical record prior to the involuntary discharge of Resident 20 to another facility. The facility did not inform Resident 20 of the reason for the discharge in writing in a discharge notice and document the reason in clinical record. The facility did not inform Resident 20 in writing of the date of discharge and the location of discharge. The facility did not inform Resident 20 in writing of the right to appeal the discharge and the contact information for the Ombudsman or other advocacy groups. The facility did not provide Resident 20 a written notice of involuntary discharge 30 days in advance of the intended discharge date. Failure to properly notify Resident 20, in accordance with regulatory requirements regarding discharge, resulted in violations of Resident 20's rights. Record review conducted on 12/17/12 showed that the facility admitted Resident 20 to the Secured Alzheimer's Unit (SAU) of the facility on 1/8/09. Resident 20's diagnoses included dementia with behavioral disturbances and anxiety.Minimum Data Sets (MDS, the facility's comprehensive assessment of the resident's condition with quarterly reviews and updates), dated 1/14/11 and 7/12/11, indicated that Resident 20 was impaired for making decisions about daily life and that community placement was not appropriate. The MDS indicated that Resident 20 often had physical behavior directed toward others that put the resident and others at significant risk for physical injury, and that significantly interfered with care, activities or social interaction. Resident 20 often rejected care and had wandering behavior. Additionally, Resident 20 did not speak English. The closed record contained copies of letters sent by the facility to the responsible party (RP) on 7/18/11 and 8/18/11. 1) The July 2011 letter contained these statements from the administrator: "In the up-coming weeks we will be gathering information and working with families, friends and conservators to assist with the relocation of residents currently residing in our secure unit. Social Service is working with area facilities for bed availability and to arrange tours for families, friends and conservators." 2) The August 2011 letter contained the following statements from the administrator: "I wanted to up-date everyone on our on-going project to transition the secure unit to a sub-acute unit. The progression is slower than we had planned which allows us more time to continue giving care to our residents on the unit. The projection is now for mid-November to early December before we will need to pursue relocation of our residents currently residing in our secure unit." There was no documented evidence in the clinical record that Resident 20 was given a written discharge notice at any time prior to the date of discharge. On 9/23/11 the physician ordered, "Discharge resident to [skilled nursing facility with] medications on 9/27/11." A nursing note written at 10 a.m. on 9/28/11 indicated, "Transfer to [skilled nursing facility]." There was no documented evidence that Resident 20 was provided with a discharge notice 30 days prior to discharge.During an interview at 2 p.m. on 11/21/12 the Administrator stated that no written discharge notice was issued for Resident 20 in accordance with the applicable regulatory requirements prior to involuntary discharge on 9/28/11. During an interview at 9:30 a.m. on 1/16/13 the responsible party (RP) stated that he learned that the facility was closing the SAU and that Resident 20 would be discharged through letters from the facility and during a meeting held at the facility to explain that residents in the SAU were to be discharged because the facility wished to provide care for residents who had different care needs. The RP stated that "All residents in the [SAU] were to be discharged. I couldn't understand the reason the facility was discharging 20 [residents]." The RP also stated that the facility started leaving the doors to the SAU unlocked, a change that potentially affected Resident 20 who wandered. The RP stated, "If the families didn't like this then they could move their relatives according to facility staff... They offered to discharge [Resident 20] to a Sacramento facility... That was too far for frequent visits. The visits would be a two-day trip." The facility planned to discharge Resident 20 to an unsecured facility. The RP stated, "I was really troubled about the plan to discharge [Resident 20] to an unsecured facility." The RP stated that he was not informed that he could appeal the discharge. Therefore: The above regulations were violated when the facility failed to issue Resident 20 a written notice of involuntary discharge that contained information to ensure an orderly transfer (including the date and location) and to document this action in the clinical record, failed to document the reason for the discharge in both a discharge notice and the clinical record, failed to inform Resident 20 in writing of the right to appeal the discharge, failed to provide Resident 20 with written contact information for the Ombudsman and consultation with advocacy groups, and failed to issue a written discharge notice 30 days prior to the intended discharge date. These violations had a direct relationship to the health, safety, or security of Resident 20. |
| 020000277 |
Windsor Healthcare Center of Oakland |
020010969 |
B |
03-Sep-14 |
GJUU11 |
11486 |
F 309 - 483.25 483.25 PROVIDE CARE/SERVICES FOR HIGHEST WELL BEINGEach resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. The facility violated the aforementioned regulation by failing to communicate to a wound care physician that Resident 1 was taking anticoagulant (blood thinners) medications prior to the physician performing surgical wound debridement (removal of tissue from a wound by a surgical instrument).This failure resulted in Resident 1 developing uncontrolled bleeding after debridement. The doctors in the facility could not stop the bleeding. The facility called 911 and sent Resident 1 to the acute care hospital emergency room for evaluation and treatment. Review of the clinical record, on 4/2/14, showed Resident 1 was admitted to the facility on 2/21/14 with multiple diagnoses that included a pressure ulcer on the sacrum coccyx (tailbone), bilateral (right and left) buttocks and right heel and ball of foot, diabetes and cardiovascular disease (involving the blood vessels of the brain).The Minimum Data Set (MDS, assessment tool), dated 2/27/14, reflected on admission Resident 1 had three unstageable pressure ulcers covered with slough and/or eschar, (dead tissue) and two unstageable pressure ulcers with deep tissue injury (purple or maroon localized area of discolored intact skin, indicates tissue death beneath the intact skin.) The MDS showed Resident 1 required total assistance with maintaining nutrition, grooming personal and oral hygiene from the facility. The admission order, dated 2/22/14, included Aspirin (thins blood to reduce formation of blood clots) 81 mg (milligrams) one tablet one time a day related to cerebrovascular disease, and Plavix (prolongs clotting time to reduce formation of unwanted clots in blood vessels) 75 mg one tablet one time a day for DVT (deep vein thrombosis or blood clot) prevention, related to cerebrovascular disease.A physician's order, dated 3/6/14, showed Resident 1's PCP 1 (primary care physician) requested a wound consult with the Provider. The facility had a contract with a wound care clinic (Provider) that provided professional wound care services to skilled nursing facilities. Review of the services agreement between the facility and the Provider, dated 7/29/13, showed the Provider would provide services to the residents of the facility as requested by the facility.In an interview, on 5/6/14 at 11:30 a.m., PCP 1 stated when a consult was requested, he expected the Provider to proceed with adequate care of the patient and give treatment as they saw fit. PCP 1 stated he spoke with LVN (licensed vocational nurse) 1 who told him the Provider said the wounds looked bad and he wanted to proceed with debridement (removal of non-healthy tissue from a wound). PCP 1 stated he told LVN 1, "Okay." PCP 1 was asked if the Provider consulted him on Resident 1's health history. PCP1 stated, "No, usually the nurse does wound care rounds, goes through the chart and reviews the patient (with the doctor)."The patient assessment note, dated 3/11/14, reflected the Provider did a new/initial assessment of Resident 1, and identified the sacrum wound as a Stage 3 pressure ulcer (full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed), the length was 7, width 13 and depth UTD (unable to determine). The units of the measurements were not given (inches or centimeters). There was no undermining (the destruction of tissue or ulceration extending under the skin edges so that the pressure ulcer is larger at its base than at the skin surface.) There was moderate purulent (pus) drainage with a mild odor and no exposed features (tendon, muscle, bone, or joint). There was no slough: percent of wound base (viable tissue layer) 50% and black eschar: percent of wound base 50%. The note showed, "Still discolored (wound) but better. No evidence of DTI (deep tissue injury) at this point."The assessment form had spaces to check if the resident had diabetes, or was on anticoagulant therapy (each could negatively affect the status of pressure ulcers). The spaces were not checked. There was a space titled, "Laboratory/Diagnostic Review". The space was left blank. There was no documentation to show the Provider reviewed Resident 1's clotting time and blood sugar before starting the treatment. The patient assessment note, dated 3/18/14, reflected the Provider performed, "Surgical debridement (also known as sharp debridement, used a scalpel or scissors)" but it was not clear what area was debrided. The assessment note for the sacrum indicated the pressure ulcer was staged as "UTD". The length was 6, width 13 and depth UTD. The units of the measurements were not given. It showed no undermining, moderate purulent drainage with a mild odor and no exposed features. There was slough: percent of wound base 20% and black eschar: percent of wound base 80%.The progress notes, dated 3/25/14, by the Provider showed, "Today the right side was covered with 100% slough and this was sharply debrided. Oozing was noted, and the wound was packed."The patient assessment note, dated 3/25/14, by the Provider indicated the sacrum pressure ulcer was Stage 3. The measurements were length 7, width 13 and depth 3 (units not given). It showed undermining, large purulent drainage with a strong odor and exposed muscle. There was slough: percent of wound base 100% and no black eschar. "Surgical debridement- skin subcutaneous muscle 100% bleeding severe. Patient on Plavix. IV started Transferred to hospital acutely".[John Hopkins Medicine advised, for sharp debridement check for bleeding or clotting problems. Debridement is contraindicated for coagulation disorders. Reference: www.hopkinsmedicine.org/gec/series/wound_care.html ] During an interview, on 4/2/14 at 1:15 p.m., LVN 2 stated she was present when the Provider performed the wound debridement on 3/25/14. LVN 2 stated the procedure was done between 11 a.m. and 12 p.m. and she observed the Provider clean the wound then cut some of the tissue and the wound started bleeding. The Provider packed the wound with gauze but it didn't stop bleeding. LVN 2 stated the Provider packed the wound and then went to see the next resident. LVN 2 stated she was not aware Resident 1 was on blood thinners. During an interview, on 4/2/14 at 1 p.m., LVN1 stated on 3/25/14 she went to lunch at 11 a.m. and returned at 11:30 a.m. She stated LVN 2 covered for her and was with the Provider when the debridement was done. LVN1 stated when she returned from lunch, she went to check on Resident 1. LVN 1 stated there was blood all over the bed sheet and chux pad (disposable pad). LVN1 stated when she turned Resident 1 on her side, blood was gushing, flowing, but she couldn't see where the blood was coming from. LVN 1 stated she got gauze and applied pressure to try to stop the bleeding then asked the PCP 1 and MD 1 to come look at Resident 1. LVN 1 stated PCP1 and MD 1 tried to stop the bleeding and MD 1 told her to call 911. The EHR (electronic health record), dated 3/25/14 at 1:56 p.m., showed LVN 1's documented, "Resident has a wound to right and left buttock which was debrided today by the wound doctor (Provider) which lead to severe bleeding; the bleeding did not stop with several attempts. PCP1 gave an order to transfer the resident to the hospital."In an interview, on 4/2/14 at 12:05, the DON (director of nursing) was asked if the Provider reviewed the resident medical history before performing a procedure. The DON stated, "Honestly, they don't review the resident's charts." She stated she told the Provider Resident 1 was on Aspirin and Plavix after they discovered the resident was bleeding. The DON stated the staff did not assist the Provider when debridement was done. She stated the staff would assess the resident after the procedure was completed. The DON was requested to provide the facility's policy and procedure for debridement. The DON was unable to provide a policy and procedure for wound debridement. During a telephone interview, on 6/25/14 at 3:35 p.m., the Provider stated he was a representative of the wound health company contracted with this facility. The Provider stated the facility staff would take him to the residents but did not assist him with procedures. They didn't do anything but stand there, watch and bring any supplies he may need for the procedure. The Provider stated Resident 1 had a large decubitus ulcer with dead tissue on top. He stated he made the decision to debride Resident 1's wound. He debrided the wound as he generally did, put in some packing but it didn't seem like a lot of bleeding at first. The Provider stated while he was with another patient; two of the house physicians went to see Resident 1 and when they turned her over, there was a lot of bleeding and pressure was applied. One of the house physicians thought it was arterial bleeding (blood from a vessel that carries blood away from the heart) and an IV (intravenous, through the vein usually to administer fluids or medication) should be started. The Provider stated, "I did not review her chart. The Resident had been on Plavix. That clearly contributed to what happened."Review of the facility's policy titled, "Skin and Wound Management Program" dated 6/23/06, showed, "Residents receive care and services necessary to promote and maintain optimum skin integrity. A plan of care addressing skin integrity alterations, risk factors and co-morbidities is developed and implemented by the Interdisciplinary Team with ongoing assessment to ensure optimum outcome."The facility's wound care services agreement with the Provider indicated the following: "Coordination of Care: Facility shall maintain resident's plan of care, medication orders and other information relevant to resident care. Upon execution of appropriate consents from residents (and/or resident family members where appropriate), the Facility shall transmit information to Provider necessary to assist and support the delivery of the Services provided under this Agreement."Review of the acute care hospital records, on 7/7/14, showed Resident 1 arrived in the emergency room on 3/25/14 at 12:40 p.m. The emergency room physician notes indicated Resident 1's vital signs were temperature 38.9 ø Celsius (102.9ø Fahrenheit), heart rate of 150, blood pressure 97/27 and respirations 36.Normal vital sign ranges for the average healthy adult while resting are: Blood pressure: 90/60 mm/Hg to 120/80 mm/Hg Breathing: 12 - 18 breaths per minute Pulse: 60 - 100 beats per minute Temperature: 97.8 - 99.1 degrees Fahrenheit / average 98.6 degrees FahrenheitReview of the laboratory results, dated 3/25/14, for Resident 1 showed PT (Prothrombin Time which measure time needed for blood to clot) was 14.5 seconds. The record indicated the normal range was 9.4 to 11.4 seconds. The INR (International Normalized Ration which shows the relationship of the patient's PT to a normal control) was 1.4. The record showed the normal range for INR was 0.8 to 1.2.Therefore the facility failed to provide the physician information about Resident 1 being on an anticoagulant medication, Plavix, before he performed the debridement procedure. This had a direct or immediate relationship to the health, safety, or security of resident. |
| 020000004 |
Wisteria Care Center |
020011063 |
B |
05-Nov-14 |
GQ2K11 |
8710 |
483.25(i) MAINTAIN NUTRITION STATUS UNLESS UNAVOIDABLE 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.The facility violated the aforementioned regulation when it failed to ensure Resident 1 maintained acceptable body weight. Resident 1 lost 29.5 pounds in one month and 42.2 pounds in six months and the facility failed to evaluate his continued weight loss and implement measures to prevent weight loss. The resident's weight loss lead to the resident's overall nutritional decline which in turn contributed to dehydration, numerous urinary tract infections, and the depletion of protein stores, which contributed to the development of an open pressure ulcer on his buttocks. (A pressure ulcer is any lesion caused by unrelieved pressure that results in damage to the underlying tissue(s).)Resident 1, an 82 year old, was first admitted to the facility on 6/7/08 and readmitted after a hospital stay on 5/10/14. The resident's diagnoses included, diabetes mellitus (a chronic form of diabetes in which insulin does not effectively transport glucose - sugar, from the bloodstream), and dementia (severely impaired memory and reasoning ability).According to the hospital "Physician Discharge Summary" dated 5/10/14, Resident 1 was admitted to the hospital on 5/2/14 with the diagnoses of dehydration, hypernatremia (elevated sodium levels in the bloodstream due to dehydration), renal failure (kidney failure), and failure to thrive (a state of decline that is manifested by weight loss, decreased appetite, and poor nutrition.) His discharge diagnoses on 5/10/14 was urinary tract infection (bladder infection), pyelonephritis (inflammation of the kidney due to bacterial infection), bladder calculus (large) (bladder stone) and nephrolithiasis (kidney stone).The facility's nurse's note dated 5/2/14 at 10 a.m., reflected Resident 1's relative called and was concerned about the him and requested the facility send him to the hospital emergency room. The nurse then called the responsible party and asked if that was what he would like and he said yes. At 10:15 a.m. the physician was informed about the family's wishes and concerns regarding weight loss and not eating. The physician gave the order to send him to the emergency room. According to the Hospital admission assessment, his weight on 5/2/14 at 6:15 p.m. was 52.7 kg (115.94 pounds) and his admission condition was, "Serious" according to the discharge summary dated 5/10/14. He was given intravenous (through the bloodstream) fluids and antibiotics for his bladder and kidney infections. Review of Resident 1's weight record showed the following monthly weights: 11/7/13 - 158.1 pounds 12/6/12 - 156.4 pounds 1/10/14 - 153.8 pounds 2/8/14 - 151.3 pounds 3/9/14 - 147 pounds 4/10/14 - 145.4 pounds A readmission minimum data set (MDS) assessment dated 12/23/13 showed the resident was independent with eating and needed assistance of staff for meal set up. He did not have any difficulty with swallowing or a significant weight loss. The physician ordered diet was changed on 12/14/13 from a mechanical soft diet, with no concentrated sweets and no added salt, to pureed diet with nectar thick liquids. The nutritional progress notes dated 12/14/13 written by the registered dietician (RD) reflected that the resident had just been readmitted from the hospital where he was treated for a urinary tract infection. The RD note included the resident's weight of 156.4 pounds, with an intake average of 50 to 100%. Her assessment revealed that the resident needed between 1700 to 1900 calories, 60-73 grams of protein, and 1800 to 1920 milliliters of fluids each day. Her plan was to continue to monitor puree diet, nectar thick liquids and follow up need for supplements. There was no documented evidence that the pureed diet served the resident contained the amount of calories and protein suggested by the RD. A significant change of condition MDS assessment dated 1/23/14 revealed that the resident declined in his ability to feed himself and was totally depended on the physical assistance of one staff person to eat. He did not have a swallowing disorder according to the assessment.A "Resident Care Conference Review" record, dated 1/23/14 reflected the resident's responsible party and another family member attended and the change in the resident's condition was discussed. The resident changed from independent in eating to needing to be fed. Resident 1's diet was changed from mechanical soft to pureed texture, and the resident was to be evaluated by a speech therapist. The record did not reflect an evaluation from a speech therapist.The RD assessed the resident on 1/26/14 and her note reflected that the resident had decreased oral intake and the resident's blood albumin (protein) level was 3.0, which is below normal (3.5 - 5.7 grams per deciliter) as of 1/21/14. The resident's monthly weight reflected a gradual decline which she noted and a 2.6 pounds last month and this month an 8 pound weight loss. "Still remains greater than ideal body weight, 117 - 143 pounds", and recommended to increase supplements 4 ounces three times a day. She recommended checking weekly weights to assess changes. The care plan, dated 6/7/08 for Potential for Altered Nutritional status was last updated on 9/11/10 to include significant weight loss. There was no update to the interventions on the care plan to reflect the change in the resident's diet texture, loss of appetite, the inability to feed himself and the change from potential for altered nutritional status to actual altered nutritional status. According to the activities of daily living (ADL) record between March 24, 2014 and April 2014, the resident's daily average meal intake was 46 percent (%). Speech therapy was started for "Dysphasia (difficulty in swallowing due to weakened throat muscles)" on 4/19/14. Resident 1 received four treatments for dysphasia before he was discharged to the hospital on 5/2/14.According to the nurses notes dated 5/10/14 Resident 1 returned from the hospital. On 5/12/14 at 11 p.m., the nurse noted that they measured the resident's weight and it was 114.2 pounds. The nurse's note on 5/13/14 revealed the resident had a poor appetite and snacks were encouraged but he refused. There was a "Care Plan Conference" on 5/13/14 and the resident's weight loss was discussed, and the family offered to bring food for the resident, and the team would continue to monitor for any changes and needs of the resident.A nurses note dated 5/22/14 revealed that the resident had an open area on his left buttock measuring 4 centimeters (cm) by 2 cm, with slight bleeding noted with an episode of scratching his buttocks. They trimmed his nails. According to the Interdisciplinary Progress Notes dated 5/22/14 at 10 a.m., "...Skin breakdown (was) developed due to resident is trying to scratch his skin, poor food intake; low albumin...incontinent in bowel, mobility deficit...will refer to RD." In a telephone interview on 7/1/14 at 3:45 p.m., the RD stated that she saw him on 5/25/14 and followed up on 6/7/14 with recommendations for supplement drink, zinc and vitamin C. She thought that he lost significant weight due to his many infections and that she didn't remember if he was eating or not. The CNAs told her it was variable. She said that in general she visits the residents once month and if the facility calls her with a problem she may go in more frequently. The record reflected that RD did not visit between 1/26/14 until 5/25/14 after his readmission from the hospital. RD's undated nutrition assessment reflected that the resident was admitted on 5/10/14 and his weight was 115.5 pounds and he had an open area on his left buttock. Her assessment was that the resident had inadequate intake related to dysphagia. He had infection and significant weight loss greater than 10 % from the past monthly weight. Her plan was to resume the high protein supplements 8 ounces three times a day with meals and 4 ounces of the supplement at 10 a.m. and 2 p.m. The care plan dated 6/7/08 mentioned above for potential for altered nutritional status was not updated with the RD's new recommendations and was not reviewed since last 4/21/14 and not due for review until 7/21/14. Therefore, the facility failed to ensure Resident 1 maintain acceptable nutritional status. This had direct or immediate relationship to the health, safety, or security of patients. |
| 140000062 |
Windsor Manor Rehabilitation Center of Concord |
020011113 |
B |
06-Nov-14 |
X75411 |
5374 |
F206 483.12(b)(3) POLICY TO PERMIT READMISSION BEYOND BED-HOLD A nursing facility must establish and follow a written policy under which a resident whose hospitalization or therapeutic leave exceeds the bed-hold period under the State plan, is readmitted to the facility immediately upon the first availability of a bed in a semi-private room if the resident requires the services provided by the facility; and is eligible for Medicaid nursing facility services. The facility violated the aforementioned regulation by failing to have a policy stating that a resident must be re-admitted to the first available bed once their bed-hold has expired, resulting in the facility failing to re-admit Resident 1 when she was ready to return to the facility after hospitalization. Resident 1 was sent to the hospital on 9/22/14 with a bed-hold of seven days and was ready to return to the facility on 9/30/14, the day after her bed-hold expired. The facility refused to re-admit her to one of their vacant beds and had no policy and procedure to direct staff to re-admit after the bed hold expires. As a result of this failure, Resident 1 has continued to remain in the hospital, although she does not require hospital care and the facility continues to refuse to admit the resident, denying her access to the home she had lived for over a year.According to the medical record, Resident 1 was admitted to the facility on 8/21/13. The face sheet showed admission diagnoses that included dementia, urinary tract infection, severe sepsis (a system- wide infection), dysphagia (difficulty swallowing) due to stroke with hemiparalysis (one side of body was paralyzed), diabetes, congestive heart failure, epilepsy (seizures), and presence of gastrostomy (a tube surgically implanted into the stomach through which liquid nutrition was given). Review of the complete resident assessment, dated 6/20/14, showed that Resident 1 had long and short term memory problems, was moderately impaired for daily decision making, required cues and supervision. Resident 1 required extensive assistance of two staff for transfers and moving about on the unit in a wheelchair, extensive assistance of one staff for eating, and was totally dependent in personal hygiene, toilet use, and bathing. Resident 1 was always incontinent (lack of control) of bowel and bladder. Review of nurses' notes, dated 9/22/14 at 5:13 a.m., showed "Resident noted at 3:20 a.m. to have difficulty breathing...was diaphoretic (perspiring) and less responsive." Resident 1 was sent to hospital emergently at 4:00 a.m. Review of Social Service (SS) Progress Notes, dated 9/29/14 at 4:35 p.m., showed, "Noted from admission that resident's seven day bed hold...has expired. Admission staff called family and left a message and given an option to pay private pay if desired. Made ombudsman aware and spoke of option to put resident on waiting list if resident wants to return to this facility." During an interview on 10/16/14 at 8:30 a.m., the Administrator (ADM) stated, "Yes, we denied her re-admission. There was a seven day bed- hold. On the eighth day, she was said to be ready to return to this facility. The Director of Nurses (DON) reviewed the referral and determined that she had become too medically complex. We continue to refuse her as needing more resources than we have available." During an interview on 10/16/14 at 10:00a.m., the Acting DON stated, "She always required a lot of care. The previous DON refused her re-admission. I don't know the details." During an interview on 10/16/14 at 10:50 a.m., the Admissions Coordinator stated, "I called Resident 1's family on the eighth day, 9/30/14, to tell them that the bed hold was up and they would have to pay privately to hold a bed." During phone interview on 10/22/14 at 8:20 a.m., the hospital discharge planner stated, "She was ready to transfer back to the facility on 9/30/14. Our department has been looking for placement. Resident 1 is doing really well. She's alert and up in a wheelchair." During phone interview on 10/22/14 at 11:30 a.m., the admission staff (AD) was asked how many vacancies were there on 9/30/14. AD stated, "On 9/30/14, we had 21 vacant beds. In the long term unit, we had two female vacancies." During phone interview on 10/22/14 at 11:50 a.m., the Acting DON stated, "We are still refusing her re-admission. We are working on a policy and procedure about what to do when the bed hold expires." Review of the facility's policy and procedure titled "Admission of Residents," revised 11/12, showed, "Policy: It is the policy of (this facility) to admit residents using a safe and orderly process, which minimizes stress and obtains baseline data for initial care planning and medical management." The procedure gives instructions on the general admission procedure and the procedure when a resident was re-admitted within seven days of transfer to hospital. The final portion of this procedure, titled "Readmission eight to thirty days since discharge/ transfer", showed instructions regarding the clinical record forms and complete resident assessment. The facility failed to have a policy to readmit residents to the first available bed after their seven day bed-hold expired and failed to readmit Resident 1 to the next available bed.The above violation has a direct relationship to the health, safety or security of patients. |
| 140000121 |
Willow Pass Healthcare Center |
020011159 |
B |
08-Dec-14 |
2IQY11 |
5608 |
483.20(k)(3)(ii) SERVICES BY QUALIFIED PERSONS/PER CARE PLANThe services provided or arranged by the facility must be provided by qualified persons in accordance with each resident's written plan of care.Therefore the facility violated the regulation by failing to: 1. Give Resident 13 Fosrenol (phosphate binder-medicine that lowers blood phosphorous for patients with kidney disease) appropriately to absorb phosphorus from food and prevent complications during dialysis treatment.2. Coordinate with the dialysis center to receive crucial laboratory results of phosphorous levels and 3. Recognize abnormally elevated serum phosphorous levels that could be life-threatening to Resident 13, risking loss of calcium in the bones and heart vessel calcification. Review of the clinical record on 10/6/14 showed Resident 13 was re-admitted on 6/18/14 with diagnoses which included end stage kidney disease and atherosclerotic cardiovascular disease (a build-up of sticky cholesterol plaque that can harden and narrow the arteries).Resident 13 was receiving hemodialysis treatment (cleans and filters waste from the blood when the kidneys cannot do this adequately). The Physician's Orders, dated 5/9/13, showed Resident 13 was to receive Fosrenol three times daily with meals.Review of Fosrenol's prescribing information showed Fosrenol should be taken with, or immediately after, meals. Fosrenol is not effective if given at any other time. Phosphorus, along with calcium, is needed for building healthy strong bones and keeping other parts of the body healthy. Normally, kidneys can remove excess phosphorus from the blood. If the kidneys are not well enough, high phosphorus levels can cause damage to the body and pull calcium out of the bones, making them weak. High phosphorus and calcium levels also lead to dangerous calcium deposits in blood vessels, eyes, and heart. Normal phosphorus level is 2.5-4.5 milligram per deciliter (mg/dcl). [Reference: ]. In an interview on 10/8/14 at 3:10 p.m., Licensed Vocational Nurse (LVN) 1 stated he gave the Fosrenol after Resident 13 ate her meals because Resident 13 did not want to take her medications until she finished eating. LVN 1 said, "I don't know if I should hold that medication when she's going to dialysis, right?"During an interview on 10/8/14 at 4 p.m., Resident 13 stated, through an interpreter, she had been taking her medication after she ate her meals. She said the nurses were busy and she had to wait until they passed medications to other residents before her. Resident 13 stated she never took any medication while she ate her meals. She said when she went out for her dialysis treatments, the facility gave her dinner at 3:30 p.m. When asked if she was given any medication with her 3:30 p.m. meal, she said, "No," and when she came back from dialysis around 9:00 p.m., her nurse would give her the medication (Fosrenol). In an interview on 10/8/14 at 4:25 p.m., LVN 2 confirmed on dialysis days, Resident 13 took her dinner at 3:30 p.m., left for dialysis at 4:00 p.m., and returned to the facility at 9:00 p.m. LVN 2 said she did not give Resident 13 Fosrenol with the 3:30 p.m. meal, but gave it when she returned to facility at 9:00 p.m. LVN 2 said "I give the Fosrenol with Nepro (nutritional supplement) that's considered food." 10/9/14 at 9:20 a.m., during an interview with LVN 3, she stated once a week she would take care of Resident 13 and she had given Fosrenol after Resident 13 had her meals. When it was pointed out the order read, "With meals," LVN 3 said, "I'm giving it with applesauce." Review of Resident 13's clinical record and concurrent interview on 10/8/14 at 4:30 p.m., the Medical Records Director (MRD) confirmed that the clinical record only showed laboratory results for 2/2014 and 7/2014.In an interview on 10/9/14 at 9:20 a.m., LVN 3 said that the charge nurses had the responsibility to call the dialysis center to follow up laboratory results.Review of Resident 13's hemodialysis care plan, revised on 9/3/14, showed that one of the approaches planned in her care was to, "Interface with dialysis unit re: labs, weights and RD (registered dietician) input." Missing laboratory results were requested from the dialysis center and reviewed on 10/8/14 at 4:10 p.m. The laboratory results showed the following increased phosphorus levels (normal range was 2.6-4.5 mg/dcl) 8/5/14- Resident 13's phosphorus level was at 5.1 milligram per deciliter (mg/dcl); 8/19/14-phosphorus level increased to 6.1 mg/dcl; 9/2/14- phosphorus level increased to 6.3 mg/dcl. According to the Clinical Journal of the American Society of Nephrology published February 2011, "Phosphate retention and, later, hyperphosphatemia (high level of phosphorous in the blood) are key contributors to chronic kidney disease (CKD)-mineral and bone disorder (MBD) ...increased serum phosphorus ...individually contribute to bone disease, vascular (blood vessel) calcification, and cardiovascular (heart/vessel) disease." Therefore, the facility failed to1. Give Resident 13 give Fosrenol (phosphate binder-medicine that lowers blood phosphorous for patients with kidney disease) appropriately to absorb phosphorus from food and prevent complications during dialysis treatment.2. Coordinate with the dialysis center to receive crucial laboratory results of phosphorous levels and 3. Recognize abnormally elevated serum phosphorous levels that could be life-threatening to Resident 13, risking loss of calcium in the bones and heart vessel calcification. These violations had a direct relationship to the health, safety or security of patients. |
| 020000071 |
Windsor Post-Acute Care Center of Hayward |
020011761 |
B |
29-Sep-15 |
DXZN11 |
7015 |
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.The facility violated the aforementioned regulation by failing to maintain a wall-hung sink so that it was securely attached to the bathroom wall. This failure resulted in the sink falling off the wall when one of three residents (Resident 1) leaned on the sink. For Resident 1, this failure resulted in a fractured coccyx (tail bone), pain, and delayed discharge from the facility. On 6/17/15, a review of the clinical record for Resident 1 indicated he was initially admitted to the facility, 5/14/14, from a hospital and discharged home on 6/4/14. The acute care hospital, transfer summary, dated 5/14/14, indicated Resident 1 was admitted to the facility for physical therapy and back pain relief, with the expectation that he would be discharged to home health care after his pain was more controlled, and his functional status improved. His admission diagnoses included cancer of the spinal cord, and chronic pain. Resident 1 had received radiation treatment to shrink the tumor at the base of his spine in order to lessen the effects of the compression of the spinal cord, but the tumor was still present. According to the "Weekly Summary; Nursing," dated 5/29/14, Resident 1 was mentally competent.A review of the facility's, "Situation Background Assessment Recommendation (SBAR) for Communication for Changes in Condition," for Resident 1, dated 5/23/14, at 2:45 p.m., indicated Resident 1 was able to ambulate independently with a four wheeled walker (4WW). Resident 1 was found seated on the bathroom floor after facility staff investigated the sound of something falling in his room. Resident 1 told the staff he had been holding on to the 4WW with one hand, and the sink with his other hand, while he leaned forward to use the sink. He said the sink fell off the wall, and caused him to fall backwards, hitting his coccyx and lower back on the commode before he landed, seated, on the floor. The SBAR indicated two abrasions of the right elbow, one was 4 cm by 4 cm, and the other was 2 cm by 2 cm in size (2.54 centimeters equal an inch); a 4 cm by 3 cm abrasion of the sacrum (the bony area at the lower back and base of the spine); redness on the right mid-back; and tenderness of the tumor at the base of the spine. Resident 1 complained of increased pain at the base of the spine. Resident 1 was transferred to a hospital emergency department (ED) for further evaluation after the attending physician, and responsible party (RP 1) for Resident 1 were notified. A review of the facility "Transfer/Discharge Report," dated 5/23/14, indicated Resident 1 was transferred to the ED after a fall with complaints of back pain. A review of the ED record for Resident 1 dated 5/23/14, at 4:43 p.m., indicated Resident 1 complained of tail bone pain at a level of 10/10 (ten, on a pain scale of zero to ten, with ten the worst pain possible). Resident 1 said he was leaning on his sink when it fell off the wall, and caused him to hit his tail bone on the toilet. The ED Discharge Instructions showed Resident 1 was discharged back to the facility the same day, with a diagnosis of, "Sacrum/coccyx fracture" (tail bone fracture). The instructions had the following explanation: "You have a compression fracture of one of the bones in your spine...It may occur after a ground level fall..."During a telephone interview on 6/17/15, at 8:30 a.m., RP 1 said before the fall, Resident 1 had improved to the point that he was going to be discharged home on 5/24/14 or 5/25/14. After Resident 1 fell, his pain was so intense his discharge was delayed. RP 1 said she joined Resident 1 in the ED, and at that time, his pain was so excruciating, he said, "Just shoot me. I can't take it." RP 1 said that Resident 1 died on 7/21/14 from lung cancer and while the pain from the tail bone injury was more controlled in the last weeks of his life, it was never absent.During observations and a concurrent interview on 6/17/15, at 3:55 p.m., in the bathroom of the former room of Resident 1, the Maintenance Supervisor (MS) demonstrated the security of the wall-hung sink by applying downward pressure to the front edge of the sink; the sink was securely attached and did not move. MS said he had remounted the sink on 5/23/14, and noted at that time that there were two empty holes at the bottom of the mounting face beneath the sink. MS said he placed bolts in the holes to securely mount the sink, and then checked the other sinks in the facility. MS said he found other sinks with missing bolts, and he placed bolts or screws in any sinks which were missing them. MS said he did not know who had originally installed the sinks, or even when they were installed. MS said he did not routinely check the sinks for mounting security. A random observation of sinks in six rooms indicated five rooms with some slight movement with downward pressure (room 220, room 221, room 103, room 110, and room 117). MS said he believed a little sink movement with downward pressure was acceptable.During a telephone interview on 6/22/15, at 1:32 p.m., MS said he did not have any manufacturer's guidelines to follow when he re-secured the sinks.During an interview and concurrent record review of the facility forms, "Quality Circle Rounds," and "Department Head Room Rounds Assignment," on 6/17/15, at 4:40 p.m., the Administrator (Admin) said the rooms were inspected daily by various department heads, according to the assignment schedule. The Admin reviewed the forms and confirmed there was no item listed for the department heads to check the security of the wall hung sinks.During a telephone interview on 6/29/15, at 2:50 p.m., the Regional Compliance Officer (RCO) for the Office of Statewide Health Planning and Development (OSHPD is a California government department which monitors the construction, renovation, and seismic safety of hospitals and skilled nursing facilities) said wall-hung sinks should not have any movement, because movement would cause "work fatigue" and eventually result in the sink falling off the wall. The RCO said if there is any movement in the sink it is because either: the sink wasn't mounted properly to the bracket, the bracket wasn't secured to a wall stud, a wall stud deteriorated due to water damage or work fatigue, or the wrong screw/bolt was used to secure the bracket. A review of the California Plumbing Code, 402.4, indicated, "Wall-hung fixtures shall be rigidly supported by metal supporting members so that no strain is transmitted to the connections." Therefore the facility failed to ensure that sinks were securely attached to the wall resulting in Resident 1 falling and fracturing his coccyx bone when he leaned on the sink. The violation had a direct relationship to the health, safety or security of residents. |
| 020000054 |
Willow Tree Nursing Center |
020011787 |
B |
21-Oct-15 |
312111 |
7000 |
483.13(b), 483.13(c)(1)(i) FREE FROM ABUSE/INVOLUNTARY SECLUSION The resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. The facility must not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion. This REQUIREMENT is not met as evidenced by: The facility violated the above mentioned regulation by failing to monitor Resident 1, as stated in their policy, after he punched Resident 2, fracturing his jaw. Resident 1 returned to his room without being monitored, hit his roommate (Resident 3) with a foot board, lacerating Resident 3's ear.On 8/10/15, the facility reported to the Department Resident 1 struck two residents (Resident 2 and Resident 3) resulting in Resident 2 having a fractured jaw and a laceration of Resident 3's ear. Review of the clinical records, on 8/25/15, showed Resident 1 was admitted with multiple diagnoses that included an illness that caused the resident to be unable to make (reasonable/safe/rational) decisions about daily life. Resident 1's care plans (measurable objectives and timeframes to meet residents' physical, mental, and psychosocial needs), for Resident 1 included 1) Behavior Care plan, dated 7/15/15, for aggressive or threatening behavior.During an initial tour of the facility, on 8/25/15 at 9 a.m., it was observed that Residents 1 and 3's room was located around the corner from the nurses' station 2, at the end of a hallway and was not visible from the nurses' station. The smoking patio was located directly across the hall from the nurses' stationDuring a telephone interview, on 8/26/15 at 10 a.m., CN 1 (charge nurse) stated she was in the medication room at nurse station 2 on 8/7/15 between 12:15 a.m. and 12:20 a.m., when CNA 1 (certified nurse assistant) called out and told her that Resident 1 had hit Resident 2. CN 1 stated she separated the residents and told Resident 1 to go to the smoking patio. CN 1 said she called the hospice nurse, because Resident 1 was under hospice and while she was on the phone, Resident 1 returned from the smoking patio and went to his room alone. CN 1 stated, "A few minutes later" (unable to determine how many minutes) she heard a noise coming from Resident 1's room and went to Resident 1's room with CNA 1 and found Resident 1 standing next to Resident 2's bed. Resident 2 was bleeding. CN 1 stated she had CNA 1 take Resident 1 back to the patio.During a telephone interview, on 8/26/15 at 12:50 p.m., RN 1 (registered nurse) was asked about the incident on 8/7/15 involving Resident 1, and she said she was at nurse station 1, located at the front of the facility, and heard CN 1 call for help. RN 1 stated when she arrived at the Resident 1's room, Resident 3 stated Resident 1 hit him over the head four times with the footboard of a bed. RN 1 stated the footboard was on the floor with two metal hooks sticking out from the board. RN 1 stated Resident 3 was bleeding and she had to clean him before she could assess the blood was coming from his left ear. RN 1 stated CN 1 called the police and an ambulance. RN 1 stated she never saw the facility's protocol for abuse and did not know what to do in the case of an assault.In an interview, on 8/26/15 at 2:55 p.m., CNA 1 stated on the 8/7/15, she was sitting at the nurses' station 2 observing Resident 2, who was a fall risk, and had been trying to get up on his own. CNA 1 stated she heard Resident 1 yelling for a cigarette, then Resident 1 walked up to Resident 2 and "With all of his might, balled up his fist and hit" Resident 2. CNA 1 stated she called for Charge nurse 1 and gave Resident 1 a cigarette and he went to the smoking patio. CNA 1 stated after Resident 1 finished the cigarette (which she stated took five minutes), he went to his room. Shortly afterwards CNA 1 stated she heard a hard, bumping noise coming from Resident 1's room and went to investigate with CN 1. . CNA 1 stated Resident 1 had taken the bottom board of the bed and hit Resident 3. CAN 1 stated she tried to redirect Resident 1 to the smoking patio and told CN 1 to call 911. CNA 1 stated she gave Resident 1 three cigarettes to keep him distracted and Resident 1 told her, "When I finish smoking these cigarettes, I'm going to finish the job".Review of clinical records, on 8/25/15, showed the document titled, "Change of Condition SBAR (Situation, Background, Assessment, Request/Responsible Party Notification/Response) - Mental Status Change", dated 8/8/15 at 1 p.m., indicating Resident 2 had increased confusion, disorientation and unable to redirect after being hit by Resident 1 on 8/7/15. Resident 2 was transported to an acute care hospital emergency room for evaluation. Review of the emergency room report dated 8/8/15 showed that Resident 2 was treated for a right mandibular condyle fracture (condyle is a rounded projection at the end of the lower jaw, or mandible which attaches to the skull near the ear.) and required stitchesReview of the facility's policy titled, "Abuse Prevention, Intervention, Investigation & Crime Reporting Policy" with a revision date of December 2012, indicated: 1. It is the basic responsibility of facility Administrator, or designee and all facility employees. 2. Every resident has the right to be free from verbal, sexual, physical and mental abuse3. The facility shall identify, analyze, and assess situations to minimize the likelihood of abuse; such as secluded areas of the facility that may make abuse or neglect more likely to occur4. The facility will monitor the adequacy of assessment care planning, and monitoring of residents with needs or behaviors that may likely lead to conflict, altercation, abuse or neglect, such as physically aggressive or self-injurious behaviors.On 8/27/15, review of the personnel file of RN 1 showed blank unsigned attestations related to viewing the Department of Justice video that provides information about mandatory abuse reporting and a facility attestation of the following: "...By signing below I acknowledge receipt of my responsibilities as a covered individual to report any reasonable suspicion of a crime committed against a resident of this facility to local law enforcement and to the state survey agency within required time frames. "A New Hire & Orientation Checklist" was signed by RN 1 on 7/22/15, the date of hire, however RN 1 did not check any of the 31 items on the checklist, including the following: "I have received and read the facilities 'Abuse Prevention, Intervention, Investigation and Crime Reporting' policy and understand my reporting requirements..."Review of the sign in sheets of the abuse prevention training classes did not include the name of RN 1. Therefore the facility failed to monitor Resident 1 after he fractured Resident 2's jaw resulting in Resident 1 hitting Resident 3 with a footboard lacerating his ear. The above violation has a direct relationship to the health, safety or security of patients. |
| 020000071 |
Windsor Post-Acute Care Center of Hayward |
020011850 |
B |
17-Nov-15 |
46T911 |
6139 |
F 309483.25 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. This REQUIREMENT is not met as evidenced by: 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 violated the aforementioned regulation by failing to ensure Resident 17 received morphine (narcotic pain reliever) ER (extended release) 100 milligrams, as ordered for pain, on 3/18/15.Resident 17 was admitted to the facility on 3/18/15 after a left hip replacement with orders for morphine sulfate 100 milligram tablet to be given orally every 8 hours for pain management, starting on 3/18/15 at 10 p.m. The facility failed to ensure the morphine was available and failed to notify the physician about the morphine not being available, resulting in Resident 17 missing the 10 p.m. dose on 3/18/15 and not receiving the morphine until 5 a.m. on 3/18/15 causing the resident to have unrelieved severe pain.On 3/24/15 at 8:30 a.m., review of the clinical record showed Resident 17 was admitted on 3/18/15, after a left hip replacement. Resident 17 had a history of bilateral (both) hips osteoarthritis (bone joints disease and swelling) and spinal stenosis of the lumbar spine. (Spinal stenosis is the narrowing of spaces in the spine (backbone) which causes pressure on the spinal cord and nerves.) Review of the physician's orders dated 3/18/15 included the following: a. monitor pain every shift, start date 3/18/15, 3:00 p.m. using the following pain monitoring scale:0 =None (no pain), 1-3 =Mild pain, 4-6 =Moderate pain, 7-10 = Severe pain.b. Morphine Sulfate ER (Extended Release) (narcotic pain reliever) 100 milligram tablet. Give 1 tablet by mouth every 8 hours for pain management. Start date 3/18/ 2015 at 22 (10 pm) . c. Percocet (pain reliever) tablet one tablet every 6 hours, as needed, for moderate pain. d. Percocet to give 2 tablets every 6 hours for severe pain.Facility's every eight hour medication schedule was 6 a.m.; 2 p.m.; 10 p.m. On 3/26/15 at 9:16 a.m., during a telephone interview, RN 4 said she went to check Resident 17 after 9 p.m. (on 3/18/15). Resident 17 was in pain and requested pain medication. RN 4 did not remember what Resident 17's pain level was. RN 4 said she told the medication nurse to give the resident two tablets of "Percocet (pain reliever) or Norco (pain reliever)." RN 4 was not sure which pain reliever was ordered but was sure it was not Morphine because there were no Morphine tablets available at that time. During the interview, RN 4 was asked if the physician was notified that Morphine was unavailable, RN 4 stated that she did not notify the physician. Review of Resident 17's admission record indicated that pain assessment was done on 3/18/15 at 11:38 p.m., several hours after admission. The assessment indicated that Resident 17 verbally described his pain intensity and was assessed at level 7. Resident 17 was in severe pain.On 3/26/15 at 9:26 a.m. during an interview, LVN 6 (Licensed Vocational Nurse 6), who was assigned to take care of Resident 17 on 3/19/15 night shift, stated that the afternoon nurse on 3/18/15 told her the morphine was not delivered by pharmacy and was not available. Resident 17 missed his 10:00 p.m. dose of Morphine (on 3/18/15). LVN 6 gave Resident 17 two Percocet tablets for his pain at 1:30 a.m. on 3/19/15. At that time according to LVN 6, Resident 17's pain level was 8 (severe pain). Review of the record showed that Resident 17's pain level was not assessed after Percocet tablets were administered.On 3/26/15 at 9:35 a.m., during an interview, Resident 17 described how "miserable" he was and in "so much pain and discomfort" on evening of 3/18 and the following night. He stated that he begged and requested the nurses to call his doctor and "do something, they seem to not understand how bad these pains are". The only answer he got was that "they (pharmacy)" did not "deliver" his Morphine. Instead he was given Percocet tablets. Resident 17 said that he was on "chronic pain" (persistent pain refers to a pain state that continues for a prolonged period of time or recurs more than intermittently for months or years) management at home and prior to his surgery. He explained that when he misses a dose of Morphine he cannot manage his pain and the Percocet medication is only for breakthrough pain in between his doses of Morphine.Resident 17 said the nurses told him Morphine was delivered at around 2 a.m., (3/19/15), the morning after he was admitted, but they did not give the morphine immediately to him because it was not time yet. The nurse did not give him Morphine until 5 a.m. on 3/19/15.On 4/8/15 at 11:05 a.m., during an interview, two of the facility pharmacy consultants (PC1 and PC2), confirmed that Resident 17's Morphine ER was delivered on 3/19/15 at 2:57 a.m. as indicated by review of the shipping manifest. On 3/26/15 at 2:45 p.m., during a telephone interview, Physician 1 stated Resident 17 was on high intravenous dose of Dilaudid (opioid narcotic pain reliever) after Resident 17's hip surgery in the hospital. Therefore it is "very important" for the resident's chronic pain management to administer the prescribed morphine on time. Physician 1 stated that when the facility failed to administer the morphine for any reason, the nurses should have notified the attending physician or the on-call physician so that they can give the nurses appropriate instructions on what to do. Physician 1 stated the facility did not notify him or the on-call physician about the morphine not being available.Therefore the facility violated the above regulation by failing to provide morphine as ordered for pain relief for Resident 17, resulting in Resident 17 having unrelieved pain for at least 8 hours. |
| 020000277 |
Windsor Healthcare Center of Oakland |
020011912 |
B |
22-Dec-15 |
EOZR11 |
14494 |
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. This REQUIREMENT is not met as evidenced by: The facility violated the aforementioned regulation by failing to assess the pain level and monitor the effectiveness of pain medications to ensure they provided pain relief for Resident 5 and Resident 16; and by failing to administer new pain medication (MS Contin) when ordered to Resident 5, resulting in both residents experiencing pain even after getting pain medications and Resident 5 waiting for over 24 hours for MS Contin. 1. Record review on 6/1/15 showed Resident 5 was admitted on 3/20/15 with diagnoses including emphysema (lung disease) and chronic pain.Record review showed the following orders for pain medication: Neurontin 300 mg. (milligrams) three times a day started 4/23/15; Norco 10-325mg (Hydrocodone-Acetaminophen) one tablet every 4 hours as needed started 4/29/15.During an interview on 5/4/15 at 10:45 a.m., Resident 5 was asked about her care and replied she was "in pain." Resident 5 stated "They give me pain pills and it takes the edge off but it is not enough. I have rib pain and pain at the top part of my stomach. It has been happening for a week now." On 5/6/15 at 8:30 a.m., Resident 5 stated she had "Pain all over. I had pain medication at 5 a.m. They, (the staff), said it is not time for me to have it again." Later that day at 1:00 p.m., Resident 5 was asked to describe her level of pain and stated she was not, "Feeling great today. I did get the pain medication at 9 a.m. which helped a little." During an interview on 5/6/15 at 1:35 p.m., Licensed Vocational Nurse 5, (LVN 5) was asked to describe Resident 5's pain and stated (Resident 5) "Has pain all the time. She has bad anxiety and shortness of breath. I think her anxiety contributes to her pain. She has pain medication every 4 hours. It is ordered on an as-needed, (PRN).She (Resident 5, says that the pain medication works but then she will ask for it before the 4 hours are up. She stays in bed a lot. I suggested that she get up out of bed and go to activities." During an interview on 5/6/15 at 2:15 p.m., Resident 5 was asked if she believed that anxiety was contributing to her pain. Resident 5 stated, "My anxiety does not cause my pain. I fell at a previous facility and fractured my ribs and had 3 staples in my head. I was in the hospital. I am trying to rehabilitate so I can get home to my kids. Having this pain impacts my ability to move. I stay in bed if it hurts so bad. The pain medication takes the edge off but I need it by the third hour and the staff tells me I have to wait." Record review on 5/7/15 at 2:05 p.m. of the document titled, "Nurses' Weekly Look Back Summary", dated 5/3/15, showed Patient 5 was alert and oriented times 3, meaning she knew her name, the time, the date, and where she was. Under the section titled, "Facial Pain Scale", Resident 5 was described as "Hurts a Little More." There was no documented numbered pain scale. (Pain scale/level: 0 = no pain, 10 being the highest number to describe the level of pain). Record review on 5/14/15 at 12:29 p.m., of the facility's policy and procedure titled, "Pain Management", showed the purpose of the policy was to "Ensure accurate assessment and management of the resident's pain. Nurses will complete the pain flow sheet for residents receiving PRN pain medication to evaluate the effectiveness of the medication regimen. Nursing Staff will implement timely interventions to reduce the increase in severity of pain." Record review on 5/18/15 at 2:31 p.m., of the facility policy and procedure titled, "Administration of Pain Medication", showed, "Residents who receive PRN medication routinely will be reassessed for around-the-clock, (ATC) pain medication to ensure the highest level of comfort." Further record review showed under the section titled, "Documentation", licensed facility nurses were to, "Document the administration of PRN pain medication on the Pain Flow Sheet. Document the resident's response to and the effectiveness of the pain medication in the resident's medical record." Record review on 5/13/15 at 11:03 a.m. of Resident 5's medication administration record, (MAR), showed the following:5/1/15 at 3:49 p.m. - Nursing Note showed Tylenol (pain medication) had been given this morning with relief. There was no documented pain assessment.5/1/15 at 7:58 p.m. - Nursing note showed Tylenol had been given with relief. No documented pain assessment 5/2/15 at 9:26 p.m. - 2 Tylenol tablets given. Pain level described as 3 out of 10. (10 being the most pain) No further documented pain assessment. No documentation showing effectiveness of the pain medication. 5/3/15: 2:38 a.m. 1 Norco, (pain medication) given. Pain level: 8/10. No further documented pain assessment. No documentation showing effectiveness. 5/3/15: 6:25 a.m. Norco given. Pain level 8/10. No documented pain assessment or description of effectiveness. 5/3/15 1:19 p.m. Pain level: 8/10. No documented pain assessment or effectiveness. 5/3/15: 6:10 p.m. Pain level: 4/10. Norco given. No documented pain assessment. No documentation showing effectiveness. 5/4/15 -1:31 a.m. Pain level 8/10. Norco given. No documented pain assessment or level of effectiveness. 5/4/15 7:28 a.m. Pain level 9/10. Norco given. No documented pain assessment or level of effectiveness.5/4/15 10:27 a.m. Pain level 6/10 Norco given. No documented pain assessment or level of effectiveness. 5/4/15 4:48 p.m. Pain level 8/10. Norco given. No documented pain assessment or level of effectiveness. 5/4/15 9:38 p.m. Pain level 6/10. Norco given. No documented pain assessment or level of effectiveness. In an interview and concurrent record review on 5/7/15 at 1:50 p.m., the Medical Records Supervisor, (MRS) was asked to show where licensed nursing staff documents the type of PRN medication that was given, why it was given, and the effectiveness of the medication. The MRS was observed looking into the computer and stated, "They, (the staff), are not filling out the progress note text on the computer screen. They are not writing what medication they gave as a PRN, why they gave it, and the effectiveness." Record review of the staff computer training document titled, Course Number: CLN-DE-15, showed when licensed nursing staff were preparing to give a medication, they were required to open the "Resident's Administration" page and select the PRN button. Following administration of the medication, the computer prompts staff to enter a progress note to document why they administered the PRN, then staff are required to hit the "Follow Up," button in order to record the effectiveness of the medication. In an interview on 5/6/15 at 2:20 p.m., the Director of Nursing, (DON), was asked what staff do if a resident's pain is not being controlled. The DON stated, "If the resident is having a lot of pain medication and it is not controlled as a PRN, then there needs to be an assessment and the pain medication should be scheduled around the clock and not PRN. A pain assessment needs to be done. First ask the resident where the pain is located. Is it sharp or dull pain? Is the pain consistent, (on-going), or does it come and go? The doctor needs to be called." In an interview on 5/13/15 at 12:11 p.m., Resident 5's doctor, (MD), was given the information regarding the number of PRN doses of Norco and Tylenol given to Resident 5 and was asked what his expectation was from staff. The MD stated, "What I try to teach the staff is to watch the PRN dose and see if the resident would like a regularly scheduled dose as opposed to as-needed. If someone is getting more than 3 PRN doses per day, then the doctor should be called and the resident should be offered pain medication on a regular schedule. Resident 5 is capable of telling the staff if a regular schedule would be better. Staff did not call me in regards to the extensive use of the PRN medication for Resident 5." Record review on 5/14/15 at 9:14 a.m. of Resident 5's plan of care, dated 3/27/15, showed no documented focus on pain.On 5/20/15 review of the physician orders showed an order dated 5/13/15 for Neurontin 600 mg. to be given three times a day for neuropathic pain and an order dated 5/17/15 for Percocet 5/325 mg. to be given every 4 hours for pain In an interview on 5/20/15 at 1:15 p.m., the MD was asked about Resident 5's pain. The MD stated he had decided to, "Start her, (Resident 5), on Morphine." (Morphine: a pain medication) Record review of the document titled, Physician's telephone order, dated 5/20/15 at 3:00 p.m., and signed by Registered Nurse 19, (RN 19), showed MS Contin, (Morphine), 15 milligrams by mouth two times per day had been ordered by the MD. In an interview on 5/21/15 at 11:30 a.m., Resident 5 was asked about her pain level and the new order for Morphine. Resident 5 stated, "Yes, I am still in pain. The morphine is not here yet." In an interview on 5/21/15 at 12:20 p.m., Licensed Vocational Nurse 24, (LVN 24), was asked about Resident 5's order for morphine. LVN 24 stated she did not give the morning dose to Resident 5 on 5/21/15 because it was, "Not in the cart." In an interview on 5/21/15 at 12:25 p.m., Resident 5 was asked if she had received the Morphine. Resident 5 stated, "I got the Percocet, (another pain medication), just now. It was an hour early." Resident 5 was asked if the Percocet relieved her pain. Resident 5 stated she, "Just started Percocet 2 days ago. It does not work. I am waiting for the morphine. My pain is at 10 out of 10. The Director of Nursing just came in and told the staff to give me the Percocet." (10 out of 10 - pain scale: 1 is the lowest amount of pain and 10 is the highest) In an interview on 5/21/15 at 1:25 p.m., RN 19 was asked to describe the steps she took after she received the morphine order from the MD. RN 19 stated she sent a copy, "To the pharmacy. I talked to the PM, (evening shift), nurses. I put it on the 24 hour report." (24 hour report: documents communications between the different shifts) In an interview on 5/21/15 at 1:55 p.m., RN 19 was asked to show this surveyor fax confirmation that the morphine order had been sent to the pharmacy. RN 19 stated she, "Had no fax confirmation that Resident 5's morphine order went through. I gave the information to the nurse. I spoke to the pharmacist today and they told me it will be delivered tonight." Record review on 5/27/15 at 3:46 p.m., of Resident 5's medication administration record, (MAR), dated 5/1/15 to 5/31/15, showed the first dose of morphine was given to Resident 5 on 5/22/15 at 9 a.m., two days following the initial order given by the MD. Record review of the facility's policy and procedure titled, Pain Management, dated December 2014, showed, "Nursing staff will implement timely interventions to reduce the increase in the severity of pain." 2. Record review showed the facility admitted Resident 16 on 3/13/15 with a diagnosis of endocarditis, (infection of the inner layer of the heart), and a spinal (back) muscle abscess. (Abscess - a collection of pus due to an infection that has built up within the body tissue).Record review of the document titled, "Nurses' Weekly Look Back Summary", dated 5/2/15, showed Resident 16 was alert and oriented and his memory was described as being within normal limits. During medication pass on 5/5/15 at 8:12 a.m., Licensed Vocational Nurse 5, (LVN 5) was observed giving Resident 16 his daily dose of methadone (methadone - used as both pain medication and an anti-addictive for drug addicts). LVN 5 asked Resident 16 if he was in pain and Resident 16 said, "Yes."LVN 5 then said, "Give me a number." (Pain level number: on a scale of 1 to 10, what is the level of pain with 10 being the highest level) Resident 16 stated, "8 out of 10 shoulder pain." LVN 5 was asked why Resident 16 had pain and replied "He has a history of drug abuse. He gets methadone for his drug abuse." LVN 5 did not further assess the pain. At 8:25 a.m., LVN 5 was asked if there were any other reasons for Resident 16's pain. LVN 5 looked at the computer screen and stated, "Oh. He has a muscle abscess on his spine." In an interview on 5/7/15 at 10:15 a.m., Resident 16 was asked to describe his pain. Resident 16 was observed lifting his right arm and running his left hand from the back of his neck down his right arm and stated the, "Pain is going to my shoulder. I told the nurse. But she still just gives me Tylenol. It does not help." In an interview on 5/7/15 at 1:10 p.m., Licensed Vocational Nurse 2, (LVN 2) was asked about Resident 16's pain and stated, "Last time he (Resident 16) got Tylenol for pain was on 5/3 and 5/4/15." LVN 2 was asked if she knew why he had the pain. LVN 2 stated, "No. I don't know why. I don't know how to look back into the computer to see why he got the pain medication." LVN 2 was asked if she had gotten a report at shift change in regards to Resident 16's pain. LVN 2 stated, "No." In an interview with Resident 16 on 5/7/15 at 1:20 p.m., Resident 16 was asked if he continued to have pain. Resident 16 stated, "Yes." He was observed grabbing his right shoulder and running his hand up to the back of his neck. Record review of the Medication Administration Note dated 5/4/15 at 6:48 p.m., showed Resident 16 received PRN medication and it was effective. There was no medication name listed or why the medication was given. There was no documented pain assessment. Record review of Resident 16's plan of care on 5/14/15 at 9:17 a.m., dated 3/16/15, showed no documented pain focus.In an interview on 5/12/15 at 10:33 a.m., Resident 16's doctor, (MD), was asked why Resident 16 was having pain. The MD stated, "He (Resident 16) gets 3-4 out of 10 (moderate) pain due to his abscess." Therefore the facility failed to assess and monitor pain levels for Resident 5 and Resident 16 before and after they received pain medication resulting in both residents continuing to have pain; and failed to administer new pain medication (MS Contin) when ordered to Resident 5 resulting in Resident 5 continuing to have unrelieved pain for over 24 hours after it was ordered. The above violations had a direct or immediate relationship to the health, safety, or security of patients. |
| 020000277 |
Windsor Healthcare Center of Oakland |
020011914 |
B |
22-Dec-15 |
EOZR11 |
28594 |
483.13(c) PROHIBIT MISTREATMENT/NEGLECT/MISAPPROPRIATION The facility must develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property.The facility violated the aforementioned regulation by failing to implement policies and procedures to ensure six residents (1, 3, 13, 14, 29 and 30) received services for untreated and unassessed skin ulcers, and untreated pain resulting in the neglect of these residents.1. Resident 1 had an extensive diabetic ulcer (open wound that can occur with diabetes and nerve damage due to diabetes) of the right heel, and pressure ulcers (A pressure ulcer is any lesion caused by unrelieved pressure that results in damage to the underlying tissue(s)) on the buttocks and was not given the treatments as ordered for 9 days, resulting in Resident 1 being at risk for further damage to his skin, bones, possibility of losing his leg and at risk for infection due to the lack of nursing care as prescribed by his physician. 2. Resident 3 was placed on Hospice (end of life) care and did not receive Morphine Sulfate (narcotic pain relief medication) for 19 hours when it was to be given every four hours, and her open pressure ulcers went untreated. The nurses did not follow doctor's orders for Hospice care resulting in Resident 3 suffering from pain and agitation due to not receiving Hospice medication, and not receiving pressure ulcer treatment. 3. Resident 13 was paralyzed and had extensive pressure ulcers to his buttocks and upper thighs, and was sent to the ER (emergency room) at the insistence of his family. The ER doctor documented the resident covered in feces from his mid back to his upper thighs, and was subsequently place in the intensive care unit for sepsis (potentially life threatening complication of an infection). 4. Resident 14 was admitted to the facility with orders for a medication to treat his pain which was not provided by the facility resulting in Resident 14 stating he felt like he was going to die if he did not get his medication. He called 911 to take him to the hospital in order to obtain his medication. 5. Resident 29 had an open pressure ulcer on his right elbow which was identified by the Occupational Therapist (OT) and reported to the DSD. The DSD did not notify the physician, obtain treatment orders or treat the resident's open area which put him at risk for further breakdown and/or infection. 6. Resident 30 had a pin (metal rod) in his left lower leg (through the skin bone) that had an open area around the pin site and was on antibiotic medication to treat a bone infection at the site. The doctor's order for pin care was not clarified as to what pin care was needed. The wound around the pin had some depth, was crater shaped, was moist with yellow tissue, and loosely covered with a gauze wrap.1. On 4/16/15 at 2:20 p.m., Resident 1 was observed sitting up in his wheelchair by the foot of the bed in his room where he was watching television. His right heel was wrapped in a gauze bandage that was brown with red drainage. At 2:40 p.m., LVN 3 came to the resident's room and stated that she was the charge nurse. When LVN 3 was asked if Resident 1 was to have his dressing changed, LVN 3 stated that she did not know because "he goes out for his treatments." LVN 3 did not look at Resident 1's foot and walked out of the room. LVN 3 went to the nursing station to check if Resident 1 had a doctor's order for treatment. The DON (Director of nurses) found an order in the "paper" chart which had not been entered into the computer for the nurses to implement. The physician's order, dated 4/6/15, was part of the discharge orders that came from the hospital when the resident was discharged to the facility on 4/6/15. The order dated 4/6/15 was for daily cleansing with normal saline, wound gel (ointment to treat pressure ulcers) and dressings to his sacral (back)wounds and daily cleaning with normal saline and Santyl ointment (debriding agent to remove dead tissue) and cover with dry gauze to his right heel wound. At 3 p.m., the DON was observed measuring and dressing Resident 1's wounds. Resident 1 was placed in his bed, and the dressing from his right heel was unwrapped and revealed a malodorous wound covering the entire area of Resident 1's heel. The wound measured 8 cm (centimeter) by 8.4 cm with a depth of 1 cm, and was reddened with some areas of yellow slough (necrotic tissue).His buttocks was assessed and there were no dressings covering the left inner buttock which had a 6 cm(centimeter) by 2 cm stage 2 pressure ulcer (Partial thickness loss of skin, presenting as a shallow open ulcer with a red-pink wound bed) and the right inner buttock had a 2.5 cm by 3 cm stage 2. His right upper thigh just below his buttocks had many scattered small areas of skin breakdown. In addition, the skin on his back was dry and dead skin was flaking off onto the bed. According to a review of the medical record on 4/17/15, Resident 1 had been a resident of the facility since 11/23/13. He had diagnoses of ulcer of the foot, diabetes mellitus type 2 (DM 2 a chronic form of diabetes in which insulin does not effectively transport glucose from the bloodstream), congestive heart failure (an abnormal condition that reflects impaired heart pumping), among others. In February 2015, Resident 1 had an infection of the right foot ulcer and was prescribed three different antibiotics intravenously at the facility. According to his MDS assessment dated 2/21/15 he was totally dependent on two persons to transfer from his bed to the wheelchair, and needed assistant to move about his room and the facility. He needed extensive assistance for bathing and personal hygiene, was occasionally incontinent of urine and frequently incontinent of bowels. He was at risk of developing pressure ulcers and had a diabetic foot ulcer as well as "moisture associated skin damage (i.e. incontinence, perspiration, drainage).During an interview on 4/17/15 at 3:10 p.m., the DSD stated that on Monday (4/13/15), Resident 1 came to the DSD office and asked him to change his dressing. The DSD said he only did the right heel dressing and then told the Station 3 charge nurse that he did it, but he did not document it. He also said he did the dressing to his heel that was ordered when he was working as the treatment nurse and he did not look to see if there were any new orders for treatment.According to a nurses' note dated 4/17/15 at 4:40 p.m., the DSD wrote the following late entry note for 4/13/15: "Resident (1) came by my office requesting to have his dressing changed for his RIGHT HEEL pressure wound ONLY...When I checked on patient's order's for clarification of his wound care order, the previous order was only present, but from DON's previous statement to me, resident would no longer be on wound vac (vacuum dressing using negative pressure to promote healing). Since there was no actual treatment order for resident, I could not clarify the order...I only did a simple dressing change which was clean with normal saline, pat dry, apply foam dressing and cover with gauze roll...Wound was only foul smelling with dressing, after cleaning wound and getting rid of the old dressing, there was no foul smell..." On 4/27/15 at 3 p.m., Resident 1 was sitting up in his wheelchair with his right foot wrapped in a pillow case. The DON and a nurse consultant (NC 1) came in the room and unwrapped the resident's foot. His foot was swollen and the gauze bandage was wrapped around his ankle so that the under part of his heel wound was uncovered and exposed.A review of the April 2015 "Treatment Administration Record" (TAR) showed Resident 1 had four different treatment orders for the right heel ulcer. The physician's order for treatment of right heel and buttocks wounds were not transcribed from the acute care discharge orders on 4/6/15. The TAR reflected a new treatment order on 4/20/15 for, "Right Heel: Clean with normal saline, pat dry apply silver alginate (antimicrobial highly absorbent dressing) over wound bed, non-adherent oil emulsion gauze (dressing that won't stick to the wound tissue) over wound, wrap with 2 layer compression. Change three times a week...every Mon, Wed, Fri." The order from 4/6/15 had not been verified by the physician or transcribed onto the TAR. The DON confirmed in an interview on 4/27/15 at 3:30 p.m. that no treatment had been performed between 4/16/15 and 4/20/15 when she discovered that nobody processed the order discovered on 4/16/15. The DON stated that on 4/20/15 she asked DSD to call the doctor to get a treatment order.DDS wrote a progress note on 4/20/15 1:52 (Late Entry date not specified) as follows: "Resident requested to have dressing on his right heel pressure ulcer dressing to be changed. I agreed to change his dressing...I also asked if he would like me to do the treatment for his other wounds, buttock and toe, resident stated I just want the dressing on the heel to be changed..." During a telephone interview on 4/24/15 at 10:30 a.m., WCN 2, the nurse at the wound care center, stated Resident 1 had been coming into the wound care center and his bandage was not being changed at the facility. She notified the facility to let them know that it needed changing and they said he was refusing. She said that Resident 1 was there on 4/23/15 and his next appointment was set for 4/30/15. He only goes to the clinic once a week, and his orders for treatment of the heel are three times a week. In a telephone interview on 4/30/15 at 3:40 p.m., Resident 1's physician (MD 1) stated the facility staff said Resident 1 refused treatment. However, Resident 1 told the physician the staff did not do the dressing changes.MD 1 said she could not figure out who was telling the truth. 2. Review of the medical record revealed that Resident 3, a 91 year old female, was admitted to the facility on 7/24/14 with the diagnosis of Alzheimer's disease. The physician's orders to admit to Hospice dated 4/23/15 included the following: Pureed diet as tolerated; Morphine Sulfate (MS) 0.25 ml (5 mg) by mouth every 4 hours around the clock for pain management, MS 0.25 ml every hour as needed for mild symptoms, 0.5 ml every hour for moderate symptom, or 1 ml every hour for severe symptoms of pain or shortness of breath; Haldol 0.5 ml (1 mg) by mouth in the morning and 1 ml (2 mg) in the evening for agitation. New orders for wound care were written on 4/23/15, wound # 1 sacrum (above the tail bone) to do wound care three times a day and more if needed, cleanse with warm soap and water, apply barrier cream (cream to protect the skin from moisture). The same was written for wound # 2 on the coccyx (tail bone). On 4/30/15 at 3:30 p.m. the physician ordered a Fentanyl patch 12 micrograms (mcg) to be applied to the back of her arm every 72 hours for pain. An order dated 5/2/15 changed the order to discontinue current 12 mcg Fentanyl patch by removing it. Add Fentanyl 12 mcg apply 2 patches (24 mcg) to back of her arm every 72 hours for pain. Once 24 mcg Fentanyl placed, discontinue routine morphine and continue the morphine on an as needed basis. On 5/4/15 at 11:45 a.m. Resident 3 was observed lying in bed with her daughter at her side. Resident 3's daughter said that her mother had been in the facility since July 2014 and recently was placed under Hospice care. She said the physician ordered Morphine (a narcotic pain medication) for pain every four hours, and the Hospice nurse came in on 4/29/15 and found that the morphine had not been given for 14 hours. Resident 3's daughter said her mother had been in a lot of pain. She said that now that the resident is getting her pain medication and the Haldol, she is better, quiet and resting.During an interview at the facility on 5/5/15 at 9:30 a.m., the Hospice nurse (HRN) stated she was upset with the facility nurses because they had not implemented the hospice physician's orders for pain medication. The resident was supposed to be on Morphine every four hours around the clock and she did not receive any Morphine for 19 hours between 4/29/15 and 4/30/15 according to the narcotic count down sheet. They did not carry out the orders for a Fentanyl patch (narcotic pain medication in a patch that delivers the medicine through the skin), Haldol for her agitation, and she could not tell if the Resident had a bowel movement because there was nothing charted. Also the resident had pressure ulcers on her sacrum and the orders for treatment had not been carried through. HRN had to instruct the facility nurse to give the medications and do the treatment; she even laid the treatment bandages out on the treatment cart for the nurse to do. According to the Hospice Clinical Note dated 4/24/15, Resident 3 was described as "...in bed, stiff, non-verbal. Yells if touched...Unable to get BP D/T (blood pressure due to) stiffness and combativeness." The plan had been for the staff nurse to assess...monitor and mitigate pain with MS around the clock and as needed. The HRN wrote, "Intervention performed by clinician. Coordinated with Facility RN and DON about the importance of transcribing orders and giving meds for comfort as ordered. DON will transcribe orders herself. Pt (patient) is comfortable and not in any distress." The Hospice Clinical Note dated 4/29/15 revealed that "The LVN today reported that she has not been giving any Haldol on her shift because she did not know where it was. I worked with her to find it in the cart with the box still sealed. The medication had not been given up to this point." The record also reflected a new area on the right heel deep tissue injury, (wound #3) and orders for facility nurse to paint with skin prep (a liquid that's applied skin to form a protective film) three times a day until healed, and float the heels at all times while in bed. The "Hospice Clinical Note" dated 4/30/15 revealed that, "Patient was in pain when I arrived. When I went to look at the MAR (medication administration record) to see when or if Pt. (patient) had a MS dose, I found in the Narcotic Count Book, that the patient had not had Morphine since 9 p.m. last night. The nurses had been documenting that they had been giving the medication in the electronic MAR but not administering the medication to the patient. Nurse (RN 4) reported the patient had been refusing the doses. Requested a dose be given immediately and then put back to bed." HRN's note continued to reveal, "Wound care orders written on 4/28 and 4/29 were not carried out and the treatment nurse knew nothing about them. Waited to ensure the orders were carried out and the initial treatment was done."Review of HRN's Clinical Note dated 5/3/15, revealed that, "Routine visit today to do skin assessment, wound care, check MD orders, and pain assessment. When I arrived the order from 5/1 and 5/2 had not been transcribed.Patient was still on the old order of Fentanyl 12 mcg every 72 hours and that patch was due to be changed today. The physician's orders written on 5/3/15 reiterated the order from 5/1/15 to discontinue the routine morphine at 8 p.m. on 5/3/15 and Fentanyl increase to 24 mcg done today. The HRN note dated 5/3/15 revealed the actions of the HRN, "I changed the Fentanyl patches per MD order...Ensured the Morphine routine was stopped at 8 p.m. tonight in the electronic MAR." 3. On 4/27/15, review of Resident 13's closed record showed Resident 13 was originally admitted to the facility on 10/12/12, and readmitted on 4/7/15 after a stay in the acute hospital from 2/11/15 thru 4/7/15. His readmission diagnoses included his pressure ulcers (a sore on the skin caused by prolonged pressure), quadriplegia (paralysis of the body from the neck down), and loop colostomy (a portion of the bowel is surgically brought to the abdominal surface and sutured in place with two openings for bowel and mucus to leave the body through one stoma (a surgical created opening)).LVN 1 documented in the progress notes on 4/10/15 at 10:58 p.m., that while Resident 13's father and sister were visiting, his father came to the nursing station twice to report his son was in pain.LVN 1 documented, without a specific time, in the progress notes on 4/10/15 he went to Resident 13's room and assessed Resident 13 for changes in his vital signs such as an in increase pulse rate, blood pressure, and respiratory rate, and change in cardiac rhythm. He documented only the changes observed, Resident 13's blood pressure was 76/48 (normal blood pressure 120/80). He went back and checked on Resident 13 and his blood pressure was still low. He notified the doctor who ordered transfer of Resident 13 via 911 to the acute hospital for further evaluation and treatment. According to the nurses' notes, Resident 13 was transferred to the acute hospital via 911 ambulance on 4/10/15 at 10:20 p.m.Review of the acute hospital ER (Emergency room) notes, dated 4/10/15 at 11:13 p.m., showed Resident 13 was just recently discharged from the hospital five days prior and now returned with hypotension (low blood pressure), altered mental status (any measure of arousal other than normal) and rigor ( shivering and chills). The ER notes indicated Resident 13 had developed what appeared to be severe sepsis (potential life threatening infection) or septic shock, (a condition that occur when a body wide infection lead to dangerous low blood pressure). Resident 13's abdomen was distended (swollen), Colostomy bag full of white brown stool and gas. According to the ER notes, Resident 13 arrived covered with feces from upper legs and to mid-torso and soiled dressing on the multiple skin ulcerations and had massive stage 4 decubitus ulcers (Full thickness tissue loss with exposed bone, tendon or muscle, slough (layer of skin off) or eschar (dead tissue) may be present on some parts of the wound bed) extending up to mid-thoracic (middle back) spine covered in feces with pus draining from at least one area on the right buttock. The acute hospital "History and Physical" report documented that Resident 13 was admitted to intensive care unit on 4/10/15 for treatment of severe sepsis, hypotension, altered mental status and had a very poor prognosis. The hospital surgery consultant wrote on 4/11/15, Resident 13 was known to have a large stage four pressure sore that required a loop colostomy a couple weeks ago and the loop colostomy did not completely divert the stool resulting in leakage of stool through the rectum, contaminating his sacral wounds.A second review of Resident 13's closed record at the facility on 5/6/15 showed that the facility did not develop a plan of care to monitor Resident 13's colostomy bag or to monitor him for regular bowel movements from his rectum. Review of Resident 13's closed record on 4/27/15 showed the wound doctor assessed Resident 13's pressure sores at the facility on 4/10/15. She wrote treatment orders for the staff to "cleanse the wounds with normal saline, pat dry and apply Silver alginate (used to assist with management of infected wounds), cover with dry clean dressing daily to the stage four pressure sores on his lower back, left and right ischium (sitting bone), sacrum (bone at the bottom of the spine); his right and left heel, and the stage three pressure sore (Full thickness tissue loss. Subcutaneous (under the skin) fat may be visible) to his left and right lower leg." The treatment sheet was reviewed and showed orders dated 4/8/15 instructing the staff to cleanse Resident 13's pressure sores with normal saline, pat dry, apply calcium alginate dressing( used on wounds that ooze bodily fluids) and cover with Meplex (a foam dressing that absorbs wound fluid) dressing one time a day. There was no indication on the treatment sheets the staff did any treatments on April 8, 9 and 10, 2015 to Resident 13's stage IV pressure sore on his lower back, left and right ischium, right and left heel and the stage III pressure sore back of his left and right lower leg. The treatment sheet further revealed that the staff did not implement the new treatment orders the wound doctor ordered for Resident 13's pressure sores on 4/10/15. During an interview on 4/27/15 at 3:00 p.m., Nurse Consultant 1 was not able to find the treatment orders written by the wound doctor on 4/10/15 for Resident 13's pressure sores.During an interview on 5/15/15 at 2:00 p.m., Resident 13's sister said, "That evening (4/10/15) when we went to visit my brother (Resident 13), he did not recognize us. My father thought something was wrong with him. So he asked the nurse if something was wrong or if he (Resident 13) had taken some kind of drugs". On 5/6/15 at 8:45 a.m., during an interview at the facility, C.N.A. 7 was asked about Resident 13's condition prior to going to the acute hospital on 4/10/15. C.N.A. 7 said, "I never changed him. When I came in at 3:00 p.m., I did rounds. He (Resident 13) had his head covered. There was nothing in his colostomy bag. I told the nurse he (Resident 13) didn't want to be touched and his bag was empty. Later when (Resident 13's) parents got here they told the charge nurse he was shaking and not himself." During an interview on 5/6/15 at 3:40 p.m., LVN 1 said, "The (Resident 13's) father came in and went to the room and then came to the nursing station and said someone came and gave him drugs. After a few minutes I went into the room to see what the father was talking about. The father came back and said Resident 13 was complaining of pain. I medicated him for pain. He was ok he was talking. The colostomy bag was closed. The father came back and said he was complaining of chest pain. I went to assess him his blood pressure was low. I gave him his medication for low blood pressure. I checked his blood pressure again and it was still low. I asked him how he (Resident 13) was feeling, he said "so, so". I called the doctor and the doctor said transfer him to the hospital, 911. When the paramedics were transferring him from the bed to the gurney, I saw the bowel movement on the bed. I told the paramedic he had a colostomy bag. I said the bag may have open that's why the feces are there. I told them to wait but they were rushing to take him." When LVN 1 was asked about Resident 13 having stools from his rectum he said, "I'm not aware of that, he has a colostomy. That was my first day working with him since he came back from the hospital. No one told me he was having stools from his rectum." 4. During an interview on 5/4/15 at 2:30 p.m., Resident 14 said he was discharged from the hospital to the facility and the day after he arrived, the nurse told him they did not have his Methadone medication. Resident 14 said "I told the nurse if she couldn't give me my medication I would have to go to the hospital. They didn't give me my medication. I was hurting, so, I called 911." Review of Resident 14's record revealed he was admitted to the facility on 5/2/15 with diagnoses chronic pain, chronic obstructive pulmonary disease (lung disease) and he was dependent on Methadone (medication used to treat severe pain). During an interview on 5/7/15 at 8:30 a.m., LVN 3 said, "The C.N.A. told me the morning of 5/3/15 he (Resident 14) wanted his medication. I checked if his medication had arrived. None had arrived. I went to his room and told him his medication had not arrived, so he said, I need my medication. Let me go to the hospital. I told him I called the pharmacy, the doctor, and Facility B (where Resident 13 was prior to hospitalization). He (Resident 14) said he needed his Methadone. He was shaking and felt like he was going to die. I called the pharmacy and they said it (Methadone) would be on the 8:00 a.m. delivery today. I called the doctor and told him we needed authorization to use the Methadone. The doctor told me he would call the pharmacy and give authorization. The Resident didn't want to wait so he called 911. The pharmacy called and did not give authorization Methadone because we didn't have the dosage in the emergency kit." During an interview on 5/7/15 at 1:30 p.m., the pharmacy consultant said, "They could have taken the medication from the emergency kit. They have five and ten milligram of Methadone in the kits." Observation of the medication storage on 5/6/15 at 2:30 p.m. with the California Department of Public Health Pharmacy consultant and the facility's DON, showed the emergency medication kit had eight tablets of Methadone 5 mg and 10 tablets of Methadone 10 mg. Review of Resident 14's progress notes dated 5/3/15 at 8:30 a.m. showed LVN 3 documented Resident 14 complained of feeling shaky and said he was going to die if he did not get his medication. She explained to him that the medication were ordered last night and would arrive today. At 9:30 a.m. Resident 14 called 911, and went to the acute hospital via ambulance. At 11:00 a.m., the acute hospital called and said they would give him his Methadone. At 3:43 p.m. Resident 14 was transported back to the facility from the acute hospital.Review of the "Pharmacy shipment summary "record showed that on 5/3/15 at 2:10 p.m., the facility received 35 tablets of Methadone 10 mg.5.Record review showed Resident 29 was admitted to the facility on 3/6/15 for treatment of pressure ulcers and had a diagnosis of Quadriplegia. He also had a left arm amputation. According to the wound assessment dated 5/19/15 at 2:45 p.m., Resident 29 had a stage IV pressure ulcer on his coccyx (tailbone) that was 0.7 cm by 0.4 cm with a depth of 0.4 cm.During an observation and interview at the bedside on 5/21/15 at 12 p.m., Resident 29 was having his right arm placed in a splint by the Occupational Therapist (OT) and her assistant. The OT told the assistant not to put the splint on over his elbow, and "Leave the wound open." The resident had a round open area that presented as a shallow crater over the bony area of his outer elbow. The OT stated that she had told the DSD about the sore on 5/20/15. A review of the medical record revealed that the new pressure sore on the right elbow was not identified and there was no treatment ordered. The wound was uncovered and unattended. In an interview on 5/21/15 at 4 p.m., the DSD said he was not aware of a new pressure sore on Resident 29.The DSD returned and provided a "Non-Pressure Skin Condition Report" that revealed Resident 29 had a right elbow "skin tear" first observed on 5/20/15, measured on 5/21/15 to be 1 cm by 0.7 cm with a depth of 0.1 cm. The DSD could not explain why a round open area over a bony prominence on a limb that had been splinted would be documented as a skin tear. 6. Record review showed Resident 30 was admitted to the facility on 4/7/15 for trauma aftercare of a fractured lower left leg, and rehabilitation. On 5/20/15 at 2:45 p.m., Resident 30 was observed sitting up in his wheelchair in his room. His left foot was wrapped in an elastic bandage with a metal pole that protruded up the front of his leg that was attached to a metal "pin" that went through the front of his shin bone. The area where the pin and pole connected there was a thin piece of gauze covering his leg. The resident pulled the gauze aside to reveal an open sore around the pin area with had depth and was moist and yellow. He said, "They were putting some antibiotic ointment on it." In an interview on 5/20/15 at 4:10 p.m., the DSD stated he was waiting for "iodine/betadine to come in." He said that the order for "pin site care" came from the hospital and the resident was to go back in two weeks for an appointment. He presented the order that was from a doctor's visit on 5/14/15 that reflected, "...Pin site care daily with dressing changes. We will see him in one week. He is to start a 2 week course of abt. (antibiotic)". The DSD stated that he did not clarify the order with the prescribing physician, nor did he call the attending physician and start the order. He also did not perform a skin assessment, nor was he aware of the open area at the pin site. A review of the "Treatment Record" (TAR) for May 2015 revealed that the resident's treatment beginning 5/15/15 was for pin site care daily and as needed at the left foot, to clean with hydrogen peroxide solution, apply gauze pads around pin site, and monitor for signs and symptoms of an infection every shift. On 5/2/15 there was an entry added, "Clean pin sites with NSS (normal saline solution) pat dry then cover with gauze, change PRN (as needed) soiled." The above violation has a direct relationship to the health, safety or security of patients. |
| 020000277 |
Windsor Healthcare Center of Oakland |
020011915 |
B |
22-Dec-15 |
EOZR11 |
5429 |
F333 483.25(m)(2) RESIDENTS FREE OF SIGNIFICANT MED ERRORS The facility must ensure that residents are free of any significant medication errors.The facility violated the aforementioned regulation by failing to ensure 2 residents (7, 12) did not miss doses of their ordered antibiotic and antiviral medications which could lead to the residents developing resistance to the medication: 1. Resident 7 missed 6 doses of Rocephin (an antibiotic medication) to treat his osteomyelitis (bone infection).2. Resident 12 missed 5 doses of his antiviral medication (Triumeq) for treatment of his HIV ((Human immunodeficiency Virus- a virus that weakens the immune system by destroying important cells that fight disease and infection).1.Review of the clinical record, on 5/4/15 at 1:30 p.m., showed Resident 7 was admitted to the facility with multiple medical diagnoses which included osteomyelitis (infection of the bone and bone marrow usually caused by bacteria.) Resident 7 was scheduled for placement of a PICC (peripherally inserted central venous catheter, used for long- term fluid and medication administration) line on 5/5/15, following an unsuccessful insertion attempt on 5/2/15. Record review of physician's orders, dated 4/30/15, for Resident 7 showed an order for Rocephin Solution Reconstituted 1GM (gram) to be given intravenously (IV, through the vein) once a day, with a start date of 5/1/15. Another order, dated 5/1/15, for Rocephin Solution Reconstituted 1 GM (gram) intramuscularly (IM, injected into the muscle) once a day for up to 7 days until PICC line is successfully placed, with a start date of 5/2/15.Review of the MAR (Medication Administration Record) dated 5/5/15, for Resident 7 showed the IV Rocephin was scheduled to be given at 9 a.m. and the IM Rocephin was scheduled to be given at 1 p.m. The MAR indicated Resident 7 did not receive any doses of Rocephin on 5/2/15 and 5/4/15. (Skipping doses of Rocephin may increase the risk of further infection that is resistant to antibiotics.) [Reference: Drugs.com] An observation during an extended survey, on 5/21/15 at 9:10 a.m., showed the empty IV Rocephin bag for Resident 7, dated 5/20/15, was hanging on an IV pole in the resident's room. During subsequent observations at 10 a.m., 10:50 a.m. and 11:05 a.m., the empty Rocephin bag dated 5/20/15 was still hanging on the IV pole and the IV Rocephin scheduled for 9 a.m. on 5/21/15 had not been given.During an observation, record review and concurrent interview, at 11 a.m., NC (nurse consultant) 2 stated the IV Rocephin was not given because there was no RN available to give the medication. At 11:15 a.m., RN 18 entered Resident 7's room and began preparations to hang the medication that was due at 9 a.m. RN 18 stated she was told to report to work for 11 a.m. The IV Rocephin was administered 2 hours late to Resident 7 at 11:23 a.m. Review of the facility's policy and procedure titled "Medication Administration" dated 1/1/12, indicated "...The Licensed Nurse will prepare medications within one hour of administration....Medications may be administered one hour before or after the scheduled medication administration time..." 2. During an observation of medication pass for Resident 12, on 5/5/15 at 8:45 a.m., LVN (licensed vocational nurse) 6 stated she did not give Resident 12 his 9 a.m. Triumeq (an antiretroviral medication) 600-50-300 mg (milligrams) because it was not in the medication cart. The medication had not been delivered from the pharmacy.On 5/5/15 review of the MAR (medication administration record) dated 5/5/15, showed that Resident 12 received one dose of Triumeq on 5/4/15, administered by LVN 6.On 5/5/15 at 1:30 p.m., LVN 6 stated that she had not given the Triumeq on 5/4/.In a telephone interview, on 5/5/15 at 3:20 p.m., the PIC (Pharmacist in Charge) at the facility's contracted pharmacy company, stated they received an order from the facility for Triumeq on 5/4/15 at 4:32 p.m. and it was shipped on 5/5/15 at 1 a.m. to the facility. Review of the facility's record of the pharmacy's shipping document showed the Triumeq was delivered to the facility on 5/5/15 at 5:46 a.m. During an observation and interview, on 5/7/15 at 10:55 a.m., RN 4 was asked if Resident 12 had received the 9 a.m. dose of Triumeq. RN 4 stated Resident 12 did not get the medication because it was not there. When RN 4 was asked to check the other drawers of the medication cart, RN4 stated, "It wouldn't be here."RN 4 opened the top drawer of the medication cart and the Triumeq medication was there.On 5/7/15 a review of the MAR for May 2015, showed Resident 12 had not received any doses of Triumeq since admission on 5/1/15. A total of five doses, from 5/1/15 through 5/5/15, had not been administered. During a telephone interview, on 5/7/15 at 10:30 a.m., RN (registered nurse) 15, who worked at the HIV clinic which followed Resident 12, stated it is important for HIV patients to take the daily prescribed dose of antiretroviral medications. One or two missed does per month could make the patient resistant to the medication and the medication would no longer be effective.Therefore the facility failed to ensure Resident 7 and Resident 12 received their antibiotic and antiviral medications as ordered which could lead to the residents developing resistance to the medications. The above violation has a direct relationship to the health, safety or security of patients. |
| 020000103 |
Windsor Gardens Care Center of Hayward |
020012177 |
B |
13-Apr-16 |
G9IQ11 |
8413 |
483.25(h) FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICESThe facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. The facility violated the aforementioned regulation by failing to provide limited assistance during meals as specified in the latest nursing assessment of 8/4/15, in the plan of care and according to the recommendations by the speech therapist, for Resident 1. Resident 1 had a history of aspiration (inhaled food into the lungs), pneumonia and a diagnosis of dysphagia (difficulty swallowing) and was last given a swallowing evaluation two years ago. As a result of the failure to provide assistance during a meal, on 10/9/15, Resident 1 aspirated, had a respiratory arrest, and died later that day in the hospital. During a phone interview on 10/14/15 at 1:30 p.m., Resident 1's relative stated that Resident 1 required individual assistance with eating as she "pocketed food" (kept food in the cheek pocket after swallowing) and needed to be slowed down. The relative stated that he visited Resident 1 every evening to assist with dinner. Resident 1 had her meals in the 'assisted dining room' and doesn't speak English. In 2013, she had aspiration pneumonia (due to inhaled food) and that's when a diet consistency of pureed foods and thickened liquids was started. The relative stated, "I got a call from the director of nurses (DON) that she (Resident 1) choked and 911 was called. The ER [emergency room] doctor told me he found food in her lungs." Review of the medical record showed that Resident 1 was admitted to the facility 5/19/08, with diagnoses that included dementia, (a chronic or persistent disorder of the mental processes 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), history of stroke, dysphagia (difficulty swallowing), epilepsy (seizures), chronic obstructive pulmonary disease (COPD), and generalized weakness. (COPD is a lung disease characterized by chronic obstruction of lung airflow that interferes with normal breathing.) The MDS (minimum data set, complete resident assessment), dated 8/4/15, showed that Resident 1 required "limited assistance" of one staff for eating; (Limited assistance was defined in the MDS as "Resident is highly involved in the activity and staff provide guided maneuvering of limbs or other non- weight- bearing assistance)." The brief interview for mental status (BIMS) "could not be conducted as resident rarely/ never understands." Review of the computerized and untitled care plan, with a revision date of 5/3/15, showed the following "Focus" or identified problem for Resident 1: "The resident had an ADL (activities of daily living) self- care performance deficit related to dementia, impaired balance, late effects of CVA (stroke), activity intolerance, limited mobility, and confusion." One of the interventions listed, and initiated on 8/20/14, for the ADL deficit was: "EATING: The resident requires assistance to eat (Specify- hand over hand, reminding, prompting, cueing, assistance)." There was no change to this instruction since 8/20/14. Another "Focus" listed on the computerized care plan showed, that Resident 1 had speech therapy for swallowing related to oral consistency- initiated 8/21/13 and resolved 9/20/13. The intervention listed and dated 8/21/13 was: "Ongoing Assessment of Swallow Efficiency..." there was no resolution date. Continued review of the untitled care plan showed another "Focus": "The resident is at nutritional risk due to chewing and swallowing deficit, nectar thick liquids, diagnosis of dysphagia, initiated 9/4/12; revised 5/3/15. The intervention showed, "Assist resident with meals as needed." During interview and concurrent record review on 10/19/15 at 12:30 p.m., the director of nurses (DON) confirmed that Resident 1 was last evaluated by a speech therapist, on 9/18/13. This report showed a "Discharge Status and Recommendation: "Swallow strategies/ Positions -To facilitate safety and efficiency, it is recommended that the patient use the following: general swallow techniques/ precautions and guided bolus/ utensil placement and upright posture during meals [These may include preferable food consistencies, changes in the position of the head while eating and drinking, and maneuvers that may help keep the airway closed during swallowing.]...Feeding assistance at all meals. Supervision of Oral intake- Close supervision." During further interview the DON stated Resident 1 "...feeds herself after set- up..." During an interview on 10/19/15 at 2:10 p.m., CNA 1 stated, "Last Friday [10/9/15] at 12:45 p.m., we passed the trays. She [Resident 1] sits alone and eats independently. One of the tables was unsteady and the RNA (restorative nursing assistant) was fixing it. Resident 1 was hitting the table and I told CNA 2 she needs attention. CNA 2 went to her and her lips were blue. CNA 2 and LVN 1 did the Heimlich and RNA swept her mouth. We called a code blue." (The Heimlich Maneuver is a first aid procedure used to treat upper airway obstruction by standing behind a person and using hands to exert pressure on the bottom of the diaphragm in an effort to dislodge and expel food stuck in the trachea.)During interview on 10/19/15 at 2:15 p.m., CNA 2 indicated that no one assisted Resident 1 with her meal prior to the choking incident. CNA 2 stated, "During lunch, we were still passing trays. She (Resident 1) likes to eat right away. She likes to feed herself. We assisted her by encouraging her. RNA was trying to fix the wobbly table next to her. I was helping with the table...Resident 1 was coughing and her color was changing and she was trying to reach RNA and hitting the table. I yelled for help and everyone came." The above staff interviewed, the DON and CNA 1 and 2, described that Resident 1 ate meals independently contrary to directions in Resident 1's nursing assessment, the care plan, and the speech therapist's recommendations that Resident 1 required supervision and one person feeding assistance at all meals.During interview on 10/19/15 at 1:50 p.m., LVN 1 (licensed vocational nurse) stated, "I was giving meds to a resident in the dining room and, as I turned, I saw three CNA's with Resident 1, asking for help, saying, 'She's choking.' She was trying to speak but couldn't...Her color changed and I knew she was lacking oxygen. We lowered her to the floor. RN 1 brought the suction machine. We tried to suction; the material (suctioned) looked like mashed potatoes."During interview on 10/19/15 at 2:30 p.m., RN 1 (registered nurse) stated, "I heard a commotion and they were wanting help. I saw them doing the Heimlich while Resident 1 was sitting in a chair. I saw her gasp for air and she was having difficulty breathing and trying to talk but no words came out. Her color changed and she passed out. We saw she was not breathing." During interview on 10/19/15 at 2:45 p.m., RN 2 stated, "I was in the front station and was called to the big dining room. I saw the staff was with Resident 1, doing Heimlich. I got suction and oxygen and RN 1 and DON were there. Resident 1 looked like she can't breathe. I called 911 and said that she was eating, we think she aspirated, and CPR was in progress." Review of Resident 1's ER discharge summary showed: "Date of Admission: 10/9/15. Date of Expiration: 10/9/15. Final Diagnosis: Acute respiratory failure leading to acute respiratory arrest associated with a major aspiration associated with chronic dysphasia associated with chronic dementia..." The Hospital Course: This 80 year old patient who has a history of severe dementia that has been progressive and has resulted in multiple aspiration events...Had a major aspiration event and presented after having a cardiac arrest which was induced by the respiratory arrest. The patient was found to have...a major amount of aspirate in her airway. The patient's chest x-ray demonstrated bilateral infiltrates (Pulmonary infiltrates may be caused by cardiac failure, adult respiratory distress syndrome (ARDS), blood clot in the pulmonary veins, hemorrhage in the lungs and inhaled food particles.) The violation had a direct relationship to the health, safety or security of residents. |
| 020000071 |
Windsor Post-Acute Care Center of Hayward |
020012675 |
B |
26-Oct-16 |
RNDL11 |
4486 |
483.25 (h) Accidents The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. The facility violated the aforementioned regulation by failing to prevent an avoidable accident by not following Resident 1's plan of care to have two or more persons assisting the resident with transfers from the wheel chair to the bed. This failure resulted in Resident 1 falling and sustaining a hip fracture which caused her pain and inability to sit up in a wheelchair after the fall. During a review of the clinical record for Resident 1, the admission record indicated she was admitted, on 12/18/13, with diagnoses that included dementia (decline in mental ability), osteoarthritis (bone and joint pain) and history of falls. Review of the care plan, last revised on 10/14/15, for Resident 1 showed she was at risk for falls due to use of cardiovascular medication, visual impairment, poor safety awareness, poor balance and severely impaired mental abilities. Review of the Minimum Data Set (MDS, an assessment tool used to direct resident's care), dated 10/9/15, for Resident 1 showed she was not able to walk but was able to sit up in a wheelchair. The MDS indicated Resident 1 required two or more staff members to transfer to and from the bed and the wheelchair. The clinical record included an Interdisciplinary Team progress note dated 12/4/15 for Resident 1 that indicated the resident had an assisted fall on 12/1/15 while transferring from the wheelchair to the bed. A review of the nurse's progress notes showed Resident 1 had pain in her left hip on 12/3/15. Her physician was notified and an x-ray of her left hip was done. The x-ray showed a left hip fracture. After an investigation the facility concluded that Resident 1 sustained the hip fracture during her fall on 12/1/15. Resident 1 was transferred to a local hospital. A review of the discharge summary from the hospital showed Resident 1's son declined surgery to repair the hip fracture. Resident 1 was placed on bedrest and hospice services (care provided at the end of life) and returned to the facility. During an observation on 12/17/15 at 1:35 p.m., Resident 1 was observed in her bed. Certified Nursing Assistant 2 (CNA 2) was providing care to Resident 1. Resident 1 frowned, cried out "Oh" and rubbed her left upper leg and hip area when turned in the bed. During an interview on 12/17/15 at 1:37 p.m., CNA 2 stated she had cared for Resident 1 prior to her fall on 12/1/15. CNA 2 stated Resident 1 always required the assistance of two staff members to transfer to and from the wheelchair and the bed. CNA 2 also stated Resident 1 enjoyed being up in the wheelchair and attending activities prior to her fall. Resident 1 was on bedrest and required frequent turning and repositioning to prevent skin breakdown since her fall. During an interview on 12/17/15 at 2:10 p.m., Licensed Vocational Nurse 1 (LVN 1) stated Resident 1 was on bedrest since her fall and she had pain when moved and turned in the bed. During an interview with Licensed Vocational Nurse 2 (LVN 2) on 12/17/15 at 3:10 p.m., she stated CNA 1 was not the usual aide assigned to care for Resident 1. During a telephone interview with Certified Nursing Assistant 1 (CNA 1) on 12/22/15 at 2:15 p.m., she stated she was assigned to care for Resident 1 on 12/1/15. CNA 1 stated, on 12/1/15 at about 7 p.m., she attempted to transfer Resident 1 from the wheelchair to the bed, without assistance, and Resident 1 slipped to the floor landing on her left side. CNA 1 stated she lifted Resident 1 off the floor and placed her in her bed. CNA 1 stated she was not aware that Resident 1 required two or more people to transfer her from the wheelchair to the bed. CNA 1 stated the facility's Director of Nursing told her after the fall that Resident 1 required two or more people to transfer. CNA 1 stated the information on care needs for the residents was available in the facility's computer system (Point Click Care) but she did not check the computer prior to attempting to transfer the resident. Therefore the facility failed to provide two staff members to assist Resident 1 in the activity of daily living, of transferring from the bed to a wheelchair, as required by Resident 1's comprehensive assessment and plan of care. The violation had a direct relationship to the health, safety or security of Resident 1. |
| 020000004 |
Wisteria Care Center |
020012918 |
B |
16-Feb-17 |
G1TU11 |
6135 |
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 violated the aforementioned regulation by failing to provide adequate supervision to prevent accidents when Resident 1 fell twice in one day sustaining a broken arm, a facial laceration, and bleeding in the brain.
A record review of Resident 1's "Admission Record," dated 5/4/16 showed Resident 1 was admitted to the facility on XXXXXXX 13 with multiple diagnoses that included dementia [wide range of symptoms associated with a decline in memory or other thinking skills severe enough to reduce a person's ability to perform activities of daily living (ADL)], hypertension (high blood pressure), lack of coordination, and anemia (symptoms can include weakness, dizziness, and fatigue).
A review of Resident 1's "Minimum Data Set" (MDS - comprehensive assessment tool), dated 4/12/16 showed Resident 1 had a short term and long term memory problem and needed set up help from staff members for all activities of daily living (ADL - dressing, eating, walking).
Resident 1 took multiple medications that included Amlodipine to lower blood pressure, Lexapro for relief of the symptoms of depression, and Norco for severe pain. All three of these medications have dizziness as one of their side effects.
A review of Resident 1's "Interdisciplinary Team Meeting" notes, dated 3/19/15 showed Resident 1 had a history of falls. She fell on 3/18/15 and had fracture of her right wrist.
Review of Resident 1's care plan, last revised in 4/16 showed Resident 1was at high risk for falls due to "Unaware of safety needs." The goal for this care plan was, "the resident will be free of falls." The interventions of this care plan included, "Anticipate and meet the resident's needs."
During an interview on 12/7/16 at 8:05 a.m., Certified Nursing Assistant (CNA) 1 stated that in the morning of 5/4/16, at the beginning of her shift, she was doing rounds to check on residents. CNA 1 stated she saw Resident 1 sitting on the side of her bed and asked Resident 1 if she was doing well, and Resident 1 nodded. CNA 1 stated she walked away and went to another resident's room. Then, CNA 1 heard the thumping noise. CNA 1 stated she went to check out what the noise was, and she saw Resident 1 was doing something in her closet.
During an interview on 12/8/16 at 7:25 a.m., Registered Nurse (RN) 1 stated in May 2016, early in the morning during her shift, she remembered hearing a thumping noise. RN 1 stated when she checked on the noise, Resident 1 was found on the floor near her room's closet. RN 1 stated Resident 1 was sent to the hospital.
Review of Resident 1's "Emergency Department Visit Note," dated 5/4/16 showed discharge diagnoses were humerus (upper arm bone) fracture, periorbital (eyelid) laceration that was four centimeters long, and osteoporosis (condition in which bones become weak and brittle). Resident 1 needed a splint on the right arm and she had stiches to repair the laceration.
Review of Resident 1's "Nurse's Notes," dated 5/4/16 at 11:15 a.m., showed Resident 1 returned to the facility on the same day.
Review of Resident 1's "Fall Risk Assessment," dated 5/4/16, showed the facility did an inadequate assessment of Resident 1's fall risk, and gave her an overall fall risk score of 9. This fall risk score included a score of "2" (took one or two medications) in the medication category and a score of "0" (none present) in the predisposing diseases category. However, Resident 1 took at least three of the medications on the list (Amlodipine, Lexapro, and Norco), which would be an actual score of "4". Also, Resident 1 had two of the listed predisposing diseases (a fracture from a fall that day, and a new diagnosis of osteoporosis) on the list which would have given her a score of "2". The higher scores in the two categories gave Resident 1 an overall fall risk score of 13. Per the "Fall Risk Assessment" instructions, a score of 10 or higher indicated the resident was considered at high risk for falls.
Review of Resident 1's "Falls Short Term Care Plan," dated 5/4/16, under the category of "Problem, Need, Concern," showed "Resident Fall" and the "Approaches/Actions Taken" by nursing staff included "Assist resident with ADL's as needed...Apply bed alarm to alert staff for getting out of bed."
Review of Resident 1's "Nurses Notes," dated 5/04/16 at 3:30 p.m., showed "Resident was found by staff on the bathroom floor in prone position. Resident was not verbally responsive, checked residents pulse and breathing. Resident responded to touch by opening eyes and moving extremities. Resident bleeding from right temporal area...."
Review of Resident 1's "Hospital Discharge Summary," showed Resident 1 was readmitted to the hospital on XXXXXXX16 at 4:08 p.m., with a diagnosis of intraventricular hemorrhage (bleeding inside or around spaces in the brain containing the cerebral spinal fluid).
Therefore, the facility violated the aforementioned regulation by failing provide adequate supervision to prevent accidents when Resident 1 fell twice in one day sustaining a broken arm, a facial laceration, and bleeding in the brain.
These violations had a direct or immediate relationship to the health, safety, or security of patients. |
| 020000275 |
Washington Center |
020012945 |
B |
8-Feb-17 |
EBVK11 |
5261 |
483.25(m)(2) RESIDENTS FREE OF SIGNIFICANT MED ERRORS
The facility must ensure that residents are free of any significant medication errors.
A review of the Admission Record of Resident 1 indicated she was admitted to the facility on XXXXXXX 16 with diagnoses that included high blood pressure and atrial fibrillation (A-fib, an abnormal heart rhythm that can lead to increased risk of stroke.). The Minimum Data Set (MDS, a resident assessment tool used to guide care) dated 8/31/16, reflected Resident 1 could feed herself, but needed assistance from one person for locomotion and other activities of daily living (hygiene, bathing, etc.).
A review of Resident 1's hospital Discharge Summary dated 8/25/16, reflected Resident 1 had paroxysmal atrial fibrillation (a condition where the heart rate suddenly increases, then subsides, in variable time intervals) and needed to continue use of the anticoagulant Pradaxa (dabigatran etexilate, a blood thinner). The Summary indicated the discharge medications included: Pradaxa, 150 milligrams (mg), twice a day.
During a telephone interview 12/1/16, at 3:30 p.m., the hospital physician (Phys 1) confirmed she had written the 8/25/16 hospital Discharge Summary with the discharge medication orders. Phys 1 said it was important for Resident 1 to have received the Pradaxa 150 mg twice a day because she had atrial fibrillation.
During an interview on 9/21/16, at 2:35 p.m., registered nurse 1 (RN 1) said Resident 1 was admitted from acute care hospital with admission orders on the Discharge Summary. RN 1 said she sent a copy of the orders to the pharmacy, and transcribed the orders to the computer. RN 1 said she did not notice she had missed transcribing the order for Pradaxa.
A review of the August 2016 transcribed Physician Orders reflected no order for Pradaxa. The Medication Administration Record (MAR) reflected no administration of Pradaxa from 8/25/16 through 8/31/16.
A review of Resident 1's care plan, "Resident is at risk for cardiovascular symptoms or complications due to A-fib," dated 8/26/16, reflected, "Administer meds [medications] as ordered and assess for effectiveness and side effects and report abnormalities to physician."
A review of the pharmacy Shipment Summary for Resident 1 dated 8/25/16 indicated 30 capsules of Pradaxa had been delivered and signed for by RN 2 at 11:12 p.m.
A review of the facility's "Summary of Investigation," dated 9/15/16, indicated the medication was confirmed to be in the medication cart, unopened. The Summary concluded because the nurse did not enter the Pradaxa order into the computer system for Physician Orders and the MAR, the resident never received Pradaxa in the facility: a medication error was substantiated.
During an interview 9/21/16 at 2 p.m., the Administrator (Admin) and Director of Nurses (DON) confirmed Resident 1 did not receive Pradaxa during her admission in the facility, despite presence of a physician order and delivery of the medication by the pharmacy. Admin and DON said the order was missed during the transcription of the admission orders, but the omission had not been discovered until after Resident 1 had been discharged to the hospital.
During an interview 11/29/16 at 3:20 p.m., LVN 1 said she assessed Resident 1 around 9 a.m. on 8/31/16 and noted increased confusion and facial drooping. LVN 1 said she alerted the DON, called the physician and family, and made arrangements for transfer to the hospital. A review of the Hospital Transfer Form Appendix completed by LVN 1 on 8/31/16 reflected Resident 1 was transferred for stroke treatment.
A review of the emergency department Provider Notes dated 8/31/16, at 10:50 a.m., indicated Resident 1 arrived in the emergency room on 8/31/16, at 10:47 a.m., for evaluation of an altered mental state and facial droop. The hospital History and Physical (H & P) dated 8/31/16, indicated Resident 1 was admitted for treatment of an acute cerebrovascular accident (stroke).
A review of a hospital imaging test (Magnetic Resonance Angiogram) completed 9/1/16 indicated Resident 1 had significantly decreased blood flow to the right side of her brain from a blood clot.
A review of the hospital Discharge Summary dated 9/3/16 indicated Resident 1 had significant brain abnormalities and physical deficits as a result of a "massive" right sided stroke from a blood clot. A review of Resident 1's Certificate of Death issued on 10/5/16 indicated she died on 9/19/16. The immediate cause of death was stroke.
A review of the Food and Drug Administration (FDA) boxed warning (a warning placed on a prescription drug label and is designed to call attention to serious or life-threatening risks) indicated abrupt discontinuation of Pradaxa increases the risk of clot formation.
Therefore the facility failed to provide an anti-coagulant medication (a blood thinner, a medication used to prevent clot formation in the blood), as ordered for one of three residents (Resident 1). For Resident 1, this failure resulted in a cerebrovascular accident (a stroke) due to formation of a blood clot in the brain (an ischemic stroke).
The above violation has a direct relationship to the health, safety or security of patients. |
| 100000048 |
Windsor Elk Grove Care and Rehabilitation Center |
030009035 |
B |
23-Feb-12 |
NCW011 |
6751 |
72527 - Patient Rights (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (9) To be free from mental and physical abuse On 6/25/09 an unannounced visit was made to initiate complaint # CA00179392. The facility reported event received 2/26/09 documented a Patient allegation of abuse by a facility staff member on 2/25/09.As a result of the investigation, the Department determined the facility failed to: Ensure Patient 1 was not subjected to physical abuse by Licensed Vocational Nurse (LVN) 1.Patient 1 was a 61 year old female admitted to the facility on 2/21/09 with diagnoses including degenerative disk disease and osteoporosis. Her Minimum Data Set (MDS- a standardized assessment tool) dated 2/26/09 documented Patient 1 was alert and fully oriented but required extensive assistance with activities of daily living (i.e. dressing, toilet use, bathing and personal hygiene). It was documented that she did not have any short or long term memory deficit.The facility reported event indicated that on 2/25/09 at 10:30 p.m., Patient 1 reported to the Registered Nurse (RN) Supervisor that License Vocational Nurse 1 (LVN) tried to pull a pill out of her hand. "The nurse was pulling hard and this action hurt my shoulder."Review of an undated facility Incident Report revealed that while LVN 1 was administering medication at approximately 10:30 p.m. on 2/25/09, when in error, he handed Patient 1 two Vicodin tablets (a medication to relieve pain) and one Temazepam (a medication for insomnia).The incident report revealed LVN 1 was checking the Medication Administration Record (MAR) when he discovered that the medications that he had passed to Patient 1 were actually supposed to be administered to her roommate and not her. LVN 1 then tried to retrieve the pills from Patient 1 but the Patient refused to give the pills to him. At that point, LVN 1 grabbed the medication cup from Patient 1.Review of Patient 1's Nurse's Notes dated 2/26/09, at 3 a.m., revealed no complaint of pain or discomfort. A Nurses Note, written on the same date at 11:10 a.m., revealed a physician's order for an x-ray of the left shoulder was received due to Patient 1's complaint of pain. At 1 p.m. on 2/26/09, a bruise was noted on Patient 1's left wrist. She complained of severe left shoulder pain and Patient 1 was then medicated for pain.The Physician Progress Notes dated 2/26/09, at 9:40 a.m., revealed Patient 1 had an "altercation" with a staff member and complained of injury to her left wrist and left shoulder." The x-ray results dated 2/26/09 at 12:29 p.m. revealed "mild degenerative joint disease of the left shoulder; no shoulder fracture, separation, or dislocation was seen." The facility's Investigative report dated 2/26/09 at 10:30 p.m. included a statement from LVN 1 that, "Patient 1 was holding on to a medication cup with three pills in it, two Vicodin for (pain) and one Temazepam for (insomnia)." After checking the MAR, he discovered the medication that Patient 1 was holding in the cup was actually prescribed for Patient 1's Roommate, so he "tried to take the pills from Patient 1 but she refused." At that point LVN 1 stated "I tried to grab the medicine cup from Patient 1 but she stated I am not going to give them to you." Patient 1 left her room and went to the nurse's station to show the pills to the supervisor.During an interview with LVN 1 by the Director of Nursing (DON) on 2/25/09 at 10:30 p.m., he stated "I made a mistake. I gave the roommate's medication to Patient 1...I told Patient 1 that the medication did not belong to her, so I grabbed the medication from her." The facility's Investigative report also included an interview with Patient 1. The Patient stated that "last night a male nurse tried to give me pain medication." She told LVN 1, "I don't take Vicodin I take Percocet." Patient 1 stated the nurse "slammed the medicine cup on her over bed table." Patient 1 stated "There were some green pills in the cup so I knew the pills were not for me."She then asked LVN 1 to show her the pictures of the tablets to make sure that the tablets were really hers but the "nurse insisted that the tablets were mine." Patientstated "I took the tablets from medicine cup and held them in my left hand and told the nurse I will show this to your supervisor as evidence that you are giving me the wrong medications."Patient 1 stated "LVN 1 came back to my room and told my roommate, I took her medicine." Patient 1 stated then "LVN 1 tried to pry the medicine out of my hand. I refused to give the medication to him so he yanked it out my hand, grabbed my wrist and pulled my left arm about 3 times. When I was on my way to the nurse's station he still tried to take the medication out of my hand out side of my room." The supervisor asked Patient 1 "are you in pain?" Patient 1 answered "yes, my left shoulder is very painful." On a scale of 1-10, Patient 1 stated "her pain level was an eight."The facility's Investigative Report also included an interview by the DON with Patient 1's roommate. The roommate stated "I heard Patient 1 telling LVN 1 "this is not my medication. I do not take Vicodin I am allergic to it." Then there was a commotion, they were fighting and grabbing the medicine. I think the medicine spilled on the floor. That male nurse was something else I have not seen one that fights the patients."In an interview with LVN 2 on 6/25/09, at 9:15 a.m., he stated "I was directed to do an assessment of Patient 1 after the incident. Patient 1 was noted to have a 0.3 x 0.5 bruise on her left wrist." LVN 2 stated "she also complained of severe pain in her left shoulder and verbalized her pain level on a scale of 1-10, to be 9/10 and Patient 1 was alert enough to recognize the color of her pills she takes."In an interview with the administrator on 12/21/09 at 2:45 p.m. she stated, "The nurse stayed and finished out his shift, he was not asked to leave the facility. The facility completed the investigation and determined that the alleged abuse was substantiated. The nurse in question was terminated on 2/26/09 and was reported to the Licensed Vocational Nursing Board by the facility.Therefore, the facility failed to:Ensure Patient 1 was not subjected to physical abuse buy LVN 1. These violations had a direct or immediate relationship to the health, safety, or security of long-term care facility patient or Patients. |
| 100000048 |
Windsor Elk Grove Care and Rehabilitation Center |
030009182 |
B |
28-Mar-12 |
4MZ411 |
6051 |
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: (12) To be treated with consideration, respect and full recognition of dignity and individuality, including privacy in treatment and in care of personal needs. This Citation is the result of an unannounced visit to the facility on 1/12/11 to investigate Facility Reported Incident #CA00205262 pertaining to a staff-to-patient abuse reported to the Department on 10/16/09. The following citation was written as a result of the investigation, in which the Department determined the facility failed to: Treat Patient 1 with respect and dignity when Patient 1 stated that Certified Nursing Assistant (CNA) 1 was rough with her during a shower.This failure had the potential to result in significant humiliation, indignity, anxiety, or other emotional trauma to Patient 1. Review of the facility's 10/16/09 letter reporting the alleged abuse to the Department, revealed Patient 1 complained that CNA 1 had been rough to her during her shower. The facility had suspended CNA 1 pending the outcome of their investigation. Review of Patient 1's Admission Information Sheet and Discharge Summary revealed she was admitted to the facility on 10/9/09, and discharged 10/20/09. The Admission Information Sheet dated 10/9/09 indicated Patient 1 was admitted with diagnoses including: chronic pain, paralysis of lower portion of the body and both legs, and anxiety disorder. Review of Patient 1's Admission Nursing Assessment dated 10/9/09, indicated Patient 1 was alert, cooperative, oriented, and had quick comprehension. Review of a facility Incident/Accident Report dated and timed 10/16/09 at 10 a.m., indicated Patient 1 complained that CNA 1 was too fast, rushing, and was rough with her during her shower that morning. The Facility's Investigative Reports included the following interviews: The facility documented that in an interview with Physical Therapist (PT) 1 on 10/16/09, PT 1 stated she arrived at Patient 1's room that day, after Patient 1's morning shower. Patient 1 was on the shower chair over the toilet, being assisted by CNA 1 and CNA 2. CNA 1 wanted PT 1 and CNA 2 to stand Patient 1 up so she could pull up Patient 1's briefs. PT 1 informed CNA 1 that Patient 1 could not stand up because of her diagnosis. PT 1 stated that CNA 1 argued with her at that point. CNA 1 and PT 1 then transferred Patient 1 back to bed to finish dressing her. PT 1 stated CNA 1 appeared "rushed" and was "not gentle" with all of her interactions with Patient 1. PT 1 then noticed blood around Patient 1's vaginal area. On the same day at 2:00 p.m., PT 1 resumed Patient 1's physical therapy. At that time PT 1 noticed red tinged urine in Patient 1's urinary drainage bag. A facility interview with License Vocational Nurse (LVN) 1 on 10/16/09 reflected LVN 1 stated Patient 1 was given a shower that morning by CNA 1. Patient 1 complained that CNA 1 was "too rough", and "too quick" with her during the shower. LVN 1 also noted a small amount of red tinged urine in Patient 1's urinary drainage bag later that day. In a facility interview with Patient 1 on 10/19/09 at 10:30 a.m., Patient 1 stated "CNA 1 was rough" during her shower on 10/16/09. Review of Patient 1's clinical records revealed the following: Change of Condition Report dated 10/16/09, written at 10:45 a.m., indicated Patient 1 was very "tearful and had some confusion." Change of Condition Report dated 10/16/09, written at 2 p.m., indicated Patient 1 had complained that CNA 1 was "rough" with her. The report also mentioned the patient had red tinged urine in her urinary drainage bag. Short Term Care Plan Report dated 10/16/09, indicated concerns of alleged abuse and the red tinged urine in Patient 1's urinary drainage bag-possibly from being pulled on. Interdisciplinary Progress Notes dated 10/19/09 noted the allegation of "rough" handling during the patient's shower on 10/16/09. A body check had been done and a scant amount of bleeding was found around the urinary tubing. Review of CNA 1's personnel file, on 1/12/11, revealed the following: Written Disciplinary Action dated 10/30/08 indicated that CNA 1 was reprimanded for comments she had made to a patient, stating "It was okay to urinate in her diaper" if CNA 1 could not get help to take patient to the bathroom. Written Disciplinary Action dated 10/16/09 indicated CNA 1 was being rough to Patient 1 during her shower. Review of the facility's Admission Packet, which each patient receives when they are admitted to the facility, included a copy of Resident's Rights. Under item (11), the form indicated the resident (patient) had a right "To be treated with consideration, respect, and full recognition of dignity and individuality . . . "In the section titled, Quality of Life, under (a) Dignity, the document reflected that, "The facility must promote care for the residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality." In an interview on 1/12/11 at 2:30 p.m., with PT 1, she stated she was a witness to CNA 1's rough treatment to Patient 1 after her shower on 10/16/09. PT 1 felt CNA 1 was "rough" and was in a "hurry" that day, and she also noticed the blood in Patient 1's vaginal area. She stated that she had informed LVN 1 about the blood. The Department determined that the facility failed to: Treat Patient 1 with respect and dignity when CNA 1 roughly handled Patient 1 during and after her morning shower on 10/16/09.This violation had a direct or immediate relationship to the health, safety, or security of the long-term care facility patient or patients. |
| 100000048 |
Windsor Elk Grove Care and Rehabilitation Center |
030009183 |
B |
28-Mar-12 |
4MZ411 |
3558 |
1418.91 - Health & Safety Code 1418 (a) A long-term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the department immediately, or within 24 hours. (b) A failure to comply with the requirements of this section shall be a class "B" violation. This Citation is the result of an unannounced visit to the facility on 1/12/11 to investigate Facility Reported Incident #CA00296638, pertaining to a staff to patient (resident) abuse reported to the Department on 10/29/09. The following Citation was written as a result of the investigation, in which the Department determined the facility: Failed to notify the Department within 24 hours of the facility being aware of an allegation of staff-to-patient abuse by Patient 1, who alleged that Rehab Aide 1 touched Patient 2's breast and then made comments of a sexual nature to Patient 2. Review of Patient 1's Admission Information Sheet and Discharge Summary revealed she was admitted to the facility on 10/09/09, and discharged 10/20/09. The Admission Information Sheet, dated 10/9/09 also indicated Patient 1 was admitted with diagnoses including chronic pain, depression, multiple sclerosis, paralysis of lower portion of the body and both legs, and anxiety disorder.Review of a typed statement submitted by the Rehab Program Coordinator (RPC) indicated she was approached by Speech Therapist (ST) 1 on 10/14/09 in the morning. ST 1 informed her Patient 1 had mentioned that (Rehab Aide 1) brushed his arm against the breast of (Patient 2), and made inappropriate comments ('Oh baby let's do that again!')."The RPC then reported the allegation to Occupational Therapist (OT) 1 and the therapy staff held a meeting that day to "decide what steps to take next." Review of the Incident Investigation/Statements obtained by facility administrative staff reflected that the investigation into the allegations was in progress between 10/29/09 to 11/3/09, 15 days after the alleged incident, and 9 days after Patient 1 had been discharged from the facility. A review of the facility policy titled, "Abuse Prevention, Investigation and Reporting," dated 5/08, revealed the following under section G. Reporting, paragraph 9: "Administrator shall report all incidents of alleged abuse or suspected abuse to DPH (Department of Public Health) within 24 hours (AB 1730)(failure to report is subject to class 5 citation) . . ." The policy also directed under section L. Administrative Procedure and Investigation, item 2: "Administrator or designee shall initiate an investigation immediately, which may include interviews of the involved resident(s), and other parties (employees, visitors, other residents, volunteers, family members, etc.) who have knowledge of the alleged incident." During an interview on 1/12/11 at 1:00 p.m. with the Director of Nurses (DON), after looking at the dates of the alleged incident (10/14/09) and the State notification (15 days later on10/29/09), she stated that the notification appeared to be late based on their policy of reporting abuse within 24 hours.The Department determined that on 10/14/09, facility staff knew of Patient 1's allegations regarding Rehab Aide 1 touching Patient 2's breast and making inappropriate comments of a sexual nature. The facility did not report this alleged incident to the Department until 10/29/09, 15 days later. Additionally, documentation indicated the facility investigation into the allegation was not conducted or completed until after Patient 1's discharge from the facility. |
| 100000048 |
Windsor Elk Grove Care and Rehabilitation Center |
030009346 |
B |
07-Jun-12 |
ORVW11 |
7213 |
California Code of Regulations, Title 22 72527. Patient's Rights -- (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (9) To be free from mental and physical abuse.72523. Patient Care Policies and Procedures -- (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved.The following citation is written as a result of complaint #CA00195126. Unannounced visits were made to the facility on 08/18/09 and 09/22/09 to investigate a facility report received on 07/15/09 at 4:25 p.m. regarding an incident of alleged staff to patient abuse on 07/13/09.The Department determined the facility failed to: 1. Ensure Patient A was not subjected to abuse by staff.2. Implement facility policies related to patient abuse and abuse reporting.Patient A was an 82 year old female admitted on 11/08/08 with diagnoses that included cerebral vascular accident (Stroke - CVA), hemiplegia (paralysis on one side of the body), and dementia. The Minimum Data Set, (MDS - a standardized assessment tool) dated 05/05/09 indicated Patient A was non-ambulatory, required full assistance with her activities of daily living (ADLs), and had moderately impaired short term memory and cognitive skills. Behavioral symptoms included resistance to care.On 07/15/09 at 3:18 p.m., the Administrator notified the Department of the alleged abuse. On 07/17/09, following an internal investigation the Administrator notified the Department the allegation of abuse was substantiated and CNA 1 (Certified Nursing Assistant) was terminated. During an interview with the Administrator on 08/18/09 at 1:00 p.m., she stated the abuse was substantiated based on interviews with Patient A and the witness's account of the incident.On 07/13/09 at 7:45 p.m., a staff member (witness) reported she observed CNA 1 "manhandling" Patient A by trying to push Patient A's head and right arm into a hospital gown while Patient A was physically resisting. The witness intervened and directed CNA 1 to leave the room. She noted Patient A's arms were reddened and reported her observations and the condition of Patient A's arms to a Licensed Vocational Nurse (LVN1). The witness completed an Incident Investigation/Statement form dated 07/13/09 at 7:45 p.m.In an interview with Patient A on 08/18/09 at 1:50 p.m., she was seated in a wheelchair and dressed in street clothing. No signs of injuries were observed. Patient A did not recall the incident with CNA 1. She stated there could be "some improvements" made to the facility but was unable to provide specifics. "The staff in charge tries hard but I can't help them. I need to make some changes in my own life."In an interview on 08/18/09 at 2:45 p.m., LVN 1 stated she assessed Patient A's arms and noted the redness. She stated the witness did not tell her she observed CNA 1 "being rough" with Patient A. LVN 1 stated she did not ask the witness what prompted her to make the report or if she observed the method by which Patient A's arms became reddened. She stated, "Later, I saw the witness talking to her (CNA 1), so I asked the CNA about it." CNA 1 told LVN 1 she was "defending herself" when the witness entered the room and asked what was going on. LVN 1 stated she did not take any action per the facility abuse policy and procedure because she was unaware there was an allegation of abuse. She stated she deferred the situation to LVN 2, who was assigned to the patient. LVN 1 stated CNA 1 was not reassigned or relieved of her duties at the time of the incident, and worked until 10:45 p.m. on 07/13/09.In a telephone interview with LVN 2 on 08/19/09 at 1:45 p.m., she stated she was fully aware there was an allegation of patient abuse. LVN 2 stated she did not contact the Administrator or the Director of Nurses, nor did she remove CNA 1 from the care and vicinity of Patient A. LVN 2 completed a Change of Condition report and an Incident Investigation/Statement form dated 07/13/09 at 8:00 p.m., documenting Patient A's reddened arms, the witness's allegation of abuse and CNA 1's statement that Patient A became combative. LVN 2 did not initiate a care plan related to the incident. LVN 2 documented the incident in the nurse's notes on 07/14/09 when directed to do so on 07/14/09. In an interview with the DSD (Director of Staff Development) on 09/22/09 at 1:10 p.m., she stated the Abuse Training Post-tests found in the employee personnel files indicated the employee received training which included the video entitled "Your Legal Duty," review of the facility abuse policy and procedure, and an overview of abuse prevention, recognition and reporting." She initially stated the training is provided "annually, every year," but later stated abuse training was provided "twice a year" per the facility policy and procedure. Three of four employee files of licensed nurses on duty on 07/13/09 PM Shift contained annual Abuse training Post-tests. The DSD provided sign-in sheets for those annual trainings. The file for LVN 2 contained a post test dated 06/03/08 and the DSD was unable to find evidence of any subsequent training. No documentation of bi-annual training for review of the facility's policy was provided.The facility policy and procedure entitled Abuse Prevention, Investigation and Reporting dated 05/08 was reviewed and sections are summarized, (in part). Under the section entitled "Training: bi-annual and as necessary in service will be provided for review of the facility's Policy on Abuse Prevention and Mandated Reporting." Under the section entitled "Protection- "a suspected perpetrator in an allegation of abuse must be removed immediately from the care or vicinity of the patient." Requirements under the section entitled "Reporting" included "immediate reporting to the Administrator or designee and the Director of Nursing, medical record documentation by the licensed nurse, and initiation of a care plan."The Department determined the facility failed to follow California Law and facility Policies and Procedures regarding alleged abuse when they failed to:1. Ensure Patient A was not subjected to abuse by staff. 2. Implement facility policies related to patient abuse. 3.Provide bi-annual in service for review of facility's policy on Abuse Prevention and Mandated Reporting.4. Implement facility policy and remove the accused employee immediately from the care or vicinity of the patient when the possible/allegation of abuse was identified. 5. Immediately notify the Administrator or designee and Director of Nurses of the alleged abuse incident per facility policy. 6. Document in the medical record and initiate a care plan to reflect the patientThe violations have a direct or immediate relationship to the health, safety, or security of long-term care facility patients or residents. |
| 100000048 |
Windsor Elk Grove Care and Rehabilitation Center |
030009350 |
B |
07-Jun-12 |
ORVW11 |
3546 |
California Health and Safety Code 1418.91 (a) A long-term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the department immediately, or within 24 hours. (b) A failure to comply with the requirements of this section shall be a class "B" violation. The following citation is written as a result of complaint #CA00195126. Unannounced visits were made to the facility on 08/18/09 and 09/22/09 to investigate a facility report received on 07/15/09 at 4:25 p.m. regarding an incident of alleged staff to patient abuse on 07/13/09.The Department determined the facility failed to: Implement State law related to alleged and suspected patient abuse and abuse reporting.Patient A was an 82 year old female admitted on 11/08/08 with diagnoses that included cerebral vascular accident (Stroke - CVA), hemiplegia (paralysis on one side of the body), and dementia. The Minimum Data Set, (MDS - a standardized assessment tool) dated 05/05/09 indicated Patient A was non-ambulatory, required full assistance with her activities of daily living (ADLs), and had moderately impaired short term memory and cognitive skills. Behavioral symptoms included resistance to care.On 07/15/09 at 3:18 p.m., the Administrator notified the Department of the alleged abuse. On 07/17/09, following an internal investigation the Administrator notified the Department the allegation of abuse was substantiated and CNA 1 (Certified Nursing Assistant) was terminated. During an interview with the Administrator on 08/18/09 at 1:00 p.m., she stated the abuse was substantiated based on interviews with Patient A and the witness's account of the incident.On 07/13/09 at 7:45 p.m., a staff member (witness) reported she observed CNA 1 "manhandling" Patient A by trying to push Patient A's head and right arm into a hospital gown while Patient A was physically resisting. The witness intervened and directed CNA 1 to leave the room. She noted Patient A's arms were reddened and reported her observations and the condition of Patient A's arms to a Licensed Vocational Nurse (LVN1). The witness completed an Incident Investigation/Statement form dated 07/13/09 at 7:45 p.m.The facility policy and procedure entitled Abuse Prevention, Investigation and Reporting dated 05/08 was reviewed and sections are summarized, (in part). Under the section entitled "Training: bi-annual and as necessary in service will be provided for review of the facility's Policy on Abuse Prevention and Mandated Reporting." Under the section entitled "Protection- "a suspected perpetrator in an allegation of abuse must be removed immediately from the care or vicinity of the patient." Requirements under the section entitled "Reporting" included "immediate reporting to the Administrator or designee and the Director of Nursing, medical record documentation by the licensed nurse, and initiation of a care plan." The facility policy indicated that any known or suspected abuse was to be reported to the administrator immediately and the administrator was to report the suspected abuse to the Department within 24 hours. The law does not specifically designate the administrator as the individual mandated to report the suspected abuse to the Department. The Department determined the facility failed to follow California Law when they failed to:Follow state law and report alleged or suspected abuse immediately or within 24 hours. Failure to comply with the requirements of Health & Safety Code Section 1418.91 shall be a Class B Citation. |
| 100000814 |
Wagner Heights Nursing and Rehabilitation Center |
030009409 |
B |
25-Jul-12 |
CJXY11 |
6065 |
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 public upon request. Patients shall have the right: (9) To be free from mental and physical abuse. The following citation was written as a result of an unannounced visit to the facility on 03/05/09 for the investigation of complaint # CA00174147 related to patient abuse. The Department determined the facility failed to prevent physical abuse to Patient A on 01/07/09 when the Certified Nursing Assistant (CNA) physically forced her to sit on the toilet leaving bruises on her right arm. These failures resulted in physical harm to Patient A. Patient A was an 85 year old female admitted to the facility on 04/27/07. Her diagnoses included a history of stroke with right side weakness. Her 12/25/08 Minimum Data Set (an assessment tool) described her as having some short term memory loss and mild cognitive impairment. She was able to understand and was usually understood. She required extensive assistance with toileting. On 03/05/09 at 2:15 p.m., an interview was conducted with Patient A in her room. She was lying in bed. Her right arm was drawn against her chest and her right hand was stiff. She was observed to be able to gesture, while speaking with her left arm. She stated her daily routine was to get up in the morning and the staff would help her to get dressed. She stated after she was dressed she would ask for assistance to the bathroom. She said she had recently changed rooms and the bathroom in her current room did not have a hand rail which allowed her to help herself as much as she used to. She asked Certified Nursing Assistant (CNA 1) to take her to the room next door to use the bathroom because "the grab bar was better and the toilet was higher." Patient A stated CNA 1 told her, "No, you have to use this bathroom." Patient A stated, "I kept telling her I had to use a different bathroom but she just kept saying, no you have to use this one, then she grabbed me by the arms and forced me down onto the toilet." Social Progress Notes dated 01/07/09 were reviewed. Documentation in the social services notes included the following: "[Patient A] was very shaken up and teary, explained to social service a complaint she had regarding a CNA who helped her to the restroom. Statement: resident called a CNA to help her to the restroom as the CNA was taking her to the restroom in the resident's room the [resident] said "I have permission to use the restroom next door.' The CNA said "No, you use the restroom in your own room." The resident said she kept on repeating "No I have permission to use the restroom next door." The CNA said no over and over. The CNA took [Patient A] to the restroom and lifted the resident very roughly and placed her on the toilet." A facility Interview Record completed by Licensed Nurse (LN 1) on 01/10/09 identified a "purplish skin discoloration on [right upper] arm and pinkish discoloration on [right forearm]... Resident states that she did not bump into anything; just rubbing her muscle on the sites; no big deal." A Verification of Investigation form, completed on 01/10/09 by LN 1 further described the injury. The description included, "purplish discoloration measuring 11 x 6 [centimeters on right] upper arm; pinkish discoloration on [right] forearm measuring 3 x 2 [centimeters]. (One inch is equal to 2.54 centimeters.) The summary of the incident included the statement from Patient A, that she did not bump into anything and "it's nothing." An interview was conducted with LN 1 on 03/05/09 at 2:40 p.m. She acknowledged Patient A had been her patient on 01/07/09. She stated CNA 1 reported to her that Patient A had hit her. LN 1 stated she went to Patient A's room to check on her and found Patient A sitting on the toilet. LN 1 said Patient A told her CNA 1 had "pushed" her onto the toilet, and told LN 1, "I told her I needed to use the other bathroom but she didn't listen." LN 1 stated she assessed Patient A for any injuries and at that time no injuries were noted, she notified the Director of Nursing and CNA 1 was suspended pending an investigation. LN 1 said she was off for the next two days. When LN 1 returned to work on 01/10/09 she said she noticed discoloration on Patient A's right arm and notified the physician. She stated Patient A had told her no one had hurt her, "since CNA 1 had forced her onto the toilet." LN 1 acknowledged the "discoloration" on Patient A's right arm could have occurred from the rough handling by CNA 1 on 01/07/09. The facility police, Suspected/Alleged Abuse Management Process, dated 09/09/05 defined Physical Abuse. The definition included the following statement: "It also includes controlling behavior through corporal punishment. Non-accidental use of physical force that results in bodily injury, pain or impairment (including but not limited to bruising, skin tears, or fractures) are physically abusive actions. Unreasonable confinement or restraint, physical coercion, pushing and shoving are also physical abusive behaviors." A concurrent interview was conducted with Administrative Staff 1 and 2 on 03/05/09 at 3:00 p.m. When asked if the bruising on Patient A's right arm could have been caused by the rough handling of CNA 1 on 01/07/09 they acknowledged that possibility had not been considered. Administrative Staff 1 stated CNA 1 had been terminated on 01/12/09. The reason for termination was documented as not following the facility standards for toileting residents. The Department determined the facility failed to prevent physical abuse to Patient A on 01/07/09 when the Certified Nursing Assistant physically forced her to sit on the toilet leaving bruised on her right arm.These violations had a direct or immediate relationship to the health, safety, or security of long-term care facility patients or residents |
| 030000160 |
Windsor Care Center of Sacramento |
030009480 |
B |
12-Sep-12 |
E5I011 |
3568 |
Nursing Service - Patient Care 72315 (b) Each patient shall be treated as individual with dignity and respect and shall not be subjected to verbal or physical abuse of any kind. Health & Safety Code 1418.91 (a) A long-term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the department immediately, or within 24 hours. (b) A failure to comply with the requirements of this section shall be a class "B" violation. On 08/07/2008, an unannounced visit was made to the facility to initiate an investigation of an Entity Reported Incident, Complaint # CA00157595. The allegations related to abusive behavior by one patient toward 3 other patients.It was determined that the facility failed to:1) Ensure patients were free of mental or physical abuse of any kind and were treated with dignity and respect. 2) Comply with statutory requirement to report all incidents of alleged or suspected abuse to the Department within 24 hours.Three incidents of abusive behavior by Patient A towards three other patients occurred on 7/17/2008 and 7/19/08. Patient A had multiple diagnoses including unspecified psychosis and dementia. None of the incidents were reported as required. Faxed reports of the events were not sent until 7/21/08. On 7/17/08, Patient B informed facility staff that Patient A had grabbed her wrist and pulled it. The undated facility report of the investigation of this allegation indicated that the patients were separated and redirected. Patient A was placed on visual checks every 15 minutes. The physician was contacted and laboratory tests were requested to rule out a possible urinary tract infection or anemia. On 7/19/08 at 11:40 AM, Patient A was observed by a staff member to come up behind Patient C and pull her hair and right ear. The facility investigation, also undated noted that these patients were both redirected without further incident.On 7/19/08 at 13:00, Patient A was observed hitting Patient D on the back of the head several times. Both patients were redirected and assessed. The reporting form (SOC 341) for all of these incidents was faxed to the Department on 7/21/08 at approximately 2:25 PM. The admission diagnoses for all four patients indentified that all had some form of dementia. Record review of each chart included documentation of follow-up assessments completed by facility staff and there were no apparent negative outcomes.On 8/08/08 at 10:15 AM, an interview was conducted with the Director of Nursing (DON) regarding Patient A's actions. The DON reviewed Patient A's chart and indicated that in the past, there was a correlation between aggressive behaviors and an anemia or urinary tract infection. The requested laboratory tests confirmed a low red blood cell count. The physician ordered medication to address the low blood count. There was no reported laboratory evidence of a urinary tract infection.The Ombudsman's office was notified on 7/19/08 regarding the incidents and behaviors of Patient A.It was determined that the facility failed to:1) Ensure patients were free of mental or physical abuse of any kind and were treated with dignity and respect and 2) Comply with the statutory requirement to report all incidents of alleged or suspected abuse to the Department within 24 hours.The above violations had a direct or immediate relationship to the health, safety or security if long-term care facility patients or residents.Failure to comply with the requirements of Health and Safety Code Section 1418.91 shall be a Class B Citation. |
| 100000039 |
Windsor Hampton Care Center |
030009548 |
B |
16-Oct-12 |
8MJ411 |
4728 |
F323 Free of Accident Hazards/supervision/devices 483.25 (h) The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. This citation was written as a result of an unannounced visit on 9/13/10 to investigate complaint number CA00234376, a facility reported incident. The Department determined the facility failed to implement the plan of care for Resident A's bed alarm resulting in Resident A falling on 7/1/10 and sustaining a hip fracture requiring surgical intervention. Resident A was admitted to the facility on 6/9/10. His diagnoses included central nervous system cancer, left sided weakness, a history of falling, and confusion. The admission Minimum Data Set (an assessment tool), dated 6/16/10, described Resident A as having both short and long term memory deficits and severely impaired cognition.He required extensive assistance with mobility. He had sustained a fall within the previous 30 days. A Fall Risk Assessment, completed on 6/11/10, indicated Resident A scored 17 points. The risk assessment tool indicated a score of greater than 10 was a high risk for falls. A Care Plan for At Risk for Injury, dated 6/9/10, indicated Resident A had left sided weakness and confusion. The interventions listed included a personal bed pad alarm in bed. This device sends out an audible alarm signal when a resident moves off of the bed. Review of care plans and Interdisciplinary (IDT) Progress Notes indicated Resident A had falls on 6/11/10 and 6/12/10. The IDT Fall review notes indicated Resident A continued with left sided weakness, forgetfulness, and a fall risk. The IDT continued to recommend a low bed, mattress on the floor, a bed pad alarm while in bed, and a tab alarm when up in the wheelchair. Nurse's Notes, dated 7/1/10 at 4 a.m., revealed Resident A was found on the floor in his room. The bed was noted to be in the low position. The Notes indicated, "The personal alarm is clipped to the gown, but the resident took off the clothes. Pad alarm found off." The Notes indicated Resident A was assisted back to bed. He had sustained a skin tear to his left hand. He initially had no complaint of pain and was able to move his upper and lower extremities without difficulty.Nurse's Notes, dated 7/1/10 at 6 a.m., revealed Resident A complained of pain in his left hip. He was medicated for pain, the physician was notified, and an order was obtained for an x-ray to rule out a fracture. Nurse's Notes, dated 7/1/10 at 8:30 a.m., revealed Resident A complained of "moderate to severe pain on his lower back to [left] hip radiating down to his thigh, [increased] pain [with] movement." The physician was notified and an order was obtained to transfer Resident A to the GACH (general acute care hospital). The History and Physical from the GACH, dated 7/1/10, was reviewed. The reason for hospitalization was documented as a left hip fracture. The x-ray of the left hip, completed on 7/1/10, identified a left hip fracture. Resident A underwent a left dynamic hip screw fixation on 7/4/10. This is a surgical procedure to repair the fractured hip which places screws through the fracture line to hold the bone together. The facility policy for Fall Management, dated July 2008, was reviewed. The policy directed that residents would be assessed for their fall risk and interventions would be implemented to reduce the risk for falls. The facility investigation for Resident A's fall on 7/1/10 was reviewed. The night nurse noted the bed was in the low position, the personal alarm was still intact to the resident's gown, but "resident had no gown on when they found him. Pad alarm was off." The investigation revealed that at "around 6 a.m." Resident A complained of pain to his left hip, the MD was notified, and an order obtained for an x-ray. The investigation further revealed that at 2:30 a.m., Certified Nurse Assistant (CNA) 1 had put Resident A back into bed and provided personal care. CNA 1 stated he turned on the motion alarm, "but forgot to turn on the pad alarm." An interview was conducted with the Administrator on 9/13/10 at 2 p.m. He acknowledged the bed pad alarm for Resident A had not been turned on appropriately on 7/1/10. He stated the CNA had not implemented the plan of care for Resident A. The Department determined the facility failed to implement the plan of care for Resident A's bed alarm resulting in Resident A falling on 7/1/10 and sustaining a hip fracture requiring surgical intervention. These violations had a direct or immediate relationship to the health, safety, or security of long-term care facility patients or residents. |
| 030000105 |
Whitney Oaks Care Center |
030009629 |
B |
07-Dec-12 |
SFB411 |
6641 |
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. An unannounced visit was made to the facility on 5/18/11 to investigate complaint # CA00268899 regarding patient safety/falls.The Department determined the facility failed to follow the nursing care plan. As a result of this failure, Patient 1 fell and sustained a fractured left femur (upper leg bone). Patient 1 was an 87 year old admitted to the facility on 2/16/10 with the diagnoses of aftercare of a traumatic fracture (to the lower left leg) and rehabilitation. Additional diagnoses included dementia, osteoporosis (degenerative bone disease), congestive heart failure, hypotension (low blood pressure), and history of falls. The MDS (Minimum Data Set, an assessment tool) dated 3/10/11, revealed Patient 1 was of moderately impaired cognition, required extensive 2+ persons physical assist for transfer; extensive one person physical assist for bed mobility, dressing, and toileting; did not ambulate; and was incontinent of bowel and bladder.In a document titled "Care Area Trigger Worksheet, Problem area: Falls," a section of the MDS dated 3/10/11, facility staff recorded, "Patient alert, with weakness, standing balance unsteady, not able to maintain balance without extensive assistance from staff, requires 2 person assist with transfer using transfer pole to aid in stability. Will proceed to care plan due to risk of fall/injury related to her poor safety awareness with dementia, and on antidepressant medication." In a document titled "Care Plan" dated 4/1/11, facility staff recorded, "Problem onset: (2/16/10) Risk for Fall due to poor balance and safety awareness, with diagnosis of dementia with history of multiple falls history of fracture of right malleolus [ankle], history of closed fracture of the vertebral [spinal] column, and on antidepressant medication." The goal was stated, "Patient risk for fall/injury will be minimized with reduction interventions." Listed approaches included, "Gait belt used for transfer with 2 person assist. Transfer pole to aid in Patient stability during transfer." In a nurse's note dated 4/7/11 at 10:30 a.m., Licensed Nurse (LN) 1 recorded, "During Transferring Patient from bed to chair the CNA states, 'I got the patient up, during transfer the patient was sliding with her left foot forward.' Patient assessed. No complaints of pain. Offered pain medication and denies pain. Left foot assessed, little movement and dent on left knee noted." In a nurse's note dated 4/7/11, LN 2 recorded, "LN 1 reported to writer that patient had some decreased range of motion to the left knee and deformity noted. MD notified and x-ray ordered STAT [immediately]."In a nurse's note dated 4/7/11, LN 3 recorded, "Patient's x-ray of the left knee returned ... X-ray noted with acute left knee fracture, left distal femur (leg bone) fracture." In an x-ray report dated 4/7/11, Medical Doctor (MD) 1 recorded, "There is a fracture involving left distal femur with displacement. The joint shows no dislocation. Osteoporosis is present." In a document titled "Interdisciplinary Progress Note" dated 4/8/11, facility staff recorded, "Status post fracture left distal femur with displacement per x-ray on 4/7/11 at approximately 10:30 a.m. CNA [Certified Nursing Assistant] was assisting Patient up the wheelchair. As per CNA, she described that she had Patient fully dressed and put a gait belt around Patient's waist. She then helped Patient stand up and hold on to the transfer pole. As the Patient stood up with both hands around the transfer pole, her left leg started to slide forward. At this time, the CNA called out for help and the charge nurse went into the room. Another CNA also came into the room and they slowly helped the patient to the floor... LN reported some deformity to the left knee. X-rays were ordered STAT by NP [Nurse Practitioner] and noted to be positive for fracture to distal [lower] femur. MD notified of results and patient sent out to acute [hospital] per orders." In a Discharge Summary from the acute care hospital dated 4/8/11, Physician's Assistant 1 recorded, "The patient was evaluated by orthopedic surgeon MD 4 and was found to have a distal femur fracture of the left lower extremity ... The family decided that they would like to accept non-operative treatment. This was initiated with immobilization." In the discharge instructions dated 4/8/11, LN 5 recorded, "No surgery performed, non-operative treatment of fracture ... Immobilizer on left leg at all times, except may remove to bathe." In an interview on 5/18/11 at 2:30 p.m., CNA 1 stated, "I had gotten the Patient up and dressed. I put her slippers on and had the gait belt on and around her waist. She grabbed the transfer pole with both hands. I grabbed the gait belt and she was assisted to a standing position. As she was standing there, her left foot started to slide forward. I tried to put my foot in front of it to stop it from sliding and she started to slide down the pole. I immediately called for help because I was alone and the nurses came running to help me. I thought since she was assisting by grabbing on to the pole so well, we would be all right. I know that two people should have been assisting in the transfer." In an interview on 4/30/11 at 3:15 p.m., LN 4 stated, "I responded to a call from CNA 1 for assistance. On entering the room the CNA was holding on to the back of the patient's gait belt. The patient was still semi-standing, holding on to the transfer pole as well. CNA 1 then eased the patient to the floor. I noticed the leg and knee was at a funny angle - not in a normal position ... the leg was in an anatomically odd position. We immobilized the leg and knee and assisted her back to bed." In an interview on 5/18/11 at 3 p.m., the Director of Nursing stated, "This Patient should have been a two person transfer. The CNA did not follow the care plan." In an interview on 8/24/11 at 9 a.m., the Administrator stated, "As to the issue with Patient 1 and the fracture, we identified that CNA 1 did not follow the care plan increasing the patient's risk for injury." The Department determined the facility failed to follow the nursing care plan when CNA 1 moved Patient 1 without 2 person assist. As a result of this failure, Patient 1 fell and sustained a fractured left femur. These violations had a direct or immediate relationship to the health, safety, or security of long-term care facility patients or residents. |
| 030001812 |
Woodland Skilled Nursing Facility |
030009721 |
B |
11-Feb-13 |
UKGN11 |
5817 |
Patients' Rights - 72527 (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (9) To be free from mental and physical abuse. The following was a result of three (3) unannounced visits to investigate an entity reported incident #CA00217009. As a result of the investigation the Department determined the facility failed to: Ensure Patient A's rights were not violated when she was verbally and physically abused by CNA (Certified Nursing Assistant) 1. Patient A, a 41 year old female, was re-admitted to the facility on 8/2/06 with diagnoses of Huntington's chorea (a severe neurological disorder characterized by random erratic movements), lack of coordination, dysarthria (difficulty speaking) and depression. In review of a MDS (Minimum Data set - an assessment tool) dated 3/31/10, Patient A was noted to have cognitive skills for independent decision making. Patient A was assessed as having the ability to understand others and make herself understood. Patient A was receiving hospice care (supportive care given in the final phase of a terminal illness). In an interview with the Acting Director of Nurses (ADON), on 3/23/10 at 9:30 a.m., she revealed Patient A was in the end stages of Huntington's chorea and had been receiving hospice care. The ADON confirmed Patient A had reported a hospice aid (CNA 1) had "hit her" on 2/1/10. The ADON said the hospice agency was immediately notified following the incident and the Director of Nursing had requested the hospice aide not return to the facility.Interdisciplinary Progress Notes, dated 2/2/10 (not timed), documented an interview between Patient A and the Interdisciplinary Team (IDT) that day. The IDT noted "Patient A was adamant she had been hit". Patient A was able to demonstrate how CNA 1 had slapped both her arms with an open hand.In a review of Resident A's clinical record, there were visits by CNA 1 on 1/22/10, 1/25/10, 1/27/10, 1/29/10, and 2/1/10. On the visit for 2/1/10, CNA 1 documented she had given Patient A a sponge bath. She also documented in the comment section "Pt.'s roommate told the nurse and me that I hurting her. Report to charge nurse and also team manager." In an interview with the Treatment Nurse (TN) on 3/23/10 at 12:45 p.m., she stated she was sitting at the nurses' station and heard Resident A "hollering." The TN stated it was "a different yell" and she immediately went to Patient A's room. The TN stated Patient A was lying toward the foot of the bed with her arms up in defensive position. The TN revealed Patient A's roommate told her CNA 1 had hit Patient A. The TN stated she asked Patient A if she had been hit by CNA 1 and she said "yes." The TN stated CNA 1 was very reluctant to leave the room to allow her to interview Patient A. However, she instructed her to remain outside.In an interview with Patient A's roommate, Patient B, on 3/24/10 at 12:45 p.m., she stated CNA 1 was "rough" with Patient A and was "pulling on her." Patient B revealed "every time she (CNA 1) came, she was rough with her (Patient A). Patient B stated CNA 1 "talked to her (Patient A) very bad in a tone of voice that was demanding and ordered her around." Patient B demonstrated rough treatment by grabbing the surveyor's arm between the elbow and shoulder and pulling it roughly towards her.An interview with Patient A was conducted on 5/14/10 at 10:45 a.m. Patient A appeared to have intact cognitive skills but it was very difficult for her to speak due to her chronic muscular disorder and constant movements. Patient A recalled the hospice aid (CNA 1) who cared for her on 2/1/10. Patient A became very agitated when speaking of the incident and strongly responded "yes" when asked if she had been hit by CNA 1. When asked to demonstrate where and how CNA 1 hit her, she thrust her arms out and moved her arms to the side to indicate she has been picked up roughly by the arms and moved. Patient A revealed CNA 1 had spoken to her roughly. She became animated and said loudly "rude." Patient A stated CNA 1 was often rude to her on the days she visited.In a review of a facility policy titled "Elder/Dependent Adult Abuse," it stipulated (in part), "the facility will enforce a policy of nom-tolerance of any form of behavior that might be considered abuse by any individual." Abuse was defined as a. Physical abuse includes hitting, slapping, pushing and shoving. b. Verbal abuse includes any use of oral, written or gestured language that includes threats and/or disparaging or derogatory terms within hearing distance of any resident c. Mental abuse includes humiliation and harassment." The policy further stipulated that, "The facility will enforce a policy of non-tolerance of any form of behavior that might be construed as abuse by any individual including (resident to resident abuse of any type), family member, staff member, visitor, volunteer or other person(s)."In an interview with the hospice agency Team Manager (TM) on 3/24/10 at 2:30 p.m., she stated the agency had investigated the incident with CNA 1 immediately. The TM revealed CNA 1 stated she had not hit Patient A but may have spoken abruptly to her. The TM stated CNA 1 was counseled regarding her communications.Therefore, the facility failed to: Ensure Patient A's rights were not violated when she was verbally and physically abused. These violations had a direct or immediate relationship to the health, safety, or security of long-term care facility patients or residents. |
| 030000160 |
Windsor Care Center of Sacramento |
030009893 |
B |
31-May-13 |
4EIH11 |
9053 |
72301 - Required Service (f) The facility shall ensure that all orders, written by a person lawfully authorized to prescribe, shall be carried out unless contraindicated. 72311 - Nursing Service -- General (a) Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (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. 72315 - Nursing Service - Patient Care (h) Each patient shall be provided with good nutrition and with necessary fluids for hydration. The following citation was written as a result of unannounced visits initiated on 2/1/11 for the investigation of complaint number CA00256069. The Department determined the facility failed to: 1. Identify patient care needs. 2. Develop and implement a plan of care. 3. Continually assess the patient. 4. Ensure sufficient fluids were provided to maintain hydration. 5. Ensure laboratory tests were completed as ordered by the physician. These failures resulted in Patient A becoming unresponsive and requiring emergency transfer to the General Acute Care Hospital (GACH) with subsequent admission to the hospital for diagnoses which included severe sepsis (blood infection) and dehydration. Patient A was a 68 year old admitted to the facility from his home on 11/17/10. His diagnoses included congestive heart failure. An Admission Nursing Assessment, dated 11/17/10, indicated Patient A was confused regarding time and place. He was fully weight bearing and could transfer independently. Nurse's Notes, dated 11/26/10 at 10 a.m., indicated Patient A had developed pitting edema of the feet (swelling severe enough, that when the skin is pressed, a deep indentation will form). Patient A's physician was notified and orders were received for Lasix (a diuretic to remove fluid) 40 milligrams (mg) daily to reduce the swelling and a Chem 7 (Basic Metabolic Panel - BMP - laboratory study to monitor kidney function and hydration status) to be drawn on 12/2/10.Results of the BMP obtained on 12/2/10 indicated Patient A's kidneys were functioning normally and he was hydrated.Nurse's Notes, dated 12/3/10 at 11 a.m., indicated Patient A had developed pitting edema of his right hand and left lower leg. He had a moist cough and diminished lung sounds (possible symptoms of worsening congestive heart failure.) Patient A's physician was notified and an order was received to increase his Lasix dosage to 80 mg daily and to obtain a BMP on 12/4/10. There was no documented evidence a BMP was completed on 12/4/10.Nurse's Notes, dated 12/7/10 at 10:30 a.m., indicated Patient A's physician was "re-notified" of the results of Patient A's BMP completed on 12/2/10. Orders were received to increase Patient A's Lasix to 120 mg daily for continued swelling of his extremities.Nurse's Notes, dated 12/15/10 at 8 a.m., documented Patient A's physician was notified the patient had lost 5.2 pounds and he was "reminded of aggressive diuretic therapy."The physician responded to the notification by instructing staff to "monitor" Patient A. A BMP, completed on 12/17/10, indicated Patient A's Blood Urea Nitrogen (BUN) level was elevated at 63 (normal 7-25). A greatly elevated BUN (60 mg/dL) generally indicates a moderate-to-severe degree of renal failure. Impaired renal excretion of urea may be due to temporary conditions such as dehydration or shock, or may be due to either acute or chronic disease of the kidneys themselves. Resource: Laboratory Tests On-Line. Patient A's blood sodium level was elevated at 146 (normal 135 - 145). A high blood sodium level is almost always due to dehydration without enough fluid intake. Symptoms include dry mucous membranes (mouth and nose), thirst, agitation, restlessness, acting irrationally, and coma or convulsions. Resource: Lab Tests On-Line. Review of the clinical record revealed no care plans had been developed to address Patient A's potential risk for dehydration related to the diuretics he was taking. A Physician's Order, dated 12/17/10, indicated Patient A's Lasix was decreased to 40 mg daily and staff were to "re-check Chem 7 (BMP) in one [week] (12-24-10)." A Nutritional Progress Note, dated 12/23/10 and completed by the Registered Dietician (RD), indicated Patient A had lost 9 pounds since his admission to the facility on 11/17/10 (25 days). The RD documented the weight loss was expected due to the Lasix therapy. The RD noted Patient A's last laboratory values, including his increased BUN and blood sodium levels. The RD noted Patient A's serum osmolality (a calculation of the sodium, glucose, and BUN levels which determines the level of fluid versus chemicals in the blood in which an elevated osmolality can indicate dehydration) was "300 (dehydration)." The RD noted Patient A's Lasix had been decreased, but made no further recommendations regarding Patient A's fluid status or the need to increase his fluid intake.Review of the clinical record indicated there were no laboratory results for the blood Chemistry panel that was scheduled to be completed on Patient A on 12/24/10.Documentation in Nurse's Notes, dated 12/30/10 at 7:30 p.m., indicated Patient A was found unresponsive after dinner. The note indicated Patient A remained unresponsive for five minutes. Patient A's physician was notified and an order was received to send him to the emergency room for evaluation. Review of the General Acute Care Hospital (GACH) consultation report, dated 1/2/11, revealed Patient A had multiple diagnoses including severe sepsis (blood infection) from an infected ulcer on his foot, with acute organ dysfunction and hypernatremia (increased blood sodium level). Documentation in the consultation indicated when Patient A presented to the GACH he had a sodium level on admission of 159 (normal 135 - 145). Patient A was described as "blood volume down, poor skin turgor (elasticity of the skin), with decreased [oral] intake at the [skilled nursing facility]. Documentation on the consultation revealed Patient A had "dehydration from diuresis (removal of fluid from the body by means of medication - Lasix)."An interview was conducted with the Director of Nurses (DON) on 2/1/11 at 10:30 a.m. The DON verified there were no laboratory results in Patient A's chart for 12/24/10. The DON telephoned the laboratory and was informed Patient A's chemistry panel had not been completed until 12/29/10, five days after it was scheduled to be completed. The DON stated the facility had never received the results of Patient A's chemistry panel completed on 12/29/10 and requested the laboratory fax Patient A's laboratory results to the facility. Review of Patient A's laboratory results, dated 12/29/10, revealed the following: BUN - 74 (normal 7 - 25) Creatinine - 1.6 (normal 0.6 - 1.3) Sodium - 155 (normal 135 - 145) (all indicators of dehydration) White Blood Cells - 16.3 (normal 4.4 - 11.0) (indicator of infection.) An interview was conducted with the RD on 3/11/11 at 11:15 a.m. The RD acknowledged she had documented in her 12/23/10 assessment that Patient A's laboratory studies indicated he was dehydrated. She stated his Lasix dosage had been decreased and she felt he was eating and taking fluid adequately. The RD stated she knew Patient A was scheduled to have his chemistry panel checked on 12/24/10 to assess his hydration status. The RD stated she was unaware Patient A had never had the chemistry panel completed as ordered by the physician. An interview was conducted with the Laboratory Supervisor on 3/4/11 at 10 a.m. The Supervisor stated that on 12/24/10, Christmas Eve, the laboratory was on a holiday schedule which meant the lab would not make a routine visit to the facility on that date to draw laboratory work. The Supervisor stated the facility is notified well in advance via a faxed notice of the holiday schedule. The Supervisor stated the laboratory staff would have come in and drawn Patient A's blood on the 24th if the facility had notified them by phone that there was ordered laboratory work. He stated otherwise routine blood draws would have resumed on 12/27/10, the next regular work day. The Laboratory Supervisor stated the order for Patient A's chemistry panel was placed on the requisition form on 12/29/10. The Supervisor stated, "It looks like they noticed on that date that it had been missed."The Department determined the facility failed to: 1. Identify patient care needs. 2. Develop and implement a plan of care. 3. Continually assess the patient. 4. Ensure sufficient fluids were provided to maintain hydration. 5. Ensure laboratory tests were completed as ordered by the physician. These violations had a direct or immediate relationship to the health, safety, or security of long-term care facility patients or residents. |
| 030000105 |
Whitney Oaks Care Center |
030009914 |
B |
10-Jun-13 |
118X11 |
3199 |
72523 - Patient Care Policies And Procedures (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. 72527 - Patients' Rights(a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the Patient 1nd to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (9) To be free from mental and physical abuse. An unannounced visit was made to the facility on 6/3/2010 to initiate an investigation of an Entity Reported Incident CA00199959 regarding patient (resident) to patient abuse. The investigation included direct observations, interviews and record reviews. As a result of the investigation, the Department determined the facility failed to: 1. Provide a safe environment for Patient 1, free from physical abuse. 2. Follow their policy to protect patients from physical abuse. These failures resulted in a witnessed physical abuse. On 8/26/2009, Patient 2 threw a four pound (dumbbell) weight at Patient 1 and injured his lower leg. Patient 1 sustained a small skin tear on that leg.A review of Patient 2's clinical record indicated he was a 70 year old admitted to the facility on 5/20/2008 with diagnoses of dementia, depression, anxiety, and angry outbursts. The most recent quarterly MDS (Minimum Data Set/a standard assessment tool) dated 4/28/2010 indicated Patient 2 was moderately impaired with decision making and supervision was required. Patient 2 was assessed to have verbally abusive behaviors toward others, was socially inappropriate at times, and was documented to resist care from the staff.A tour of the facility was conducted on 6/3/2010 at 4:25 P.M. at which time an observation was made of Patient 2. He was sitting in his wheelchair against the wall across from the nurse's station. Patient 2 was approached and addressed by name. He yelled back, "What do you want?"When questioned about the living situation in the facility, he said, "I don't know. Leave me alone!" An interview with Licensed Nurse (LN) 1 was conducted at 4:40 P.M. on 6/3/2010. When questioned about the measures in place to protect Patient 1 from Patient 2, she stated "we have 30 minute checks of Patient 2." When questioned about the time the 30 minute checks began from Patient 2, she stated she couldn't recall. A review of the facility policy titled, Preventing Patient 1 abuse with a revised date of 1/5/2000, indicated (in part) the following information: 1. "Preventing Patient 1 abuse is a primary concern for this facility. It is our goal to achieve and maintain an abuse free environment." The Department determined the facility failed to protect Patient 1 from possible harm when Patient 2 threw a four pound dumbbell at Patient 1 and injured his lower leg. These violations had a direct or immediate relationship to the health, safety, or security of long-term care facility patients or residents. |
| 100000039 |
Windsor Hampton Care Center |
030009917 |
B |
31-May-13 |
28ZM11 |
4858 |
72527 - Patients' Rights (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (9) To be free from mental and physical abuse. The following citation was written as a result of an unannounced visit on 2/24/11 to investigate complaint number CA00258033, an entity reported incident. The Department determined the facility failed to prevent physical abuse to Patient A on 2/1/11 resulting in bruising. Patient A was admitted to the facility on 10/25/10. His diagnoses included failure to thrive and chronic abdominal pain. His clinical record was reviewed on 2/24/11. A Minimum Data Set (MDS - an assessment tool), dated 2/1/11, described him as having no short term or long term memory deficits. He had some difficulty with decision making in new situations only. He was assessed as requiring extensive one person physical assistance with bed mobility, transfers, toilet use, and personal hygiene. He was always incontinent of urine, but was always continent of bowel. A care plan for Activities of Daily Living, dated 11/5/10, identified Patient A was to be encouraged to participate in positioning and toilet use. This care plan indicated he required assistance with transfers, grooming, toileting, and bed mobility. Nurse's Notes, dated 1/31/11 at 2 p.m., indicated Patient A was able to use the toilet with Certified Nurse Assistant (CNA) assistance. Notes, dated 2/2/11 at 11:30 a.m., indicated he was continent of bowel and bladder, "CNA assisted to toilet." Notes, dated 2/2/11 at 4 p.m. indicated "noted bruise to [left] wrist." An interview was conducted with the Director of Nursing (DON) on 2/24/11 at 9:10 a.m. She stated she had been informed on the morning of 2/2/11 that Patient A alleged he had been handled roughly by the night shift CNA 1. She stated she interviewed Patient A and he told her he had put his call light on to go to the bathroom and CNA 1 told him "later." He told her he waited and then put the light on again and CNA 1 came in again and said "later." The third time he put his call light on, he had already had a bowel movement in his bed. He told the DON that when CNA 1 came in she started to pull him out of bed and roughly pulled on his arm causing the bruise on his left wrist. The DON stated Patient A had consistently told the same sequence of events to his son and other staff when he was questioned. She stated CNA 1 was interviewed and it was determined that she had not provided appropriate care to Patient A. CNA 1 was terminated. An interview was conducted with Patient A on 2/24/11 at 9:50 a.m. He stated he had put his call light on "a couple of times" because he needed to use the bathroom. He stated CNA 1 came in and turned off the call light and said "wait till 7." He said he thought it occurred "around 2:30 a.m." He stated the third time he turned the call light on "she came in and pulled me by the arm and pulled me out of bed. He demonstrated by pulling his left wrist with his right hand in a jerking motion. He then pointed to the bruising on his left wrist. The area on his left wrist was dark purple in color and measured approximately 1 3/4 centimeters (cm) by 1 3/4 cm in size.The Notice of Employee Separation, dated 2/3/11, was reviewed. The form revealed, "Employee is accused of physical abuse. Resident is alert and oriented. Repeated same description of events to charge nurse, [Director of Staff Development] and DON. Resident [A] states that at 2:30 a.m. call light on, CNA turned off call light and told him to wait till later. Call light on at 3 a.m. and told him to wait till later. By 5 a.m. had [bowel movement] in bed. CNA came in angry and grabbed his arm and jerked him out of bed. And saying he needed to wait till the next shift (day shift). Pulling on residents arm caused a bruise." CNA 1 was terminated on 2/4/11. The facility Abuse Prevention, Investigation, and Reporting policy, dated 7/08, was reviewed. The policy directed, in part, that each resident had the right to be free from verbal, sexual, physical and mental abuse. "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 servicing the resident, family members or legal guardians, friends, or other individuals." The Department determined the facility failed to prevent physical abuse to Patient A on 2/1/11 resulting in bruising. The above violations had a direct relationship to the health, safety and security of the residents. |
| 100000048 |
Windsor Elk Grove Care and Rehabilitation Center |
030009920 |
B |
29-May-13 |
DG8C11 |
4116 |
72505 - Fire Safety The licensee shall conform to the regulations adopted by the State Fire Marshal establishing minimum standards for the prevention of fire and for the protection of life and property against fire and panic. A copy of the State Fire Marshal's current fire clearance shall be available in the facility. This citation was written as a result of an unannounced visit on 12/20/11 to investigate complaint number CA00293455. The Department determined the facility failed to initiate a fire watch during the time the alarm system was turned off on 12/13/11 and 12/14/11. This failure had the potential to delay an evacuation in case of a fire. On 12/20/11 an anonymous complainant alleged the fire alarm system was off line on 12/13/11 and 12/14/11. The complainant stated the facility did not conduct fire watch during the time the system was off. An unannounced visit was made to the facility on 12/20/11 at 11:57 a.m. The facility was observed to be undergoing the remodel of a nurse's station. Workmen were observed pulling wallpaper off a wall and texturing the sheet rock. Two standard sized (8.5 x 11 inch) pieces of paper with the words, "Pardon our dust while we fix things up," were observed posted near the area under construction. An interview was conducted with the Facility Administrator (FA) on 6/20/12 at 12:13 p.m. The FA was asked to provide documentation for all "fire watches" performed the week of 12/11/11 through 12/17/11. An interview was conducted with the Maintenance Supervisor (MS) and FA on 6/20/12 at 1:45 p.m. The MS stated the document titled, [Alarm Company] 30 Day Customer Signals Listing Report, dated 12/13/2011 to 1/12/2012, indicated the fire alarm was only off for eight minutes on 12/13/11. The FA stated a fire watch was not required because the fire alarm was off for only eight minutes.A second interview was conducted with the FA on 6/20/12 at 2:45 p.m. The FA was asked whether the fire department came to the facility on either 12/13/11 or 12/14/11. He stated the fire department came to the facility once, because the dust triggered the smoke detectors.An interview was conducted by phone with Alarm Company Staff (ACS) 1 on 6/21/12 at 11:35 a.m. ACS 1 was asked whether the facility had their fire alarm turned off on either 12/13/11 or 12/14/11. ACS 1 stated the facility had their fire alarm taken off for about four hours on 12/13/11 and for over six hours on 12/14/11. On 6/21/12 at 2:19 p.m. a phone interview was conducted with ACS 2. ACS 2 was asked to explain what Alarm Company 30 Day Customer Signals Listing Reports indicated. ACS 2 stated these reports indicated when timers were tested and alarms were triggered, but not when the fire alarms were turned off. The 12/13/11 entry on the facility's [Alarm Company] 30 Day Customer Signals Listing Report indicated the fire alarm was triggered. ACS 2 was asked whether the facility had their fire alarm turned off on either 12/13/11 or 12/14/11. ACS 2 stated the facility's alarm was triggered on 12/13/11 and shortly thereafter facility staff called to request the fire alarm be turned off for one hour. Less than an hour later, the facility staff called to extend the amount of time the fire alarm system was turned off until18:01 (6:01 p.m.), an additional 4 hours and 18 minutes. On 12/14/11, facility staff called the Alarm Company at 10:35 a.m. to request the system be turned off until 5 p.m., a total of six hours and 25 minutesAn interview was conducted with the FA on 6/22/12 at 12:24 p.m. The FA was asked to provide documentation a fire watch was conducted when the facility's fire alarm was turned off for more than 4 hours on 12/13/11, and for over 6 hours on 12/14/11. He was unable to provide the documentation requested. The Department determined the facility failed to initiate a fire watch during the time the alarm system was turned off on 12/13/11 and 12/14/11. This failure had the potential to delay an evacuation in case of a fire. These violations had a direct or immediate relationship to the health, safety, or security of long-term care facility patients or residents. |
| 030000105 |
Whitney Oaks Care Center |
030009931 |
B |
10-Jun-13 |
118X11 |
5724 |
72523 - Patient Care Policies And Procedures (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. 72527 - Patients' Rights (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the Patient 1nd to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (9) To be free from mental and physical abuse. An unannounced visit was made to the facility on 6/03/2010 to initiate an investigation of an Entity Reported Incident # CA00231143 and Complaint # CA00230516 regarding patient (resident) to patient abuse. The investigation included direct observations, interviews, and record reviews. As a result of the investigation, the Department determined the facility failed to: 1. Provide a safe environment for Patient 1 free from physical abuse. 2. Implement their policy to protect patients from physical abuse. These failures resulted in a witnessed physical abuse on 5/25/2010 by Patient 2 towards Patient 1. Patient 2 was found by CNA 1 (Certified Nurse's Assistant) with "his hands in Patient 1's underpants" as reported by the witnessing staff. A review of Patient 2's clinical record indicated he was a 70 year old admitted to the facility on 5/20/2008 with diagnoses of dementia, depression, anxiety, and angry outbursts. The most recent MDS (Minimum Data Set, a standard assessment tool) dated 4/28/2010, indicated Patient 2 was moderately impaired with decision making and supervision was required. Patient 2 was assessed to have verbally abusive behaviors towards others. He was socially inappropriate at times and was documented to resist care from the staff. Patient 2 required assistance transferring from his bed to a wheelchair, but was able to self-propel his wheelchair.Patient 1 was a 77 year old female admitted on 10/01/2009. Her diagnoses included Alzheimer's disease with dementia and diabetes. The MDS dated 4/08/2010 documented she had short and long term memory deficits and moderately impaired decision making ability. She was usually able to understand others and be understood. There were no documented mood or behavior problems.A tour of the facility was conducted on 6/3/2010 at 4:25 PM, at which time an observation was made of Patient 1 and Patient 2. Both Patients were sitting in their wheelchairs against the wall in front of the nurse's station. Patient 1 had two patients sitting between her and Patient 2. When Patient 1 was approached and addressed by name, she did not respond verbally. Patient 1 appeared to be looking at something in the hallway. There was no verbal response or visual acknowledgement from Patient 1. Patient 2 was approached and addressed by name. He yelled back, "What do you want?" When questioned about the living situation in the facility, he said, "I don't know. Leave me alone!" An interview with the Licensed Nurse (LN) 1 was conducted at 4:40 PM on 6/3/2010. She stated the patients often sit near the nurse's station in the late afternoon and sometimes all day. When questioned about the proximity of Patient 1 and B and whether it was safe, she said; "Patient 2 is now on every 30 minute checks so we know where he is and what he is doing."A review of a document titled, Interdisciplinary Progress Notes dated 9/21/2009, documented the following incident: "...patient (2) went into room and touched a female patient's (1) upper thigh...was in her bed. She was awakened by this and told him, "I will slap you if you move forward." This incident also awakened her roommate. A CNA escorted the patient (2) back to his room." The following care plans for Patient 2 indicated problem areas were identified: 1. 5/20/2008- indicated verbally abusive behavior..."history of physical abuse, verbal abuse, and inappropriate sexual comments towards female residents...Goal: Will not injure self or others." Reviewed on 5/13/2010. 2. 2/18/2009- indicated a problem area of "difficulty making decisions related to dementia..." 3. 7/21/2009- indicated a problem area of altercation in activity pursuit patterns related to: impaired thought process related to dementia... 4. 5/20/2010- indicated "inappropriate behavior towards peers, made unwelcomed sexual toward female peer- fondling." Goal: "Will have no episodes of behavior x 30 days." Approach: ..."Protect other residents by keeping close monitoring of resident." The Administrator was interviewed on 6/3/2010 at 5:45 PM. When questioned about a policy for patients on a 30 minute check, he said, "There was no policy." When questioned about when the 30 minute checks were started with Patient 2, Administrator stated they were started after 5/25/2010. When questioned about having any process in place to protect patients from Patient 2's outbursts, he said there was "nothing in place prior to 5/28/2010." A review of the facility policy titled, Preventing Resident Abuse with a revised date of 1/5/2000 indicated the following information (in part): 1. "Preventing Patient abuse is a primary concern for this facility. It is our goal to achieve and maintain an abuse free environment." The Department determined the facility failed to: 1. Provide a safe environment for Patient 1 free from physical abuse. 2. Implement their policy to protect patients from physical abuse.These violations had a direct or immediate relationship to the health, safety, or security of long-term care facility patients or residents. |
| 030001812 |
Woodland Skilled Nursing Facility |
030009944 |
B |
25-Jun-13 |
15G911 |
3542 |
72527 - Patients' Rights (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (9) To be free from mental and physical abuse. The following citation was written as a result of an unannounced visit on 7/2/10 to investigate an Entity Reported Incident, #CA00227506. The Department determined the facility failed to ensure Patient A's rights were not violated when he reported he had been verbally abused by a Certified Nursing Assistant (CNA1) on 5/3/10.Patient A was re-admitted to the facility on 7/28/08 with diagnoses of stroke with left paralysis, dysphasia (difficulty in swallowing), aphasia (difficulty in speaking) and depression. In review of a Minimum Data Set (an assessment tool) dated 5/28/10, Patient A was noted to have cognitive skills for independent decision making. Patient A was assessed as having the ability to understand others and make himself understood. In an interview with the Administrator (ADM) on 7/2/10, he stated he had conducted the investigation of the allegation of abuse by Patient A and had confirmed CNA1 spoke rudely to Patient A on 5/3/10. The ADM stated CNA1 had subsequently been terminated. Patient A was interviewed in his wheelchair in the vacant dining area on 7/2/10 at 1:30 p.m. Patient A was observed to have difficulty speaking but understood the questions asked and responded with head nodding and grunting. Patient A confirmed CNA1 had spoken rudely to him on 5/3/10. He further revealed CNA1 cared for him roughly and had spoken to him rudely in the past. Patient A stated CNA1 "hurt his feelings". In an interview with Patient B on 7/2/10 at 2 p.m., she revealed she had witnessed CNA1 speaking rudely to Patient A. Patient B stated CNA1 had also "spoken rudely" and treated her "roughly" in the past.In a review of an Interdisciplinary Progress Note dated 5/4/10, there was documentation Patient A had requested that CNA1 not care for him because she was "verbally abusive". In review of a Short Term Care Plan (STCP) dated 5/6/10, there was documentation Patient A had expressed concerns regarding the care of a "specific" CNA and Patient A was to be provided maximum opportunities to express his rights. The STCP revealed, "staff counseled & immediate action taken." In review of a Social Service Progress Note dated 5/6/10, the Social Services Director (SSD) documented a follow up with Patient A after "the report of dissatisfaction of the services from the direct care staff. The SSD revealed she informed Patient A of the termination of CNA1. In a Social Services Annual Review on 5/18/10 the SSD documented Patient A had "related his disapproval of the way a staff member has handled him." In a review of the employee file of CNA1, there was documentation of prior counseling received by CNA1 on 3/4/10 for "yelling at residents while doing care" and "arguing with residents in loud tone of voice."The Department determined the facility failed to ensure Patient A was not subjected to verbal or physical abuse due to intimidation, humiliation and rough handling by CNA1. These violations had a direct or immediate relationship to the health, safety, or security of long-term care facility patients or residents. |
| 100000039 |
Windsor Hampton Care Center |
030010007 |
B |
25-Jul-13 |
R4K511 |
13113 |
F314 Treatment/svcs to Prevent/heal Pressure Sores 483.25(c) Based on the comprehensive assessment of a resident, the facility must ensure that a resident who enters the facility without pressure sores does not develop pressure sores unless the individual's clinical condition demonstrates that they were unavoidable; and a resident having pressure sores receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing. The following citation was written as a result of an unannounced visit to the facility on 8/2/10 for the investigation of complaint number CA00236654. The Department determined the facility failed to ensure: 1. Resident A received necessary care and treatment to promote the healing of an existing pressure sore. 2. Resident A did not develop additional pressure sores. These failures resulted in Resident A developing pressure sores on his left and right heels that were described by physician's at the general acute care hospital (GACH) as unstageable and gangrenous and a Stage III pressure sore (full thickness skin loss which presents clinically as a deep crater with or without undermining of adjacent tissue) on his buttocks. "Pressure ulcers are areas of necrosis (dead tissue) and ulceration where tissues are compressed between bony prominences and hard surfaces; they result from pressure alone or pressure in combination with friction, shearing forces, or both. Risk factors include old age, impaired circulation, immobilization, undernutrition, and incontinence. Severity ranges from nonblanchable skin erythema (redness) to full-thickness skin loss with extensive soft-tissue necrosis. Diagnosis is clinical. Prognosis is excellent for early-stage ulcers; neglected and late-stage ulcers pose risk of serious infection and nutritional stress and are difficult to heal. Treatment includes pressure reduction, avoidance of friction and shearing forces, local care, and sometimes skin grafts." Reference: Merck Manual, November 2012.Resident A was a 64 year old admitted to the facility on 3/22/10. His diagnoses included spinal surgery for spinal cord compression, chronic kidney disease requiring kidney dialysis three times a week, bacteremia (blood infection), and diabetes.A Minimum Data Set (MDS - an assessment tool), dated 4/1/10, indicated Resident A had short term memory impairment. He had some cognitive difficulty in new situations. Resident A required extensive staff assistance to change position in bed. Resident A had one Stage I pressure sore (a defined area of persistent redness of the skin which does not disappear when the pressure is relieved). The MDS indicated pressure relieving devices were not used in Resident A's chair or bed. A turning/repositioning program had not been implemented. An Admission Nursing Assessment, dated 3/22/10, indicated Resident A had a left heel pressure area. The skin was intact and described as dark brown skin measuring 3 centimeters (cm) x 3 cm. A Pressure Ulcer Risk Assessment, dated 3/22/10, indicated Resident A scored a 10 on the pressure sore risk assessment. Information on the form indicated a total score of 8 or above represented a high risk to develop pressure sores. A Physician's Order, dated 3/22/10, indicated staff were to monitor Resident A's left heel pressure sore daily and notify the physician of changes for 14 days and then re-evaluate. A "Stage I Pressure Area Resident Care Plan," dated 3/23/10, indicated Resident A was admitted with a pressure sore on his left heel. Documentation on the care plan indicated Resident A's risk factors included alterations in sensation and mobility, bowel incontinence, and risk for further deterioration. The care plan goal indicated Resident A "would show signs of healing and will prevent further deterioration of skin integrity." Multiple approaches were listed on the care plan and nursing staff were to place check marks next to the approaches that were to be implemented in order to obtain Resident A's goal of ulcer healing and prevention of further skin breakdown. No approaches on Resident A's pressure area care plan were checked as being implemented. An interview was conducted with the Director of Nurses (DON) on 1/5/11 at 11:10 a.m. The DON reviewed Resident A's "Stage I Pressure Area Resident Care Plan" and acknowledged no interventions or approaches had been checked on the care plan directing the care Resident A was to receive to promote healing of his left heel pressure sore and prevention of any further skin problems. A "Skin Integrity Care Plan: Prevention," dated 3/24/10, indicated Resident A had a potential for impaired skin integrity related to spinal cord injury. Interventions included a pressure reducing sleep surface to the bed. An interview was conducted with the DON on 1/5/11 at 11:15 a.m. The DON stated a pressure reducing sleep surface would be an air mattress; however, Resident A did not have an air mattress on his bed at the time the care plan was developed. Nurse's Notes, dated 4/12/10 at 4 p.m., indicated Resident A was having loose stools on the "AM shift" and a Stage I pressure sore was noted on his coccyx. Resident A's Physician was notified via a fax. On 4/13/10 a treatment order was received to cleanse his coccyx with normal saline and apply Duoderm every 72 hours (a gel substance that absorbs liquid and is an occlusive dressing).A Wound/Skin Healing Record, dated 4/12/10, indicated Resident A had a Stage II (partial thickness loss of skin presenting as a shallow open ulcer with red/pink wound bed) 4 cm x 2 cm pressure sore on the coccyx, described as pink in color without odor or drainage. This description differed from the Stage documented in the Nurse's Note on 4/12/10. Nurse's Notes, dated 4/13/10 at 8 a.m., indicated, "While checking pressure sore coccyx noted [decubitus] sores (same as pressure sores) to [right] & [left] lateral (outside) heels." A Wound/Skin Healing Record, dated 4/13/10, indicated Resident A had developed a pressure sore on the lateral area (outside) of his left heel. The sore was described as 4 cm x 4 cm deep tissue injury (deeper, full-thickness damage to underlying tissue which may appear as purple areas or dark necrotic tissue) that was dark purple in color. A Wound/Skin Healing Record, dated 4/13/10, indicated Resident A had developed a pressure sore on his right lateral heel. The sore was described as 4 cm x 3 cm deep tissue injury that was dark purple in color. A Fax Request For Physician's Orders form, dated 4/13/10, informed Resident A's Physician that the Resident had a pressure sore on his right lateral heel and his left lateral heel. Orders were received to apply skin prep daily for 14 days then re-evaluate and apply heel protectors while in bed. "Check every shift for placement." Documentation on Resident A's April 2010 Treatment Records indicated the application of Resident A's heel protectors was to be documented as done by the nurse initialing the treatment record. On the "Noc" (night) shift the heel protectors were documented as being in place on 13 of 18 opportunities. Documentation for the "PM" (evening) shift indicated Resident A's heel protectors were in place on 0 of 19 opportunities. Resident A's Wound/Skin Healing Records for his right and left lateral heel sores indicated: On 4/14/10, the left lateral heel was initially found unstagable, 4 cm x 4 cm with deep tissue injury and undeterminable depth. The right lateral heel was described as Stage II (partial thickness loss of skin presenting as a shallow open ulcer with red/pink wound bed) 4 cm x 3 cm with deep tissue injury and undeterminable depth. On 4/19/10, Resident A's left lateral heel description changed to a Stage II with deep tissue injury. The right lateral heel was described as Stage II with deep tissue injury. On 4/23/10, Resident A's Physician ordered an air mattress applied to Resident A's bed for pressure reduction. On 4/26/10, the wound healing record indicated both Resident A's left and right lateral heels had turned from purple to brown with inflammation of the surrounding tissue. On 5/3/10, Resident A's left lateral heel was described as 5 cm x 5 cm Stage IV (full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle and bone a) with undetermined depth. Wound bed was black with brown swollen tissue surrounding. Resident A's right heel was 4 cm x 3 cm Stage II with undeterminable depth and deep tissue injury. Wound bed was black with brown swollen tissue surrounding. According to the documentation neither pressure sore had drainage or odor. An interview was conducted with the DON on 11/5/11 at 11:45 a.m. regarding the descriptions and staging of Resident A's left and right lateral heel sores. The DON stated when an area is found with deep tissue injury and undeterminable depth then the sore cannot be staged because it is impossible to tell how deep the tissue is injured below the skin surface. The DON stated Resident A's right and left heel pressure sores had not been assessed and staged properly. A Non-Pressure Skin Condition Report, dated 4/19/10, indicated the pressure sore first identified on 4/12/10 on Resident A's coccyx had been "reclassified" as a non-pressure sore related to incontinence from a C-difficile infection. (Clostridium difficile is a Gram-positive bacterium that causes diarrhea and other intestinal disease.) Documentation on the Non-Pressure Skin Condition Report, dated 4/19/10, indicated Resident A had also developed diffuse excoriations on his right and left buttock. The areas were described as a diffuse excoriation with no depth, odor, or drainage, red in color with normal surrounding skin. Resident A's Non-Pressure Skin Condition Report indicated Resident A's coccyx and buttocks were described as follows: On 4/25/10, the areas were described as an excoriation, diffuse in size with no depth, drainage, odor, or slough (dead tissue separating from live tissue), bright red, with swelling of surrounding skin. On 5/2/10, the areas were described as an excoriation, diffuse in size with no depth, odor or drainage. Slough noted, areas bright red with swelling of surrounding skin. Nurse's Notes, dated 5/3/10 at 12 p.m., indicated Resident A's "Stage II pressure ulcer on [left] lateral heel had increased in size with opening of ulcer. Moist eschar (hard, dead tissue) to 3/4 of ulcer with no foul odor or drainage noted." A fax was sent to the physician requesting a podiatry consult. New treatment orders were received to apply Santyl (medication that aids in removing dead tissue) to the pressure sore. Nurse's Notes, dated 5/5/10 at 3:30 p.m., indicated Resident A was sent to the GACH for treatment related to ongoing diarrhea related to C-difficile.A History and Physical, dated 5/5/10 and completed at the GACH, indicated Resident A had bilateral necrotic heel ulcers "most likely related to pressure."A "Primary" intake assessment, dated 5/5/10 and completed at the GACH, indicated Resident A had pressure sores on his right and left heels that were "gangrene" (infected tissue). The buttock wound was described as Stage III (full thickness tissue loss involving damage to, or necrosis of, subcutaneous tissue). A Progress Record, dated 5/6/10, indicated Resident A had been assessed by a Wound Nurse at the GACH. The nurse documented Resident A had a wound on his coccyx and buttocks that was unstageable. A large percentage of the wound bed was covered with yellow slough. He also had a peri wound (groin area, previously unidentified) which was pink with red edges and had an odor and a moderate amount of yellow drainage. Resident A's left lateral heel was described as 4 cm x 5 cm unstageable ulcer with necrosis and grey slough, odor, and a moderate amount of yellow drainage. A right medial heel wound (inside heel, previously unidentified) was described as 5 cm x 5 cm unstageable and covered with eschar with odor and a small amount of yellow drainage. Resident A's right lateral heel was described as 4 cm x 6 cm unstagable wound with 40% eschar in the wound bed. The remaining wound bed was red, with sloughing skin and scant yellow drainage. Resident A remained at the GACH for five days for treatment for C-difficile and multiple pressure sores. Resident A was readmitted to the facility on 5/10/10. On 5/17/10, he was evaluated by the Podiatrist who documented the Resident A had infected heel decubitus ulcers and recommended evaluation at the emergency room. Consultation Notes, dated 5/21/10 and completed at the GACH, revealed Resident A's right and left heels had full thickness tissue loss over the entire heel area with poor vascularity (blood supply). On 5/22/10, Resident A had bilateral leg amputations. The Department determined the facility failed to ensure: 1. Resident A received necessary care and treatment to promote the healing of an existing pressure sore. 2. Resident A did not develop additional pressure sores. These violations had a direct or immediate relationship to the health, safety, or security of long-term care facility patients or residents. |
| 100000039 |
Windsor Hampton Care Center |
030010024 |
B |
01-Aug-13 |
1JZM11 |
11445 |
F201- Reason for Transfer/discharge483.12(a)(2) 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. F203-Notice Requirements Before Transfer/discharge483.12 (a)(4)-(6) Before a facility transfers or discharges a resident, the facility must notify the resident and, if known, a family member or legal representative of the resident of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand; record the reasons in the resident's clinical record; and include in the notice the items described in paragraph (a)(6) of this section. Except when specified in paragraph (a)(5)(ii) of this section, the notice of transfer or discharge required under paragraph (a)(4) of this section must be made by the facility at least 30 days before the resident is transferred or discharged. Notice may be made as soon as practicable before transfer or discharge when the health of individuals in the facility would be endangered under (a)(2)(iv) of this section; the resident's health improves sufficiently to allow a more immediate transfer or discharge, under paragraph (a)(2)(i) of this section; an immediate transfer or discharge is required by the resident's urgent medical needs, under paragraph (a)(2)(ii) of this section; or a resident has not resided in the facility for 30 days. The written notice specified in paragraph (a)(4) of this section must include the reason for transfer or discharge; the effective date of transfer or discharge; the location to which the resident is transferred or discharged; a statement that the resident has the right to appeal the action to the State; the name, address and telephone number of the State long term care ombudsman; for nursing facility residents with developmental disabilities, the mailing address and telephone number of the agency responsible for the protection and advocacy of developmentally disabled individuals established under Part C of the Developmental Disabilities Assistance and Bill of Rights Act; and for nursing facility residents who are mentally ill, the mailing address and telephone number of the agency responsible for the protection and advocacy of mentally ill individuals established under the Protection and Advocacy for Mentally Ill Individuals Act. The following citation was written as a result of unannounced visits to the facility initiated on 1/12/12 for the investigation of complaint #CA00295772. The Department determined the facility failed to: 1. Ensure residents were not transferred out of the facility for reasons other than those regulated by law. 2. Provide a notice before transfer to residents whom the facility determined should be transferred due to non-compliance with the implementation of a stringent smoking policy.These failures resulted in violation of resident rights when residents were transferred without their consent and were not afforded the opportunity to appeal their transfers. An interview was conducted with the County Ombudsman (patient advocacy agency) on 1/12/12 at 11 a.m. The Ombudsman stated their office had been trying to assist the residents in the facility that smoked with the newly implemented smoking policy. The Ombudsman stated the facility went from allowing capable smokers to keep their own cigarettes and lighters and smoking when they desired to a very stringent and controlled smoking policy "overnight." The Ombudsman stated three residents had already been discharged for breaking the rules and the facility was just "trying to push the smokers out." The Ombudsman stated the facility's Administrator drove two of the residents who were discharged to Sacramento in his own car. An interview was conducted with the facility Administrator on 1/12/12 at 11:15 a.m. The Administrator stated he became the Administrator in November 2011. He stated when he came to the facility he noticed that the smoking population was not typical of "nursing home smokers." The Administrator stated the resident's had their own cigarettes and lighters and smoked whenever they wanted. The Administrator stated he pulled the facility's Smoking Policy, dated 7/20/08, spoke with the corporate office, and then implemented the policy. The Administrator stated he met with the smokers and told them if they broke the rules, discharge could be initiated. The Administrator stated three residents had already discharged "voluntarily." An interview was conducted with 14 residents on 1/12/12 at 1 p.m. during a designated smoking break on the smoking patio. Per the residents, they stated as a group, "They live in fear of breaking the rules because they are afraid they will be sent out if they don't abide." An interview was conducted with the Social Service Director (SSD) on 1/17/12 at 1:25 p.m. The SSD stated she was instructed by the Administrator that residents who were not compliant with the smoking policy would have to find a facility to move to with a less stringent smoking policy. The SSD stated some of the residents had asked for another opportunity to not break the rules; however, she was instructed to find alternate placement for residents who were not compliant.Resident A was a 40 year old admitted to the facility on 4/6/11 with diagnoses including breast cancer that had spread to her bones. Resident A was receiving hospice services. A hospice Progress Notes, dated 12/23/11 and completed by the hospice Registered Nurse (RN), indicated the RN had a discussion with the hospice social worker regarding the "SNF Administrator's decision to transfer [patient] to another facility." The note indicated an article was written by the facility's smokers and published in a local paper, complaining about the facility's new smoking schedule. Documentation by the RN indicated the hospice social worker was trying to hold off on discussing the "Administrators plan to transfer [Resident A] to another facility" as she was "trying not to ruin [Resident A's] holiday. A hospice Progress Notes, dated 1/6/12 and completed by the hospice RN, indicated she had discussed with the facility's SSD "about their Administrators determination to have [Resident A] transferred to another facility - that 5 residents have already been transferred." The note indicated the RN would inform the hospice social worker about their conversation and then discuss it with Resident A. A hospice Progress Notes, dated 1/6/12 and completed by the social worker, indicated a team meeting was held at the facility to discuss Resident A's possible discharge. The Note indicated Resident A did not attend the meeting because she was sleeping. Documentation indicated the "majority of the visit centered around [Resident A's] status at facility and the willingness to move. During the visit, it was expressed that management was requesting that [Resident A] be moved." Social Service Progress Notes, dated 1/10/12 and completed by a Social Service Assistant (SSA), indicated [Resident A] had "decided" to move to another facility as she did not feel comfortable with the smoking policies that were implemented. The note indicated Resident A had toured the new facility the previous day and hospice would continue to follow her at the new facility. A Notice of Transfer or Discharge, dated 1/10/12, indicated Resident A was being transferred because she "chose another facility [with] less restrictive smoking rules." The notice included information regarding how to appeal the discharge decision; however, staff did not include the address or telephone number of the State Long Term Care Appeal Agency. The notice was given to Resident A on the day she discharged. An interview was conducted with Resident A on 2/27/12 at 11:30 a.m. She was lying in her bed at her new facility. She stated she left her previous facility because she was "tired of feeling stressed out about being thrown out." Resident A stated staff would search her room everyday looking for cigarette contraband. Resident A stated she missed all of her friends at her previous facility, but she didn't know what else to do. Resident B was a 49 year old admitted to the facility on 9/30/09 with diagnoses including liver cirrhosis, hepatitis C (liver disease), and anxiety disorder. Resident B was also receiving hospice services. A Social Service Progress Notes, dated 12/15/11, indicated the SSA was approached by Resident B and was upset over the facility's newly implemented smoking policy. Documentation in the Note indicated Resident B was reminded, "We all have to follow the policies. Some of them we like and some we don't like." The SSA documented she told Resident B, "You know we don't like changes." A Social Service Note, dated 12/16/11, indicated that Resident B had been caught smoking outside and said she wasn't sure if she could follow the facility's new smoking policy. The note indicated Resident B asked if she should move to a different facility.A Social Service Note, dated 12/28/11, documented "appropriate placement" had been found for Resident B. The note included, "The only hard part is it's in the [Sacramento] area. A Hospice Aide Progress Report, dated 1/3/12, included the following. [Resident B] "Upset she got a 30 day notice today telling her she needs to move to a facility in Sacramento." Nurse's Notes, dated 1/4/12 at 1:20 p.m., indicated Resident B was transferred to a nursing facility in Sacramento. An interview was conducted with Resident B on 2/15/12 at 9:20 a.m. Resident B stated she got caught smoking during non-smoking hours and she got caught smoking outside on the sidewalk. Resident B stated the Administrator told her he wanted her to go. She stated her hospice provider found her current facility in Sacramento because the hospice contracted with the facility. Resident B stated she was not given a choice in moving or a 30 day notice. Resident B stated she missed her friends at her previous facility and it is difficult now for her family to visit her because she is far away in Sacramento. Resident B stated she hasn't appealed the transfer because she's just been "too sick to deal with it."The Department determined the facility failed to: 1. Ensure Residents were not transferred out of the facility for reasons other than those regulated by law. 2. Provide a notice before transfer to residents whom the facility determined should be transferred due to non-compliance with the implementation of a stringent smoking policy. These violations caused or are under circumstances likely to cause significant humiliation, indignity, anxiety or other emotional trauma to patients or residents of a long term health care facility. |
| 100000814 |
Wagner Heights Nursing and Rehabilitation Center |
030010094 |
A |
20-Aug-13 |
DSML11 |
10841 |
F327 - Sufficient Fluid To Maintain Hydration 483.25(j) The facility must provide each resident with sufficient fluid intake to maintain proper hydration and health. The following citation was written as a result of an unannounced visit on 9/13/10 for the investigation of complaint number CA00241974. The Department determined the facility failed to ensure sufficient fluids were provided to Resident A to maintain hydration. This failure resulted in Resident A developing an altered mental status which required transfer to the General Acute Care Hospital (GACH). Resident A was admitted to the GACH with profound dehydration and acute renal (kidney) failure (dehydration can cause renal failure). Resident A was an 81 year old admitted to the facility on 3/23/10 with diagnoses including transient ischemia attacks (mini strokes) with left sided weakness and history of a heart attack. A Minimum Data Set (MDS - standardized assessment tool), dated 3/23/10, indicated Resident A had moderately impaired cognition. She was dependent on staff for eating and drinking. Resident A would leave 25% or more of her food uneaten at most meals. A care plan entry, dated 3/23/10, revealed Resident A was at high risk for dehydration related to her impaired cognition. The care plan interventions included fluids at bedside, remind and assist to consume fluids, monitor intake, report poor meal and or fluid consumption, and observe for signs and symptoms of dehydration which included lethargy (fatigue), thirst, dry mucus membranes, dry and cracked lips and poor skin turgor (when the skin is pinched it remains in a tented position). A Nursing Admission Assessment, dated 3/23/10, indicated Resident A's skin turgor was "good." She needed assistance to eat and her fluid intake was "fair." Resident A weighed 150.6 pounds when she was admitted.The Admission History and Physical from the GACH, dated 3/17/10, identified Resident A's baseline laboratory values for kidney function were: BUN (Blood Urea Nitrogen) 29 (normal 8 - 22) and Creatinine 0.99 (normal 0.35 - 1.18). Resident A's Intake and Output Record, dated 3/23/10 through 3/28/10, indicated she averaged 1028 cubic centimeters (ccs) of fluid every 24 hours and there were no signs or symptoms of dehydration. The section of the form for the residents' estimated fluid needs and minimum fluid requirements was not completed. On 3/29/10 Resident A was evaluated by the Speech Therapist (ST). The ST documented Resident A was alert with poor intake and she required feeding assistance. Nurse Assistant Care Records, dated 3/23/10 through 3/31/10, recorded Resident A's food consumption as follows: Breakfast: Refused on 7 of 8 opportunities and 15% on 3/29/10. Lunch: Refused on 3 of 8 opportunities and averaged 28% on 5 of 8 opportunities. Dinner: Averaged 40.5% on 9 of 9 opportunities. Nurse Assistant Care Records, dated 4/1/10 through 4/10/10, indicted Resident A's food consumption as follows: Breakfast: Refused 8 of 11 opportunities and averaged 28.3% on 3 of 11 opportunities. Lunch: Refused 3 of 11 opportunities and averaged 26.4% on 7 of 11 opportunities. Dinner: Refused 1 of 10 opportunities and averaged 31.6% on 9 of 10 opportunities. Laboratory Studies, completed on 4/2/10, indicated Resident A's BUN was 19 (normal 8 - 22) and Creatinine was 0.94 (normal 0.35 - 1.18). Resident A's Intake and Output Records, dated 3/29/10 through 4/4/10, indicated she averaged 897 ccs of fluid every 24 hours. The estimated fluid needs section of the form indicated Resident A's minimum fluid requirements were 1600 ccs per 24 hours.A Notice of Reduced Fluid Intake form was faxed to Resident A's physician on 4/4/10. Documentation indicated Resident A's intake was poor and she showed no signs of dehydration. The physician signed that he had reviewed the information on 4/21/10, 10 days after Resident A was discharged to the GACH with dehydration. An interview was conducted with Licensed Nurse (LN) 1 on 9/13/10 at 1 p.m. LN 1 stated she faxed the information on the Reduced Fluid Intake form to Resident A's physician on 4/4/10. LN 1 acknowledged the physician did not respond to the faxed information until 10 days after Resident A was discharged and the facility did not follow up to ensure he was aware of Resident A's decreased fluid intake.On 4/6/10, the ST documented Resident A was not opening her mouth to accept food or drink. On 4/7/10, the ST documented Resident A was non-responsive to verbal or tactile (touch) stimulation and she would not accept food or drink during the morning meal. On 4/6/10 the Registered Dietician (RD) documented Resident A had a significant weight loss of 7 pounds and she consumed less than 1000 ccs of fluid per day. Her food intake was less than 50% at each meal. The estimated caloric, protein, and fluid needs section of the form was blank. The RD documented Resident A was at high nutritional risk as evidenced by weight loss, difficulty swallowing, and dementia. The RD recommended puddings, Jell-O, ice cream, and 4 ounces of health shake three times a day.An interview was conducted with the RD on 9/13/10 at 12:40 p.m. She acknowledged she had not calculated Resident A's fluid requirements. She stated whatever Resident A's fluid requirements were she wasn't meeting them.A Physician's Order, dated 4/8/10, indicated Resident A was to receive a Health Shake three times a day with the medication pass. Resident A's Fluid Intake and Output Record, dated 4/5/10 through 4/11/10, indicated Resident A averaged 554 ccs of fluid intake daily. Resident A's clinical record indicated her minimum fluid requirement was 1600 ccs per day. There was no documented evidence Resident A's physician was notified of her reduced fluid intake. Nurse's Notes, dated 4/10/10 at 11 p.m., documented Resident A was "weak looking" and fluid intake was encouraged. "Unable to consume health shake 2 boxes" and "refused to eat and drink." "Unable to take medications also..."A Change of Condition - Unplanned Weight Loss notification, dated 4/5/10, was sent to the physician. The notification indicated Resident A weighed 143.5 pounds. A notification, dated 4/11/10, indicated Resident A weighed 137.7 pounds, a loss of 13 pounds between admission on 3/23/10 and transfer to the GACH on 4/11/13. There was no documented evidence the physician received or responded to the notifications. Nurse's Notes, dated 4/11/10 at 6 a.m., documented Resident A slept through the night and was "Awake/alert [at] times, though unable to answer verbally."There was no further documentation regarding Resident A's condition until approximately 11 hours later on 4/11/10 at 4:45 p.m. which indicated Resident A was refusing to eat and would not open her mouth. She was "lethargic." Resident A's family member was notified and she was asked if the facility could send Resident A to the hospital. Resident A was discharged to the emergency room for evaluation on 4/11/10 at 5 p.m. A History and Physical (H&P) was completed by the hospitalist at the GACH on 4/11/10. The hospitalist documented that three weeks previously Resident A had been discharged from the GACH "in good shape, communicative, and with normal laboratories. She comes back now 3 weeks later with profoundly altered mental status." Information in the H&P indicated upon examination Resident A's mouth and throat were extremely dry. Her diagnoses included profound dehydration with hypernatremia (elevated blood sodium level), acute renal failure, urinary tract infection, and acute heart attack. A Consultation Report was completed by Resident A's admitting physician on 4/11/10. He indicated since Resident A was not eating and not taking her medications, it "may explain her blood pressure being out of control and her severe dehydration." He further indicated, "There is absolutely no turgor in the upper or lower extremities, chest wall..." He also indicated she had been "eating almost nothing for 3 weeks...interval severe deterioration in her electrolytes (sodium and calcium)... BUN is well over 100, her creatinine is less than 3, suggesting a severe prerenal (acute renal failure)...The acute findings are of hypertension (high blood pressure), severe dehydration, a prerenal state, hypercalcemia (increased calcium) and hypernatremia (increased sodium)..."Resident A's laboratory values when she arrived at the GACH on 4/11/10 were: Sodium level 160 (normal 136-143) Blood Urea Nitrogen (BUN) 111 (normal 8-22) Creatinine 2.12 (normal 0.35-1.18) Calcium 13.9 (normal 8.4 - 10.5) Common causes of elevated sodium (hypernatremia) include: Inadequate intake of water, typically in the elderly...who are unable to take in water... This is the most common cause of hypernatremia. Reference: Answers.com. A greatly elevated BUN (60) generally indicates a moderate to severe degree of renal failure. Impaired renal excretion of urea may be due to temporary conditions such as dehydration... Reference: LabTest On Line. The facility's Hydration Policy and Procedure, dated 9/08, included, in part: Policy: Residents at risk for dehydration will be identified, assessed, and provided with sufficient fluid intake to maintain proper hydration and health to the extent medically possible. Risk factors for dehydration will be identified through continual nursing assessment to assure that each resident receives sufficient amounts of fluids based on individual need to prevent dehydration and maintain health. Procedure: 1. Calculations of fluid needs are generally based on the following estimates: Residents without renal or cardiac distress 30 milliliters (ml)/kilogram (kg) body weight (2.2 pounds = 1 kilogram). (On admission Resident A weighed 150 pounds or 68 kilograms. With the above formula, Resident A's estimated fluid needs would have been 2040 mls per 24 hours. 1 ml = 1 cc) 2. Residents are assessed for hydration status by the Licensed Nurse using common clinical indicators of proper hydration. Rick factors included, dementia and refusal of fluids. b. Clinical signs of possible insufficient fluid intake are assessed through continual nursing assessment and (RAP) protocol for dehydration. Dry skin and mucous membranes and significant weight loss. 3. Residents with poor hydration status or at risk for dehydration will be identified and dietary notified. Resident A remained hospitalized at the GACH from 4/11/10 through 4/18/10. The Department determined the facility failed to ensure sufficient fluids were provided to Resident A to maintain hydration. These violations presented either (1) imminent danger that death or serious harm to the patients or residents of the long-term health care facility would result therefrom, or (2) substantial probability that death or serious physical harm to patients or residents of the long-term health care facility would result therefrom. |
| 030000046 |
Windsor El Camino Care Center |
030010193 |
B |
11-Oct-13 |
0GMP11 |
8926 |
72315 - Nursing Service - Patient Care (b) Each patient shall be treated as individual with dignity and respect and shall not be subjected to verbal or physical abuse of any kind. 72523 - Patient Care Policies and Procedures (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. On 8/9/11 at 10:00 a.m., an unannounced visit was made to the facility to investigate two Entity Reported Incidents (CA00228027 and CA00228037) regarding incidences of alleged sexual abuse by a Certified Nurse Assistant (CNA 1).The Department determined that the skilled nursing facility (SNF) staff failed to: 1. Follow its "Abuse Prevention, Investigation and Reporting" policy and procedure (P&P, last revised 7/08) by (1) not immediately notifying the Administrator and Director of Nurses that there were two separate possible incidents of sexual inappropriateness by a facility staff member when the facility became aware of it on 5/3/10, (2) the on-duty charge nurse (CN 1) did not complete a physical assessment or document the suspected incidents in either patient's medical record after being made aware of the allegations and (3) the suspected abuse was not brought to the facility's attention until later on the next day (5/4/10) which allowed the suspected perpetrator (CNA 1) to work half the day providing care to facility patients. 2. Prevent three patients (Patients A, B, & C) from being abused by CNA 1.These failures resulted in three patients being abused by Certified Nursing Assistant (CNA) 1.On 8/9/11 at 10:10 a.m., the SNF's Director of Social Service (DSS) and the Assistant Director of Social Services (ADSS) were interviewed about two separate incidents of alleged sexual assault. Two female patients (Patients A & B) stated that one of the male certified nursing assistants (CNA 1) was sexually inappropriate with them during care. A review of the two facility reports (SOC 341) submitted by the SNF to the Department showed that on 5/4/10 at 1:50 p.m., the facility was aware that CNA 1 was allegedly inappropriate with Patient A and Patient B on different occasions. Both the DSS and ADSS could not recall how the incidents were discovered but that both patients resided on hallway one. The ADSS stated that CNA 1 was normally assigned to hallway five but was assigned to hallway one when there was a need. The ADSS stated that because of that, she and the Director of Staff Development (DSD) interviewed all the patients on hallways 1 and 5 regarding any inappropriate interactions between them and CNA 1. The ADSS stated that was how they discovered a third patient on hallway 5 (Patient C) who complained that CNA 1 had been too "touchy-feely" with her during care and she requested that CNA 1 no longer be assigned to her. The DSS and ASSD were asked if Patient C's allegations had ever been investigated prior to this and they both stated, "No."A review of a 5/4/10 facility interview with Patient A indicated that when CNA 1 was cleaning her vaginal area (date unknown) his tongue was hanging out and he was getting aroused. She stated that she asked him to stop twice before he stopped.A review of the written investigations dated 5/10/10, showed that CNA 2 was taking care of Patient A on 5/3/10 and that Patient A had told her about the male CNA (CNA 1) touching her inappropriately (wiping so hard inside her vagina) during her care and that Patient B also had concerns about inappropriate touching by CNA 1. CNA 2 spoke with Patient B and confirmed that Patient B had concerns with CNA 1 being inappropriate to her during care (kissed her periarea). On 5/3/10, CNA 2 notified the on-duty charge nurse (CN 1) about both patients' allegations. There was no documentation that CN 1 assessed either patient, investigated the concerns or immediately reported the alleged assaults to facility administration as specified per their P&P. On 5/4/10 CNA 2 (time unknown) reported the allegations to the DSD and Patient A also told the DSS (unknown time). On 5/4/10, Patient A also told the housekeeping supervisor at approximately 1:45 or 2 p.m. and it was at this time the facility began to investigate the allegations.On 8/9/11 at 11:10 a.m., the SNF's Staffing Coordinator (SC) and human resource personnel member (HR) were interviewed to find out when CNA 1 last worked and when he was suspended. The SC stated that CNA 1 had worked on 5/4/10 (the day after the allegations were known) and was scheduled to accompany another in-house patient to a doctor's appointment. A review of the printout of CNA 1's timecard with the HR staff member showed that he worked approximately 5 hours on 5/4/10 and then was suspended until 5/24/10. At Corporate Office's direction, CNA 1 returned to work on 5/24/10, but was relocated to a non-direct patient care position as a worker in the laundry.On 8/9/11 at 11:30 a.m., the SNF's administrator (AD) was interviewed. The AD was asked how he found out about the allegations and he stated that the housekeeper heard Patient A and B discussing it and reported the allegations. The AD was asked if he had been contacted on 5/3/11, when the allegation was discovered and he stated, "No." The AD was asked if he knew about Patient C's allegations and he stated not until the Department's investigation was started.A documented interview (dated 5/3/10) between the AD, two other staff members and CNA 1 was reviewed. The document indicated that the interviewers asked CNA 1 if he was aware of Patient C's allegations and he stated that CN 2 had told him that he could no longer take care of Patient C. CNA 1 stated that he did not know why Patient C no longer wanted him as her caregiver. The AD was asked if this allegation by Patient C had been investigated and he stated that he knew nothing of the allegation until the Department's investigation was initiated. The AD was asked if all of the staff were mandated reporters and he stated, "Yes." The AD was asked if he expected these allegations to be reported as possible abuse and he stated, "Yes."On 8/9/11 at 11:50 a.m., Patient B was interviewed about the allegations. Patient B stated that one day CNA 1 had performed an inappropriate sexual act while performing pericare (washing of the genital and rectal areas). Patient B described that after the CNA was done with pericare and had placed an adult diaper on her; he bent down and kissed her over her pubic area. Patient B stated that after the act, she asked him, "Hey, what are you doing?" and he told her he was, "trying to make her feel better." Patient B asked him to leave and not come back. In a document titled, "Interviews RE (CNA 1)" the facility documented a 5/4/10 interview with Patient B. In this interview Patient B told the same story to the facility interviewers. Patient B also stated to the facility interviewers that the on-duty charge nurse (CN 2) came into her room and said, "If you report this, he could be fired." Patient B stated that she was alert and what was he doing to the non-alert people? Later CNA 1 came into her room, crying and said if she told on him, he would be fired. Patient B stated that she told him he had two options, either he reported himself or she would have to report him.On 8/9/11 at 12:20 p.m., Patient C was interviewed in her room. Patient C remembered that she had reported the CNA to on-duty charge nurse but could not remember when or who she reported him to. Patient C stated that she told the charge nurse that she no longer wanted him to take care of her. Patient C described the CNA's care as too "touchy-feely" and she was able to hold his hands back several times when he was inappropriate. Patient C stated that when they interviewed her after the Patient A and B episode, she stated that she warned them that CNA 1 should never be allowed to take care of anyone again. On 8/9/11 at 3:30 p.m., a review of the facility's policy and procedure (P&P) titled, "Abuse Prevention, Investigation and Reporting" (last revised 7/08) read (in part) identification of abuse included complaints which would be investigated to rule out abuse. In regards to protection in the event the alleged perpetrator was an employee, the employee would be removed from the area and suspended during the investigation. The reporting aspect of the P&P indicated that all staff were mandated reporters who should notify the facility and the appropriate state agencies and fill out the reporting forms.The facility's failure to thoroughly investigate Patient C's allegation, placed all patients at risk for unwanted sexual encounters and allowed for two additional incidences of sexual abuse (Patient A and Patient B) to occur.These violations caused or are under circumstances likely to cause significant humiliation, indignity, anxiety or other emotional trauma to the patients or residents of a long term health care facility. |
| 030001821 |
Woodside Healthcare Center |
030010280 |
B |
03-Dec-13 |
HP2I11 |
12586 |
72311 - Nursing Service -General (a) Nursing service shall include, but not be limited to, the following: (1) Planning of Patient care, which shall include at least the following: (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. 72313 - Nursing Service -Administration of Medications (a) Medications and treatments shall be administered as follows: (2) Medications and treatments shall be administered as prescribed. 72547 - Content of Health Records (a) A facility shall maintain for each Patient a health record which shall include: (5) Nurses' notes which shall be signed and dated. Nurses' notes shall include: (B) Meaningful and informative nurses' progress notes written by licensed nurses as often as the Patient's condition warrants. However, weekly nurses' progress notes shall be written by licensed nurses on each Patient and shall be specific to the Patient's needs, the Patient care plan and the Patient's response to care and treatments. The following citation was written following an unannounced visit on 8/6/10 to investigate a complaint (#CA00237762).As a result of the investigation the Department determined the facility failed to: 1. Assess and provide timely pain management for Patient 1; 2. Implement Patient 1's Care Plan for pain; 3. Implement Patient 1's physician ordered treatment of constipation, resulting in fecal impaction; and 4. Make meaningful and informative nurse's progress notes to include the presence of fecal impaction. Patient 1 was a 94 year old admitted to the facility on 8/7/06 with diagnoses which included dementia and a general decline in her health. A Minimum Data Set (MDS, an assessment tool) dated 5/17/10 described the patient as having both long term and short term memory impairment and being moderately impaired for decision making. Patient 1 was totally dependent on facility staff for most activities of daily living.A physician's order indicated Patient 1 had been on "comfort care" since 9/7/06 (supportive treatment for patients who have a terminal condition, aimed at relieving symptoms, enhancing the quality of remaining life, and easing the dying process).A Resident Care Plan for pain dated 5/17/10 listed arthritis and osteoporosis (brittle bones) as the problems causing pain and it directed staff to "Administer medication as ordered to ensure adequate pain relief; check the effectiveness of the medication after 30 minutes; Notify the MD if medication ineffective... Be sensitive to patients expression of pain..."A Nurses Note dated 7/15/10 at 5 p.m. described Patient 1 having difficulty breathing, likely from aspiration (inhalation of liquid or food into the lungs) which indicated she was not able to swallow properly.Patient 1's clinical record contained a 7/15/10 physician's order for liquid morphine (an opiate pain reliever), 10 milligrams (mg.) every hour, to be given as needed. The order also directed to withhold food and liquids to prevent further aspiration. Review of a journal submitted to the Department by Patient 1's Responsible Party (RP 1), post marked 8/9/10, included the following entry dated "Saturday 7/24/10...I got there at 9 a.m. She seemed to be in a lot of pain...I asked [Licensed Nurse [LN 2] if she had her pain medicine already? He said NO, he hadn't given anything to her yet. I said well she is in pain, he just gave me a lecture on how the morphine is really bad for her body and it shortens her life...I said look at her she is not going to get better, she is almost 95, and she is in pain...This is when I started my Journal...I called [the doctor's office]. Got an advice nurse [Outside Registered Nurse [ORN] ...and explained to her [Patient 1] was in pain!....[ORN] called me back and said she spoke with [LN 2]...Finally at 1:15 that day [LN 2]...brought her some morphine." Review of a physician's office document titled "Continuing Care Telephone," dated 7/24/10 at 1:03 p.m. and electronically signed by ORN, indicated ORN had telephoned the facility after receiving a complaint from RP 1 about pain medicine not being administered to Patient 1. ORN spoke to LN 2 at the facility and confirmed the facility had a physician's order for Patient 1 for morphine 10 mg. to be given as needed. LN 2 told ORN that Patient 1 had her last dose on 7/20/10, but that LN 2 would give the medicine "now." The "Controlled Drug Record" for morphine documented a dose was given on 7/24/13 at 1:30 p.m. A Nurse's Note by LN 3, entry dated 7/24/10 at 4 p.m., indicated "[RP 1] very upset regarding pain control issue with [Patient 1], requested [morphine] be around the clock, as I spoke to [MD] on 7/15 she was OK to do everything possible to control patient pain, plan, will [discontinue] Tylenol [around the clock] and replace it with [morphine] 10 mg. [every 6 hours] for pain management." In an interview with Certified Nursing Assistant 2 (CNA 2) on 8/6/10 at 11:30 a.m. she stated "It was obvious [Patient 1] was in pain, she was screaming. I let [LN 2] know she was in pain. He thinks we [CNAs] know nothing...I tried to make her as comfortable as possible." CNA 2 also stated that a few days before Patient 1 died, "I told [LN 2] she was in pain and he said it was constipation, that she was OK. She did have an impaction but she was still in a lot of pain."In an interview with CNA 1 on 8/6/10 at 12:10 p.m. she stated Patient 1 "Couldn't express her pain, she grimaced, twitched and screamed out. She obviously needed more pain medication than she was given." CNA 1 stated that when she told LN 2 about the patient being in pain "He said, that's OK, she's fine." During an interview with LN 3 on 9/2/10 at 10:20 a.m. he stated "The CNAs have more interaction with patients than we nurses do, they have good knowledge and I can rely on them."During an interview and record review with LN 2 on 9/24/10 at 8:30 a.m. he stated on 7/24/10 Patient 1 was on routine Tylenol, "She had no need for Roxinol, no terminal diagnosis and no strong pain." LN 2 stated the CNAs did "not have enough knowledge to figure out what's going on." LN 2 stated on 7/24/10 "I gave Roxanol only 1 time per family request...She was in pain from constipation from pain meds and not eating. It aggravated her condition by giving Roxanol per family request." LN 2 stated "[RP 1] wanted to go back home, she wanted [Patient 1] to go fast so she could go to her family....I did my best per knowledge and license, only God can take a life." LN 2 stated "Every time I come in [to her room] she's [Patient 1] quiet." Review of facility policy titled Comfort Care/Palliative Care, undated, included: "Comfort care....is the aggressive treatment of physical and emotional pain and symptoms. All palliative care treatments focus on enhancing a resident's comfort and overall quality of life."Review of an undated facility policy titled Pain Assessment and Management included "In residents who have dementia and cannot verbalize that they are in pain, symptoms or indicators of pain can be manifested by particular behaviors such as: ...calling out, repetition of words, moaning, crying, restless, pained facial expressions, wincing, frowning, grimacing,....refusing to eat..." The policy included the following under the heading Principles of Analgesic Therapy: "Increase drug dose or strength for insufficient pain control, In addition to "around the clock" administer "as needed" doses to control breakthrough pain." During an interview with MD 1 on 12/30/10 at 1:30 p.m. he stated during the last week of Patient 1's life "There was reluctance on the nurses' part to provide appropriate pain medication." MD 1 stated some nurses at the facility had "restorative rather than pain control goals, though the patient outcome was clear." MD 1 stated Patient 1's pain was not controlled and orders had to be clarified over the weekend, then medications increased on Monday and again during the week to control Patient 1's pain. Patient 1's clinical record contained a physician's order for two bowel medications dated 8/7/06: Milk of Magnesia (MOM) 30 cubic centimeters (approximately one ounce) every day for constipation as needed; and Dulcolax (laxative) suppository rectally 10 milligrams (mg) as needed for constipation if the MOM did not work. A Resident Care Plan for pain dated 5/17/10 listed arthritis and osteoporosis [brittle bones] as the problems causing pain and it directed staff to... Monitor any side effect of the drug: GI [gastrointestinal] distress, constipation... Monitor BM [bowel movement] q [every] shift; If no BM in 3 days implement protocol" (the protocol consisted of administration of the MOM and laxative suppository if the MOM did not work as above). Review of a journal submitted to the Department by RP 1, post marked 8/9/10, included the following entry dated 7/26/10: "I arrived...at 7:30 a.m. Resting but crying out a bit....she started screaming and crying out bad. Very intense I told him [LN 2] something is wrong. [LN 2] said.... she was impacted and removed some stool. He said now she will not be in pain anymore. 12:00 still restless-little screams in pain. [LN 2] gave morphine and told me she was screaming out in reaction to my voice and me being there...I went out into the hallway....I sat there over 1 hour. She still was screaming in pain....2:25 p.m. [LN 2] checked her for more stools-none." Review of the Medication Administration Record (MAR) for July 2010 documented entries for MOM and Dulcolax suppository were blank, indicating they had not been administered during July. An ADL (Activities of Daily Living) Flow Sheet dated "7/10" included on the line labeled Bowel the value "0" was written into the sections for each shift starting on the night shift 7/18/10 through 7/26/10, indicating Patient 1 had not had a bowel movement for more than 7 days. Patient 1's clinical record did not contain any Nurses Notes from 7/20/10 at 4 p.m., until 7/24/10 at 6 p.m. The Nurses Notes through 7/27/10 did not include any entry by LN 2 regarding constipation or removal of fecal impaction. Review of an undated facility policy titled Pain Assessment and Management included "Prevent and treat analgesic side effects...common effects are ... constipation. All residents on opioids should receive stimulant laxative therapy unless otherwise contraindicated."During an interview and record review with LN 2 on 9/24/10 at 8:30 a.m. he stated "I gave Roxanol only 1 time per family request...Roxanol had side effects of constipation, [Patient 1] became constipated." LN 2 further stated that at approximately 2 p.m. on 7/26/10 he removed impacted stool from Patient 1. LN 2 stated he did not chart the removal but it was witnessed by a CNA and RP1. He stated, "She was in pain from constipation from pain meds and not eating. It aggravated her condition by giving Roxanol per family request."During an interview with the DON (Director of Nurses) on 12/30/10 at 4:35 p.m. she stated the facility management protocol required CNAs to document each time a patient had a BM on the ADL sheets. She stated the nurses were required to monitor patient ADL sheets each shift and if a patient did not have a BM the MOM was to be administered. If the MOM was not effective they were to administer the suppository, then an enema if the suppository was not effective. During an interview and clinical record review with the Nurse Consultant (NC) on 12/30/10 at 4:35 p.m. she verified that according to the record Patient 1 had not had a BM for 7 days, from 7/19/10 and 7/25/10. NC was not able to find documentation in either the MAR or nurse's notes of administration of bowel medications during the 7 days the patient did not have a BM. Patient 1 died on 7/29/10. Therefore, the Department determined the facility failed to: 1. Assess and provide timely pain management for Patient 1; 2. Implement Patient 1's Care Plan for pain; 3. Implement Patient 1's physician ordered treatment of constipation resulting in fecal impaction; and 4. Make meaningful and informative nurse's progress notes to include the presence of fecal impaction. The above violations had a direct relationship to the health, safety, or security of patients of the long-term health care facility. |
| 100000049 |
Windsor Elmhaven Care Center |
030010380 |
A |
24-Jan-14 |
4SU711 |
6195 |
CFR 483.10(b)(11) - Notification of Changes (injury/decline/room,Etc) - A facility must immediately inform the resident; consult with the resident's physician; and if known, notify the resident's legal representative or an interested family member when there is an accident involving the resident which results in injury and has the potential for requiring physician intervention; a significant change in the resident's physical, mental, or psychosocial status (i.e., a deterioration in health, mental, or psychosocial status in either life threatening conditions or clinical complications); a need to alter treatment significantly (i.e., a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or a decision to transfer or discharge the resident from the facility as specified in Section 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 Section 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. On August 26, 2011 at 11 a.m., an Informal Conference was conducted as part of the Complainant Appeal process provided in the California Health & Safety Code Section 1420(b)(c). The Department findings of Complaint #CA00111573 were reviewed and documents reevaluated. The allegations were re-investigated.Based on family statements and document review, it was determined that the facility failed to immediately consult with Resident A's physician and notify Resident A's family member when Resident A fell from his bed and hit his head. This failure placed the resident at risk of life threatening injury to the brain requiring admission to the acute care hospital, loss of consciousness, surgical repair, and death.Resident A was a 95 year old male admitted to the facility on 3/13/07. His diagnoses included dementia and an irregular heart rhythm. He was prescribed a blood thinner to prevent the formation of blood clots in his body.On 4/3/07 at 3 a.m., Interdisciplinary Notes (IDT) documented Resident A was "observed by a C.N.A. (Certified Nursing Assistant) trying to get out of bed near the foot of his bed. Before he could be assisted to a safe position, Resident A fell from his bed onto the floor." Resident A was assessed by a licensed nurse (LN) and found to have a small cut on his left eyebrow, a larger cut on his left elbow and a small abrasion on his right inner arm. Resident A's left elbow cut was reported as bleeding heavily; the licensed nurse had some difficulty controlling the bleeding.On 4/3/07 at 7 a.m., the IDT note documented LN 1 called Resident A's daughter, but nobody answered. The physician was notified of the fall at 7:30 a.m. "The daughter arrived at 7:15 a.m. and requested that Resident A be sent to the Emergency Room for evaluation." At 8 a.m. LN 1 again called Resident A's physician. The physician ordered that Resident A be sent to a local hospital emergency department for further evaluation. On 4/3/07 at 8:25 a.m., Resident A arrived at the hospital via ambulance. An x-ray scan of Resident A's head was done. The scan showed that Resident A had an area of pooled blood on the surface of his brain (a subdural hematoma). The area of bleeding was sufficiently large to shift the brain contents such that structures of the brain were compromised. The emergency department initiated blood component transfusion to reverse the effects of the blood thinner in Resident A's blood. When the effects of the blood thinner had been sufficiently reversed, Resident A had surgery to remove the area of pooled blood on the surface of his brain. The procedure included anesthesia to render Resident A unconscious, cutting an opening in his skull to expose the area of his brain where the bleeding occurred, removal of the blood on the surface of Resident A's brain, repair the injury to stop further bleeding, insertion of a drain for the escape of fluids that accumulate during the healing process, and closing the surgical wound after the surgery.After his surgery, Resident A never regained consciousness. His condition did not improve and the decision was made for "comfort measures only." Resident A expired on 4/10/07. Resident A's death certificate listed the cause of death as "Complications of subdural hematoma" caused by "Blunt force injuries." The facility "FALL MANAGEMENT" policy and procedure, revised 3/22/04, included the following instruction: "...3. Physician is to be notified as soon as practicable following a fall...Responsible party is also to be promptly notified of the incident..." On 10/18/07 the Director of Nurses (DON) was interviewed. The DON stated that notification of the physician and responsible party depended on the degree of injury and the time of day. Normally contact was as soon as possible.On 9/4/13 at 8:40 a.m. Resident A's physician (MD 1) was interviewed. When asked, MD 1 stated that had he been called at 3 a.m. (the time of Resident A's fall), he "hoped" that he would have given the same order to send Resident A to the hospital for evaluation. Therefore, the facility failed to immediately consult with Resident A's physician and notify Resident A's family member that Resident A fell from his bed, hitting his head. The interval from the fall until the physician was consulted and family was aware of the fall with injury was over four hours.This failure placed the resident at risk of life threatening bleeding on the brain requiring admission to the acute care hospital, loss of consciousness, surgical repair, and death.These violations presented either (1) imminent danger that death or serious harm to the patients or residents of the long-term health care facility would result therefrom, or (2) substantial probability that death or serious physical harm to patients or residents of the long-term health care facility would result therefrom. |
| 100000049 |
Windsor Elmhaven Care Center |
030010401 |
A |
29-Jan-14 |
N0PY11 |
12408 |
72523. Patient Care Policies and Procedures - (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. 72311. Nursing Service-General - (a) Nursing service shall include, but not be limited to the following: (1) Planning patient care, which shall include at least the following: (B) Development of an individual written patient care plan which indicates the care to be given, the objectives to be accomplished and the professional discipline responsible for each element of care. Objectives shall be measurable and time limited.On 12/14/11, at 9:30 a.m., an unannounced visit was made to the facility to investigate Entity Reported Incident #CA00292037, regarding a self-reported unusual occurrence of Patient (A) who had been transferred to the hospital by ambulance after a code blue (a code used to indicate a patient requiring immediate resuscitation) was initiated. The facility report also indicated that Patient A may have disconnected herself from her ventilator (a machine that pushes air in and out of her lungs). Patient A expired at the hospital four days later after being placed on comfort care. The Department determined that: 1. The facility failed to follow its September, 2009 ventilation policy and procedure (P&P) titled, "Mechanical Ventilation," by failing to ensure that the ventilator alarms were set and functioning before leaving Patient A's room on 12/3/11. 2. The facility failed to develop a care plan to protect the patient from accidentally or intentionally disconnecting herself from the ventilator. This failure resulted in the ventilator warning alarm not sounding when Patient A's ventilator tubing became disconnected. Staff discovered Patient A in a life threatening condition that required emergency care and hospitalization. On 12/14/11 Patient A's medical record was reviewed. A review of Patient A's most recent MDS (Minimum Data Set, a core set of screening and assessment elements that facilitate care management in nursing homes) dated 11/8/11, indicated that she did not have an altered level of consciousness (ALOC). Patient A's, "Brief Interview for Mental Status" (BIMS) was scored at a 9 which indicated she was moderately impaired cognitively. Nursing staff documented on the MDS that Patient A exhibited impairments in both her upper and lower extremities. Documentation in Patient A's nurse's notes from 11/30/11 through 12/3/11 (day of incident) described Patient A as alert, oriented and able to make needs known using an electronic communication board (a device used by patients who cannot speak). Patient A's MDS dated 11/8/11, also indicated that Patient A was ventilator dependent due to her ALS (amyotrophic lateral sclerosis). ALS causes muscle weakness with a wide range of disabilities (i.e., muscle weakness and atrophy [wasting away], muscle cramps, and fleeting twitches, swallowing problems, and difficulty speaking or forming words). Eventually, all muscles under voluntary control are affected, and patients lose their strength and the ability to move their arms, legs, and body. When muscles in the diaphragm and chest wall fail, patients lose the ability to breathe without ventilator support. Most people with ALS die from respiratory failure (http://www.ninds.nih.gov/disorders/amyotrophiclateralsclerosis/detail_ALS.htm).On 5/9/12 at 7:57a.m., the MDS Coordinator (MDSC) was interviewed via telephone. The MDSC stated that when she would assess Patient A, she would ask "yes" and "no" questions and Patient A would respond by shaking her head or mouth the answer. The MDSC stated she remembered that Patient A was able to move her upper extremities. On 12/14/11 at 10:15 a.m., an interview was conducted with Patient A's Licensed Nurse (LN 1). LN 1 stated that he had taken care of Patient A since her admission to the facility on 9/29/11. LN 1 stated that Patient A was able to mouth words and use an electronic communication device to let her needs be known. On 12/14/11 at 10:30 a.m., the respiratory therapist (RT) who took care of Patient A was interviewed along with LN 1. The RT stated that Patient A was alert with no respiratory distress (confirmed by nurses' note entries from 11/30/11 to 12/2/11 of alert, no distress, able to make needs known). The RT stated that on 12/3/11 at approximately 9:00 a.m., LN 1 told her that Patient A needed a "breathing treatment". The RT stated that she suctioned a moderate amount of secretions from Patient A's tracheostomy and then attached an apparatus that would allow respiratory medication to be inhaled through her ventilator tubing. The RT stated that she left the Patient's room while the breathing treatment was running. The RT stated that at about 10:00 a.m., a "Code Blue" (a condition needing emergency care to restore breathing and circulation of blood pumped by the heart) was called for Patient A. The RT stated that she grabbed the resuscitative equipment cart and brought it down to Patient A's room. Upon arrival to the room, the RT stated that Patient A was attached to a ventilator. The RT disconnected Patient A from the ventilator and assisted her breathing with an "ambu bag'' (bag used to assist ventilation). The RT stated that she noted a large amount of secretions in Patient A's mouth and she suctioned her again and continued to assist her breathing with the ambu bag. The RT stated that she was told by another licensed nurse (RN 1) that Patient A had been discovered disconnected from the ventilator. Both RT and LN1 indicated that Patient A would disconnect herself accidentally from the ventilator and demonstrated how Patient A would push it off her shoulder with her hands, which sometimes resulted in her being disconnected from the ventilator. At this time LN 1 was asked how many times he knew of that Patient A had disconnected herself from the ventilator and he responded, "Multiple times." The RT stated that they would know when Patient A was disconnected because the ventilator would be connected to the room alarm, which would also set off the alarm at the nurses' station and turn the outside room light on. The RT stated that when she brought the cart into the room she noticed that Patient A's ventilator alarm was not attached to the room alarm.On 12/14/11 at 11:10 a.m., the registered nurse (RN 1) who told the RT that Patient A had been disconnected from the ventilator was interviewed. RN 1 stated that she was in the hallway charting on another patient when a restorative nursing assistant (RNA 1) asked her to check Patient A to see if Patient A was feeling alright. RN 1 stated she walked into the room and saw that Patient A looked very pale and the ventilator tubing was not connected to her breathing tube, and was instead lying on her chest. RN 1 recalled that the ventilator alarm not gone off. RN 1 stated that she reconnected Patient A to the ventilator. RN 1 stated that Patient A was unresponsive; she (RN 1) could not feel a pulse and a Code Blue was initiated. On 12/14/11 at 11:15 a.m., RNA 1 was interviewed. RNA 1 stated that she and another RNA (RNA 2) had passed by Patient A's room, and had "peeked" into her room to see if she was available to be weighed and she noticed that Patient A, "looked very pale." RNA 1 immediately called RNA 2 over and told her to look at Patient A stating, "She doesn't look good." RNA 1 was asked if the ventilator alarm was making any noise and she stated, "No." Furthermore, RNA 1 stated the outside room light was not flashing. On 12/14/11 at 11:25 a.m., RNA 2 was interviewed. RNA 2 concurred that RNA 1 had asked her to look at Patient A and further stated that Patient A was very pale and she called the nurse to come check Patient A. RNA 2 stated, "I saw her (Patient A) face and I knew she wasn't right." RNA 2 stated that she did not see or hear any alarms coming from Patient A's room. On 12/14/11 at 11:30 a.m., the Unit Manager (UM) demonstrated that the ventilator's alarm had 2 settings, soft and loud, but the UM was not sure what the ventilator alarm was set at that day. The UM was asked if the facility had a P&P that addressed staff being at the bedside when a breathing treatment is given and the UM responded, "There is no P&P. However, it should be a standard of practice." Patient A's care plan entitled, "Ventilator Care Plan," did not show any documentation relating to Patient A disconnecting herself from her ventilator or any safety approaches to ensure that she could not disconnect herself from her ventilator. A review of the facility's September, 2009 P&P entitled, ''Subject Mechanical Ventilation," indicated that an RN or RT should check the tracheostomy tube connections to "ensure a tight fit." Under the ''Procedure" area, were directions that the ventilator alarms were to be properly set before staff left the room and "with every vent (ventilator) check q4h," (every 4 hours).The nurse's notes and ventilator flow sheets for the dates of 11/30/11 (at 6 p.m.) to 12/3/11 (at 2 a.m.) showed that Patient A was alert, while awake with no respiratory distress. Documentation by LN 1 and the RT showed that Patient A had a severe change of condition on 12/3/11 at approximately10:00 a.m. that resulted in 911 being called for transport to the hospital emergency department (ED). The transfer form sent with Patient A read that she was being transferred to the ED for a "respiratory arrest." The form did not contain information that Patient A was found disconnected from her ventilator for an undetermined time.On 1/26/12 at I 0:00 a.m. Patient A's hospital admission medical record was reviewed. The ambulance, "Pre-Hospital Care Report", dated 12/3/11, read that Patient A had an acute onset of altered level of consciousness (ALOC) and was to be transported to the ED. A review of the ED provider's documentation indicated that Patient A was transported to the ED for ALOC and was non-responsive. Patient A was admitted to the ICU with a diagnosis of "ALOC" and ''Probable Sepsis-Most likely pulmonary (an infection in the bloodstream that is a life threatening condition)." Patient A was evaluated in the ED and admitted to the ICU. A history and physical, dated 12/3/11, performed by the admitting physician indicated that Patient A was sent to the ED due to ALOC. A "Pulmonary/Critical Care Management" consultation performed on 12/4/11 read that Patient A was admitted for ALOC and new onset of seizures. The note also read that her eyes remained open, but she is barely responsive.A "Neurology Consultation", dated 12/5/11, read that Patient A was found with an ALOC and had some twitching while in the ED and was given medication for possible seizures. The documented physical exam read that Patient A's eyes remained open and on occasion she would blink, however, there was no response to verbal stimuli or enacted threatening behavior and "minimal stiffening to deep pain."An EEG (electroencephalogram, a test that measures the electrical activity of the brain) performed on 12/5/11 was interpreted as abnormal with possible, "ongoing underlying seizure activity." A second EEG performed on 12/6/11 read under "History" that Patient A was in a coma of uncertain etiology, possibly anoxic encephalopathy (brain damage due to lack of oxygen)." The second EEG was also called abnormal, however, this one no longer showed any seizure activity. Both EEG's noted that Patient A remained in a comatose state during the procedure. A Palliative Care Consultation was performed on 12/6/11 at the request of Patient A's doctor to meet with Patient A£s family to discuss her current "clinical status, clarify goals of care, address life-sustaining interventions" and discuss the possibility for comfort care. A progress note, dated 12/7/11 and written by the facility's chaplain read that the family decided to put Patient A on comfort care. Patient A was taken off the ventilator at 11:20 p.m. on 12/7/11. Patient A expired at 11:55 p.m., 35 minutes after being removed from her ventilator (mechanical breathing) support. These violations presented either (1) imminent danger that death or serious harm to the patients or patients of the long-term health care facility would result therefrom, or (2) substantial probability that death or serious physical harm to patients or patients of the long-term health care facility would result therefrom. |
| 100000814 |
Wagner Heights Nursing and Rehabilitation Center |
030010840 |
B |
10-Jul-14 |
8G7611 |
5218 |
1418.91 Health and Safety Code (a) A long-term health care facility shall report all incidents of alleged or suspected abuse of a Patient 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. An unannounced visit was made to the facility on 4/1/14 to investigate an entity reported incident CA00392522.The Department determined the facility failed to report an allegation of abuse to the Department immediately or within 24 hours. This failure put all patients in the facility at risk for abuse when Certified Nurse Assistant (CNA) 1 was not immediately removed from care.Patient 1's medical record was reviewed on 4/1/14. Patient 1 was admitted to the facility on 3/17/14 with diagnoses including intellectual disabilities (trouble thinking), psychosis (confusion and disorientation), and cerebral palsy (a movement disorder). Patient 1 had trouble walking and a history of falls. According to the Minimum Data Set (MDS - an assessment tool) Patient 1 had a Brief Interview for Mental Status (BIMS) score of 13 (a score of 13-15 indicates no trouble thinking).Review of a facility policy titled "Abuse Prevention, Intervention, Investigation & Crime Reporting", dated September 2011, discussed the following in pertinent part; "It is the responsibility of employees to immediately report to the facility administrator, local ombudsman (or local law enforcement agency), and to State Licensing and Certification immediately or as soon as practically possible within 24 hours of detection, any incident of suspected or alleged neglect or resident abuse...." The policy further stipulated under Definitions; Mandated Reporter "Any allegation of abuse or neglect, regardless of source or subjective belief concerning the truthfulness of allegation shall be reported."During an interview with the Director of Nurses (DON) on 4/1/14 at 11:45 a.m., she indicated there was an allegation made by Patient 1 on 3/19/14 of CNA 1 choking him. The DON stated both CNA 1 and Licensed Nurse (LN 1) had acknowledged being aware of Patient 1's allegation of abuse on 3/19/14 and neither of them had completed a report. The DON verified that the allegation should have been reported and investigated.Review of the follow up investigative findings submitted to the Department of Public Health on 3/26/14 included the following notation; "On 3/24/14 the resident reported to facility staff on 3/19/14 'he scratched his CNA during care'..." In addition the document disclosed the CNA denied the allegation and stated on 3/19/14 while he was giving care the patient "scratched him and accused him of choking him". During an interview with CNA 1 on 4/2/14 at 10:15 a.m., he stated on the evening of 3/19/14 just before dinner, Patient 1 "scratched his arm and began throwing punches" at him while he was providing care. CNA 1 indicated Patient 1 had accused him of strangling him and cussing at him. CNA 1 explained he had completed and submitted a "Stop & Watch" (written note) to LN 1 describing the occurrence and allegation. CNA 1 indicated the DON then switched his assignment with another Certified Nurse Assistant (CNA 2). CNA 1 indicated that he reported the allegation to his supervisor but did not report it to anyone else although he "should have."During an interview with LN 1 on 4/2/14 at 10:35 a.m., she stated CNA 1 reported to her on 3/19/14 during "med pass" (medication administration rounds) at dinner time Patient 1 had accused him of "scratching him in [sic] the neck". LN 1 reported the DON had been present and switched CNA 1's assignment with CNA 2. LN 1 stated after CNA 1 assignment had been switched, Patient 1 kept asking for CNA 1. LN 1 reported when she asked Patient 1 what had happened he just kept asking for CNA 1 and stated he did not want CNA 1 to get in trouble. LN 1 indicated a report of abuse was not done and it "should have been."During an interview with Director of Staff Development (DSD) on 4/2/14 at 4:30 p.m., she indicated participating in interviews and investigation of the allegation of abuse made by Patient 1 which revealed LN 1 believed she had reported to LN 2 and LN 2 had no recall of a report. DSD verified that no report of abuse was completed on 3/19/14 and it "should have been."During an interview on 4/3/14 at 12:25 p.m. with the DON and Administrator (ADMIN), the ADMIN confirmed he was the facility abuse coordinator. The ADMIN stated Patient 1 had been the one to report the allegation of abuse occurring on 3/19/14 to him in the lobby on 3/24/14.The ADMIN confirmed that upon investigation it was determined CNA 1 had reported Patient 1's allegation to LN 1, LN 1 then followed up with Patient 1 but did not report it to anyone else. The ADMIN stated a report of the allegation "should have been completed."Therefore, the Department determined the facility failed to report an allegation of abuse to the Department immediately or within 24 hours. This failure put all patients in the facility at risk for abuse when CNA 1 was not immediately removed from care. This violation had a direct or immediate relationship to the health, safety, or security of the residents. |
| 030000046 |
Windsor El Camino Care Center |
030011854 |
B |
18-Nov-15 |
XHKF11 |
9497 |
F223 483.13 (b) Free from Abuse/Involuntary Seclusion The resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion.The facility must not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion The following citation is written as a result of an un-announced visit to investigate facility reported event #CA00454964.The Department determined the facility failed to: 1) Ensure Resident A was not subjected to physical abuse when Licensed Nurse 1 (LN 1) slapped Resident A's left cheek with an open right hand, placed a sheet over her head, and slapped her left cheek again with an open right hand on 8/18/15 in the evening after dinner. 2) Ensure Resident B was not subjected to psychological abuse when she witnessed LN 1 slap Resident A on 8/18/15 in the evening after dinner.Review of the clinical record for Resident A indicated admission to the facility with medical diagnoses including high blood pressure, Diabetes Mellitus (high blood sugar), and dementia (a memory loss disease). Resident A's Quarterly Minimum Data Set (MDS, an assessment tool), dated 8/5/15, indicated Resident A was unable to communicate, spoke very little English, and had long and short term memory problems. Resident A did not make her own decisions. Resident A required either extensive or total assistance with activities of daily living with one to two staff persons providing physical assistance, was incontinent of urine and bowel, and had a Gastrostomy Tube (G Tube, a surgically inserted tube that goes directly into the stomach to provide food and medicine) for supplemental feedings and medication administration. A telephone interview was conducted on 9/8/15 at 1:37 p.m. with Certified Nurse Assistant (CNA) 1. CNA 1 described Resident A as "a little, thin, fragile [Resident]" who was easily redirected. CNA 1 reported the slapping incident occurred on 8/18/15 in the evening after dinner. CNA 1 stated LN 1 pushed Resident A in a wheelchair from the hallway into the fireside dining room to administer medication via the G Tube. CNA 1 reported Resident A was "really agitated" at the time and was refusing medication. She stated Resident A put both feet down on the floor to stop the wheelchair from moving when LN 1 wheeled Resident A into the dining room. CNA 1 stated Resident A did not want to go into the dining room. LN 1 did not listen and was "relentless". CNA 1 stated she was standing on the left side of Resident A in the dining room. She was holding Resident A's left hand to calm her. CNA 1 stated LN 1 was standing across from Resident A, partially to the right. CNA 1 stated there were one container of clear liquid and one container of "cloudy" liquid being administered to Resident A via the G Tube. CNA 1 stated Resident A spit on LN 1. CNA 1 further stated LN 1 "slapped" Resident A on the left cheek with an open right hand. CNA 1 then asked LN 1 to "stop" and come back later. LN 1 then pulled a sheet over Resident A's face. The sheet fell off Resident A's face and LN 1 slapped the resident on the left cheek again with an open right hand. CNA 1 stated LN 1 was "frustrated" when Resident A had spit on her. CNA 1 and CNA 2 called the Administrator by telephone to make a report. In a continued interview with CNA 1, she stated Resident B was one table away from the incident in the dining room. CNA 1 described Resident B as "distraught" and stated Resident B started crying after witnessing LN 1 strike Resident A. CNA 1 further stated Resident B was not confused and "mentally is there." LN 1 stated "no one can give [Resident A] medicine but me" to CNA 1. CNA 1 explained, "I was shocked. I couldn't believe it."A review of the clinical record for Resident B indicated a short term admission to the facility. Resident B had a Brief Interview for Mental Status (BIMS, a test for mental acuity with a possible best score of 15 meaning cognitively intact), dated 6/6/15, score of 15. An interview was conducted at the facility on 8/28/15 at 11:46 a.m. with Resident B. Resident B stated she was in the fireside dining room after dinner on 8/18/15. Resident B stated Resident A and CNA 1 were also in the fireside dining room. Resident B said Resident A was "really agitated" and "[Resident A] was swinging her arms all over the place." Resident B stated "[Resident A] could not defend herself." Resident B stated LN 1 was giving Resident A "meds." Resident B described LN 1 as "mad" and LN 1 "swung" at Resident A. Resident B provided a return demonstration of the incident with an open hand, recoiled arm, and pointed to the surveyor's left cheek. Resident B stated the left cheek was "slapped" twice. Resident B was observed being tearful and trembling during the interview. Resident B further stated LN 1 then put her arms around [Resident B] to comfort [Resident B] after witnessing the slapping incident. Resident B stated LN 1 said, "See, that's what happens when you don't listen." Resident B also stated "It really opened my eyes that this could happen" and "it scared me." In a telephone interview on 8/28/15 at 3:42 p.m., LN 1 was asked to describe the incident on 8/18/15 in the fireside dining room. LN 1 stated it was after dinner. LN 1 said Resident A was "very, very agitated" and maybe hypoglycemic (sugar level in the blood was too low). LN 1 reported Resident A would hit or spit sometimes. LN 1 confirmed CNA 1 and Resident B were also present in the dining room during the incident. LN 1 denied slapping Resident A and denied administering medication via the G Tube at that time. LN 1 stated she was explaining to Resident B, Resident A was "ok" and was just agitated. When questioned about which hand was dominant, LN 1 stated her right hand. At the closing of the telephone interview, LN 1 was crying and stated "I'm so sorry, ma'am."A review of the clinical record for Resident A dated 8/18/15 included a review of the Medication Administration Record (MAR) with date and times of the medications administered for Resident A:isosorbide dinitrate (a medication for high blood pressure), metoprolol tartrate (a medication for high blood pressure), and risperidone (an antipsychotic medication) were administered by LN 1 on 8/18/15 at 1700 (5:00 p.m.).G Tube placement and residual feeding was also checked by LN 1 on 8/18/15 at 1700 (5:00 p.m.).Enteral Feed Order "flush G-tube with 100 cc [cubic centimeters- a unit of measurement] q [every] 6 hrs [hours]" was documented as administered by LN 1 at 6:00 p.m. on 8/18/15."monitor specific behavior such as fear of being poisoned and striking out others q shift (every shift) for (risperidone) use "0" for none or record number of episodes." There was no evidence of behaviors documented for Resident 1. On 9/11/15 at 3:30 p.m., a telephone interview was conducted with CNA 2. CNA 2 stated she was working on 8/18/15. CNA 2 stated Resident A had a history of striking out and spitting when resisting care. Upon returning from a lunch break, CNA 2 witnessed Resident B crying in the fireside dining room on the evening of 8/18/15. Resident B reported to CNA 2 "[LN 1] slapped [Resident A]."A telephone interview was conducted on 9/11/15 at 10:07 a.m. with the Director of Nursing (DON). The DON recalled she was notified by phone at home on 8/18/15 of an alleged abuse in the facility. The DON arrived at the facility at approximately 8:30 p.m. The DON stated LN 1 told her that Resident A was agitated when LN 1 was attempting to administer medication or tube feed via G Tube. LN 1 stated to the DON that Resident A's arms were flailing around and LN 1's hand made contact with Resident 1's cheek by accident due to her hand being pushed by Resident 1's flailing arms.The DON stated Resident B was "very upset" when she initiated the investigation on 8/18/15.A review of a facility document titled "Notice of Employee Separation, dated HR 2/12/2014," indicated LN 1 was terminated on 8/19/2015. The section under "...incident that caused termination..." included, "Employee was suspended and leads to termination due to resident abuse."A review of a facility document titled "Resident Abuse Investigation Report Form," signed and dated 8/21/15, under section titled "Summary of investigator's findings" indicated "... the nurse was then witnessed to have slapped the Resident twice and threw a towel over the Resident face." The next question on the document read "Did the findings indicate that abuse occurred?" This question was marked "Yes."Review of the facility policy titled, "Abuse Prevention, Investigation and Reporting reviewed/revised 3/13" included: "Abuse, neglect, abandonment, isolation, financial abuse... will not be tolerated in this facility at any time... H. Corrective Action...3. Any employee suspected of alleged abuse will be suspended during the investigation and ultimately terminated if investigation confirms willful abuse."Therefore, the Department determined the facility failed to: 1) Ensure Resident A was not subjected to physical abuse when LN 1 slapped Resident A's left cheek with an open right hand, placed a sheet over her head, and slapped her left cheek again with an open right hand on 8/18/15 in the evening after dinner. 2) Ensure Resident B was not subjected to psychological abuse when she witnessed LN 1 slap Resident A on 8/18/15 in the evening after dinner.The above violations had a direct relationship to the health, safety, or security of Residents. |
| 030000160 |
Windsor Care Center of Sacramento |
030012176 |
B |
20-Apr-16 |
5JOX11 |
5232 |
California Health and Safety code, 1418.19 (a) A long-term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the department immediately, or within 24 hours. (b) A failure to comply with the requirements of this section shall be a class "B" violation. The following citation is written as a result of entity reported incident #CA00476188. Unannounced visits were made to the facility on 3/01/16 and 3/18/16 to investigate an allegation of abuse. The Department determined the facility failed to report an allegation of abuse within 24 hours as required, when Certified Nursing Assistant (CNA) 2 witnessed suspected abuse of Patients A, B and C by CNA 1 on 2/10/16. On 2/13/16 (three days after she witnessed suspected abuse) CNA 2 reported that on 2/10/16, she witnessed CNA 1: 1. Make rude hand gestures towards Patient A; 2. Clean Patient B's genital area roughly; and 3. Yell at, hit at and push Patient C.These violations potentially placed facility patients at risk for continued abuse. Patient A was a 91 year old admitted to the facility in late 2015 with diagnoses that included major depressive disorder and symbolic dysfunctions (social impairment). His Minimum Data Set (MDS- a standardized assessment tool) dated 2/17/16, documented Patient A had a Brief Interview for Mental Status (BIMS- an assessment screening tool used to assess cognition) score of 6. This indicated severe cognitive impairment. Patient B was a 63 year old admitted to the facility in 2013 with diagnoses that included Alzheimer's disease, dementia with behavioral disturbance and altered mental status. His MDS dated 12/3/15, documented Patient B had a BIMS score of 00. This indicated severe cognitive impairment. Patient C was a 69 year old admitted to the facility in late 2014 with diagnoses that included Alzheimer's disease, anxiety disorder and major depressive disorder. His MDS dated 1/3/16, documented Patient B had a BIMS score of 99. This indicated the patient was unable to complete the BIMS interview. Licensed nursing staff objectively assessed Patient C's cognition as severely impaired on the 1/3/16 MDS. On 2/16/16 at 7:17 a.m., the Department processed a report of alleged abuse of Patients A, B and C by a CNA 1. On 3/1/16, following an internal investigation, the Administrator notified the Department the allegation of abuse was substantiated and CNA 1 resigned before being terminated. During an interview with the Administrator on 3/1/16 at 12:35 p.m., she stated the abuse was substantiated based on interviews with CNA 2 who witnessed the abuse. Review of a letter, written by CNA 2 to the Administrator on 2/13/16 (more than 24 hours after witnessing suspected abuse), it indicated an outline of what she had witnessed and slipped the letter under the administrator's office door. In her written report CNA 2 indicated that on 2/10/16 during the night shift, she witnessed CNA 1 make a rude hand gesture (flipped off) towards Patient A. Patient A was asking "random questions." CNA 2 further reported that on 2/10/16, CNA 1 administered rough cleaning to Patient B's scrotum area. CNA 2 reported she asked CNA 1 to wipe more gently. CNA 2 added in her report that on the same night, 2/10/16, CNA 1 yelled at Patient C, hit him on his arms, pushed him to try to get him to go to bed, and pushed him into the bathroom and told him he needs to use the bathroom like a man.During an interview with CNA 2, on 3/17/16 at 10:05 a.m., she confirmed she witnessed the following on the night shift on 2/10/16: 1. Patient A kept asking where his room was and CNA 1 gave Patient A the middle finger; 2. CNA 1 grabbed the (cleaning) wipes and was wiping Patient B's scrotum very hard; and 3. CNA 1 was hitting (slapping) Patient C on his arms trying to make him stay in bed. CNA 2 also said, "[CNA 1] pushed him [Patient C] into the bathroom and told him [Patient C] he needs to use the bathroom like a real man." CNA 2 stated CNA 1 called Patient C a vulgar name. During the same interview with CNA 2, on 3/17/16, at 10:05 a.m., she said she had to report incidents of abuse within 24 to 48 hours. CNA 2 also stated she did not know who to report the suspicion of abuse to and she thought she had to report it to the facility first and they would report it to the Department of Public Health. The facility policy and procedure entitled "Abuse Prevention, Investigation and Reporting," revised 3/13, was reviewed and indicated in pertinent parts: "1. All mandated reporters are required by law to report incidents of known abuse in two ways: 1) by telephone immediately or as soon as practically possible (within 24 hours), to the local Ombudsman or the local law enforcement agency and to the Department of public Health..." Therefore, the Department determined the facility failed to report an allegation of abuse within 24 hours as required, when CNA 2 witnessed suspected abuse of Patients A, B and C by CNA 1 on 2/10/16. On 2/13/16 (three days after she witnessed suspected abuse) CNA 2 reported that on 2/10/16, she witnessed CNA 1: 1. Make rude hand gestures towards Patient A, 2. Clean Patient B's genital area roughly; and 3. Yell at, hit and push Patient C. |
| 100001453 |
WRS Inc., Marshall Program |
030012524 |
AA |
31-Aug-16 |
SM9111 |
30308 |
F331 483.460 Nursing Services (c) The facility must provide clients with nursing services in accordance with their needs. The following citation was written as a result of an unannounced investigation of entity reported incident #CA00427024. The investigation was initiated on 1/27/15 regarding the death of Client 1 following misplacement of his percutaneous endoscopic gastrostomy tube (PEG-Tube, a surgically placed tube that goes through an opening in the abdominal wall directly into the stomach to provide liquid nutrition). The Department determined that the facility failed to assess and transfer Client 1 to the General Acute Care Hospital to ensure prompt medical care and treatment when his PEG-Tube became dislodged. The Registered Nurse (RN) directed a Licensed Vocational Nurse (LVN) and a Licensed Psychiatric Technician (LPT) to continue attempting to re-insert a PEG-Tube when they reported meeting resistance and had a return of blood in the tube. The RN failed to conduct an assessment or notify the physician of the significant findings. These failures resulted in inadequate provision of prompt medical care and treatment, which contributed to Client 1's transfer and admission to the acute care hospital on 12/24/14 with chemical peritonitis (inflammation of the tissue that lines the abdominal wall and covers most of the organs in the abdomen) due to significant fluid collection in the abdomen from a malpositioned PEG-Tube (a PEG-Tube for which the tip of the tube is no longer in the stomach or small intestine, but instead in the abdominal cavity). Chemical peritonitis is a potentially fatal inflammation of the abdomen's lining caused by a chemical irritant, a substance from outside the body that gets into the abdominal cavity, for example during use of a feeding tube. An article titled Peritonitis and Abdominal Sepsis (blood infection) from Medscape, dated 2/23/15 and authored by a physician, indicated, "In severe intra-abdominal infections and peritonitis, the mortality (death) rate may increase to greater than 30 - 50%. The concurrent development of sepsis...can increase the mortality rate to greater than 70%..." The clinical record revealed Client 1 was 46 years old. His diagnoses included profound mental retardation (inability to understand or comply with requests or instructions, immobility, uses very basic nonverbal communication, cannot care for own needs), cerebral palsy (disorder of muscle movement and coordination), seizure disorder, and aphasia (inability to speak). He was unable to advocate for himself due to his intellectual disability and was vulnerable to his providers for care and decisions. On 12/13/14, Client 1 had placement of a PEG-Tube following a procedure known as a percutaneous endoscopic gastrostomy (PEG), an opening made specifically for a PEG-Tube. A PEG-Tube is a feeding tube placed directly into the stomach through a small incision in the abdominal wall with the assistance of an endoscope (an instrument to see the inside of the stomach and intestines). On 12/16/14, Client 1 was admitted to the facility from the acute care hospital with diagnoses that included the PEG-Tube placement, sepsis (whole body inflammation caused by infection) and pneumonia. On 12/20/14, 7 days after initial placement, Client 1's PEG-Tube became dislodged. Client 1 was transferred to the acute care hospital for replacement of the PEG-Tube. Rather than replacement with a PEG-Tube, a Foley catheter was inserted and Client 1 returned to the facility the same day. A PEG-Tube is usually made of silicone or polyurethane making it very durable, more rigid, and less likely to be damaged by gastric secretions. A Foley catheter is a softer, more flexible tube. A Foley catheter is generally used to drain urine from the bladder, but may be used in place of a PEG-Tube temporarily. Because of the greater flexibility of the tube, using a Foley catheter when inserting into a new or unhealed PEG site decreases the risk of perforation through to the abdomen. The World Journal of Gastrointestinal Endoscopy, dated January 16, 2013, indicated, "In general, the tract of PEG begins to mature in 1-2 [weeks] after placement and it is well formed in 4-6 [weeks]...If a PEG tube is dislodged within a month after placement, it is advised that a repeat endoscopy (scope passed through the mouth into the stomach, to view the stomach) be performed to replace the tube since the stomach may not well adhere to the abdominal wall, thus resulting in a free perforation. Blindly replacing a new tube in this scenario could cause intraperitoneal placement (in the abdomen rather than the stomach) and consequent peritonitis (inflammation of the tissue that lines the abdominal wall and covers most of the organs in the abdomen)." An indication for placement of a PEG-Tube is the inability to take in adequate nutrition (food and fluids) by mouth and the intestines are still capable of absorbing nutrition. New PEGs are created after failed attempts to consume adequate nutritional. A client with poor nutritional intake would likely experience nutritional deficiencies, slowing the healing process of the PEG. The Medscape Journal of Medicine, dated June 17, 2008, indicated, "Maturation of the PEG tract can occur as early as 1 week after tube placement. Often maturation takes up to 3 weeks given that a majority of patients are severely ill, on corticosteroids, malnourished, and generally manifest poor wound healing... If a PEG-tube is inadvertently removed from a mature tract (>3-4 weeks old), a Foley catheter can be inserted to maintain tract patency, but this should not be attempted if the PEG tract is immature." Review of Client 1's Post-PEG Tube Placement care plan, dated 12/16/14, included the following instructions on when to call the RN: 1. Excessive bleeding from stoma site, or bloody residual... 2. Vomiting more than once or ANY vomit that has blood or coffee grounds in it 3. Stools that are black and look like they have coffee grounds in them 4. Distended (swollen) or tight stomach 5. Signs and symptoms of pain (grimacing, moaning, pinching), especially chest or abdominal pain 6. Signs and symptoms of infection (fever, discharge from stoma, red streaks around stoma) 7. Any time a feeding is held due to high residual 8. Any other questions about his care OR this care plan Client 1's Nursing Care Plan Attachment for Accidental PEG-Tube Displacement, undated, included the following interventions: "Keep [PEG]-Tube out of reach of client when not in use for medications, hydration or feeding. (Can be covered with shirt or a towel when showering or dressing.)" "Notify [facility] RN immediately if [PEG]-Tube becomes displaced and no licensed staff is presently on shift. (Licensed staff may replace [PEG]-Tube independently then notify the RN)" "The RN will replace the PEG-Tube within 4 hours unless otherwise stated below." "Until the [PEG]-Tube is replaced protect the client's skin from gastric contents by placing towels... [as needed] to keep the skin as dry and clean as possible until the [PEG]-Tube is replaced." There were no additional notes written on the bottom of the attachment. Client 1 had a Physician's Order, dated 12/18/14, for a 20-hour continuous feeding (uninterrupted administration over an extended period of time) of 1250 milliliters of formula via gastrostomy. The start of the feeding was to begin at 8 p.m. and to end at 4 p.m. Documentation in the clinical record indicated Client 1's temperature was taken once on the night shift on 12/23/14 and was not elevated. Client 1 had a Physician's Order, dated 12/23/14, to "change 24 FR (a unit of measurement) [PEG]-Tube [every] three months scheduled and [as needed] when displaced or damaged/occluded. (Licensed staff only)." On 12/23/14 at 8:30 p.m.,10 days after initial placement of the PEG, Client 1's feeding tube became dislodged a second time and was replaced by nursing staff at the facility using a PEG-Tube, not a Foley catheter. A Nurse's Note, dated 12/23/14 at 10 p.m. and completed by the Licensed Nurse 2, indicated "At [8:30 p.m. Direct Care Staff 1] proceeded to give [Client 1] a shower. Direct Care Staff 1 informed me that [Client 1's] [PEG]-Tube had come out, brown mucous around stoma (opening through the abdominal wall). Called on-call [Registered Nurse (RN)], advised me to seek assistance from another licensed staff on the clock. [Licensed Nurse 1] came over immediately and talked me through preparation and insertion. (Used 24 FR [term of measurement] [PEG]-Tube [borrowed from another client] per RN on call). Used clean procedure, inserted PEG-Tube about an inch and met resistance. Tried again and tried to insert 15 [cubic centimeters (cc)] sterile water but would not stay in. [Licensed Nurse 1] took over and reinserted tube. Checked placement [negative]. Called RN again who instructed [Licensed Nurse 1] to try again. After pulling tube out to retry, coagulated blood came out/bleeding. Called RN, asked if it was ok to reinsert with all the blood in the tube (yes). [Licensed Nurse 1] reinserted, achieved [positive] placement, flushed successfully, able to get residual. Gave [Client 1] 650 [milligrams (mg)] Tylenol per order. Hooked up feeding continuous per/advised by ... RN and [Licensed Nurse 1] ..." A Nurse's Note, dated 12/24/14 and completed by Licensed Nurse 2, indicated, "Clocked in today [at 1:30 p.m.]. I immediately noticed [Client 1's] hair and shirt was wet (diaphoretic [symptoms]) skin was pale and clammy, ears dry and cold. [Client 1] showed [symptoms] of pain: grimacing, crying, moaning. [Oxygen]: 88%, [Temperature]: 97... [Client 1] was definitely anxious, apprehensive, restless, and in pain. Gave [650] mg Tylenol per order/ [PEG]-Tube. Called ... House Manager and ... RN on call. [RN] informed me that she will find someone to take [Client 1] to the [emergency room]. RN instructed me to increase [Oxygen] to 5 [liters per minute]. Continued to attempt vital signs. Unsuccessfully got [blood pressure] due to [Client 1] rocking back and forth. Unable to hear lung sounds as well due to [Client 1's] movement." "[At 2 p.m.] continued to check vitals. Elevated [blood pressure]: 159/123, [temperature]: 97, [pulse]: 50, [respirations]: 28, [oxygen]: 80%. Updated [RN], instructed me to check pulse manually. Tried several times, unsuccessful due to [Client 1's] movement, tried radial (at the wrist) and carotid (on the neck). Updated [House Manager 1] who stated that [House Manager 2] would be on her way to pick up [Client 1] as soon as she found someone to cover her shift." "[At 2:20 p.m. Client 1] began salivating excessively. Called...on-call RN and expressed concern that if [House Manager 2] did not arrive soon that I would call 911. She stated that another [Direct Care Staff] would cover [House Manager 2], but to go ahead and call in 5 minutes if she didn't arrive." "[At 2:25 p.m.] called 911 ..." "[At] about [2:30 p.m.] ambulance/fire truck arrived. [Emergency Medical Technician (EMT)] requested that I unhook [Client 1's] feeding pump..." House Manager 1 was interviewed on 1/28/15 at 12:35 p.m. regarding dislodgement of Client 1's PEG-Tube. House Manager 1 stated she assisted Client 1 with a shower on 12/23/14 at approximately 8:30 p.m. when she observed Client 1's PEG-Tube was out and laying on his abdomen. House Manager 1 stated she immediately notified the nurse and the PEG-Tube was replaced. When asked how clients were monitored following a PEG-Tube replacement, House Manager 1 stated Direct Care Staff were only responsible to check the pump for rate and to ensure the PEG-Tube was not dislodged. Direct Care Staff 1 was interviewed on 1/28/15 at 12:50 p.m. regarding the care she provided to Client 1 on the night shift on 12/23/14. Direct Care Staff 1 stated she checked on Client 1 every 2 hours, ensured Client 1's oxygen was on and that the PEG-Tube wasn't clogged. Direct Care Staff 1 stated she knew the PEG-Tube wasn't clogged because the machine didn't beep. Direct Care Staff 1 stated she checked Client 1's vital signs (blood pressure, heart rate, respiratory rate, and temperature) and oxygen level (%). Direct Care Staff 1 stated Client 1 slept throughout the night, awoke at approximately 5 a.m., and his behavior was as usual. Direct Care Staff 1 stated Client 1 did feel warm to touch and slept with a sheet throughout the night, but did not have a fever. When asked if she had received report or instructions regarding monitoring for potential complications related to Client 1's PEG-Tube replacement, Direct Care Staff 1 stated she received a report Client 1's PEG-Tube was replaced, but could not recall if it was that night or if the report was from a few days prior when Client 1's PEG-Tube came out the first time. A message was left for the Qualified Intellectual Disabilities Professional (QIDP), on 1/29/15 at 4:45 p.m., requesting the facility's policy and procedure related to PEG-Tube replacement, including when to replace the PEG-Tube and when to send the client to the emergency room for replacement. A QIDP is a professional staff person whose role is to ensure the individual client receives those services and interventions necessary by competent persons capable of delivering them. The QIDP develops and modifies programs for significant needs of the individual client. A voice message from the QIDP was received on 1/29/15 at 4:58 p.m. The QIDP stated there was no specific facility policy and procedure regarding PEG-Tube replacement. The QIDP stated PEG-Tube replacement was "common nursing process" and indicated it was something nurses were taught in nursing school. The QIDP stated if a nurse was uncomfortable or it was the first time inserting a PEG-Tube, additional training with a more seasoned employee was provided. Licensed Nurse 1 was interviewed on 3/4/15 at 6:30 p.m. regarding the replacement of Client 1's PEG-Tube on 12/23/14. Licensed Nurse 1 stated her primary responsibilities included changing PEG-Tubes every 3 months and as needed. Licensed Nurse 1 stated on 12/23/14 she was called to go to the facility to assist Licensed Nurse 2 with a PEG-Tube replacement for Client 1. Licensed Nurse 1 stated after she arrived at the facility, she called the RN to inform her that she only had 1 experience with that new of a PEG-Tube. Licensed Nurse 1 stated she was told Client 1's PEG-Tube was already replaced once at the acute care hospital a few days earlier and that Client 1 now had orders to replace the PEG-Tube at the facility. Licensed Nurse 1 stated Client 1 was breathing fast, and was told by staff that was "normal" for him. Licensed Nurse 1 stated she then guided Licensed Nurse 2 through the steps to replace Client 1's PEG-Tube. Licensed Nurse 1 stated she instructed Licensed Nurse 2 to insert the PEG-Tube into Client 1's stoma (PEG-Tube opening). Licensed Nurse 1 stated Licensed Nurse 2 inserted the PEG-Tube "slightly" when a small amount of blood was observed. Licensed Nurse 1 stated Licensed Nurse 2 did not want to continue, so Licensed Nurse 1 proceeded. Licensed Nurse 1 stated she inserted the PEG-Tube about 2 inches into the stoma and there was a flash back of blood, about 3 inches. Licensed Nurse 1 stated she pulled the PEG-Tube back out and there was 3-4 inches of coagulated blood hanging on the end of the tube. Licensed Nurse 1 stated she notified the RN and was given instructions to try once more. Licensed Nurse 1 stated she tried, there was no further bleeding around the stoma, and she inserted the PEG-Tube "a good 3-4 inches." Licensed Nurse 1 stated she instilled air and tried to listen to verify placement, but it was muffled. Licensed Nurse 1 stated she manipulated the tube and "still didn't get it." She stated, "It felt like it was not in place." Licensed Nurse 1 stated she sat a couple minutes, tried again, and this time the PEG-Tube went right in. Licensed Nurse 1 stated she again listened when air was inserted to verify placement. Licensed Nurse 1 stated there was no residual (aspiration of stomach contents with a syringe) when checked. Licensed Nurse 1 stated she had spoken with the RN on the phone regarding Client 1, but acknowledged the RN did not come out to the facility to see Client 1. Licensed Nurse 1 also acknowledged Client 1's physician was not contacted and stated, "We don't contact the doctor directly. We always go through the RN." When asked about training, Licensed Nurse 1 stated she had prior experience with PEG-Tube replacement so she didn't need training. She stated someone who hasn't had experience had a staff member with them the first time they replaced a PEG-Tube or if they were uncomfortable. Licensed Nurse 2 was interviewed on 3/5/15 at 10:30 a.m. regarding the replacement of Client 1's PEG-Tube on 12/23/14. Licensed Nurse 2 stated Client 1's PEG-Tube came out on 12/23/14 while he was in the shower. Licensed Nurse 2 stated she had no prior experience with a new PEG-Tube so Licensed Nurse 1 came to the facility to assist with the replacement. Licensed Nurse 2 stated she questioned whether this was something they should be doing at the facility. Licensed Nurse 2 stated Licensed Nurse 1 instructed her to insert the PEG-Tube into Client 1's stoma. Licensed Nurse 2 stated she inserted the tube about 1 inch and met resistance almost immediately. Licensed Nurse 2 stated she was not comfortable proceeding so Licensed Nurse 1 took over. Licensed Nurse 2 stated Licensed Nurse 1 inserted Client 1's PEG-Tube and then checked for placement. Licensed Nurse 2 stated, "You could hear air going in without the stethoscope. It didn't feel right." Licensed Nurse 2 stated the RN gave instructions to take the PEG-Tube out. Licensed Nurse 2 stated Client 1's stoma started to bleed when the PEG-Tube was pulled out and "It scared me." Licensed Nurse 2 stated she again questioned whether Client 1 should be taken to the emergency room. Licensed Nurse 2 stated the RN gave instructions to try again. Licensed Nurse 2 stated Licensed Nurse 1 reinserted Client 1's PEG-Tube and placement was verified by nursing staff by instilling air and listening with a stethoscope. Licensed Nurse 2 stated there was no residual when checked. Licensed Nurse 2 stated Client 1 appeared anxious and was given medication for pain. Licensed Nurse 2 stated she asked the RN if it was okay to start Client 1's feeding and was told it was okay. Licensed Nurse 2 stated she let the night shift staff know what happened, but there was nothing for them to do as Client 1 was on a continuous feeding all night. She stated she instructed staff to check Client 1's vital signs every shift. Licensed Nurse 2 stated they did not contact Client 1's physician. She stated, "We're instructed to follow the chain of command. I would notify the House Manager and RN." Licensed Nurse 2 also stated an RN never came out to the facility, despite difficulties during replacement of Client 1's PEG-Tube, and Client 1 did not go to the hospital to verify correct placement of the PEG-Tube. Licensed Nurse 2 also confirmed on 12/24/14 Client 1's gastrostomy feeding was hooked up and "on" until asked by the EMT to unhook it. When asked about training related to PEG-Tube replacement, Licensed Nurse 2 stated there was no equipment to actually perform PEG-Tube replacement in nursing school. Licensed Nurse 2 stated it was supposed to be part of training when I first started working at the facility. She stated, "I informed the RN I had never replaced a [PEG]-Tube and asked to watch the next time the RN had to replace one." Licensed Nurse 2 stated she had been there such a short time she never had the chance. RN 1 was interviewed on 3/5/15 at 12:45 p.m. regarding client assessment and physician notification. RN 1 stated an RN was not required to go to the facility to assess a client each time there was a change. RN 1 stated, based on information received from facility staff, the RN would make a determination to give instructions over the phone, go to the facility to assess the client, have facility staff transport the client to the emergency room, or have facility staff call 911. RN 1 stated this determination was also dependent upon the specific situation and the experience of the Licensed Nurse on duty, including their understanding of the client's baseline. RN 1 also acknowledged clients were not seen each time a PEG-Tube was dislodged or pulled out, and stated, "Especially if there was a licensed staff on duty to handle it." RN 1 stated Licensed Nurse 1 was present and assisted Licensed Nurse 2 with the replacement of Client 1's PEG-Tube on 12/23/14. RN 1 acknowledged she did not go to the facility on 12/23/14 to physically assess Client 1, stating she was on the phone with Licensed Nurse 1 and received constant updates on what Licensed Nurse 1 was thinking and feeling. RN 1 stated she received plenty of information to indicate Client 1's PEG-Tube was placed correctly and it was okay to resume the feeding. RN 1 stated Licensed Nurses typically did not contact the physician when there were changes in condition. RN 1 stated Licensed Nurses were told if they felt an issue was not being addressed, they were more than welcome to call the doctor, but the preference was to have the RN call. RN 1 acknowledged the physician was not notified of the difficulties during replacement of Client 1's PEG-Tube on 12/23/14 and stated there was a Physician's Order to replace the PEG-Tube at the facility. RN 1 was asked for the facility's policy and procedure regarding replacement of a PEG-Tube and physician notification. RN 1 was unable to provide the documentation requested and stated, "I don't believe we have a policy. It's standard nursing practice." Client 1's physician was interviewed on 3/16/15 at 3:40 p.m. regarding the replacement of feeding tubes in the facility. The physician acknowledged feeding tubes were replaced in the facility by Licensed Nurses as long as "the nurse felt comfortable" and the gastrostomy was "open." The physician stated it was okay to replace a PEG-Tube with a Foley catheter, and further stated Foley catheters were usually available and sometimes used just to keep the gastrostomy open until replaced with a PEG-Tube. When asked about the expectation regarding replacement of a dislodged PEG-Tube for a new/immature (recently placed) gastrostomy versus a mature gastrostomy, the physician stated if the gastrostomy was placed 2 days ago, staff may send the client out to the acute hospital for replacement. The physician stated if the gastrostomy tube was placed 1-2 weeks ago, it was okay for replacement to occur at the facility, but depended on what the nurse was seeing. The physician stated he expected to be notified of complications during replacement of a PEG-Tube, such as resistance and hemorrhage. The physician was unable to recall if he was notified of the difficulty with placement or the bleeding that occurred during the replacement of Client 1's PEG-Tube on 12/23/14. Client 1's clinical record and facility policies revealed no documented evidence a policy and procedure for PEG-Tube replacement was developed that included, a) staff guidance on whether to replace the feeding tube with a PEG-Tube or Foley catheter, b) a protocol for feeding tube replacement to prevent, or minimize potentially serious complications, especially if there were difficulties during the tube replacement, c) instructions on whether or not to send the client to the emergency room to verify correct placement, especially if it is was a new/immature gastrostomy, d) all staff training on heightened monitoring following replacement of a feeding tube and signs and symptoms of a malpositioned PEG-Tube, and e) clear direction on when and who was responsible for notifying the physician. Review of emergency room documentation from the acute care hospital, dated 12/24/14 at 3:09 p.m., indicated Client 1 was in "severe distress, ill-appearing, mottled (spots or patches with different shades or colors on the skin), cold extremities, poor respiratory effort." The History and Physical from the acute care hospital, dated 12/24/14 at 6:13 p.m., indicated Client 1 was "intubated (connected to a breathing machine) in the [emergency room] for severe respiratory distress." The "HISTORY" indicated, "[Client 1's PEG-Tube] came out and was replaced by the care facility staff as far as I can tell." The "PHYSICAL EXAMINATION" indicated Client 1's nasogastric tube (tube through the nose into the stomach) was aspirating (suctioning out) "moderate amounts, (200 ml in 2 hours)", of black fluid, which looked like it was "probably blood." A CAT scan (type of x-ray) of Client 1's chest, abdomen, and pelvis, dated 12/24/14 at 11:55 p.m., indicated there was a suspected PEG-Tube entering from the left abdominal wall with the balloon inflated along the inferior edge of the stomach body. The CAT scan indicated the balloon appeared to be within the peritoneum (abdominal cavity) rather than within the stomach. The CAT scan also indicated there was moderate to appreciable intraperitoneal fluid throughout the abdomen and pelvis, and that Client 1 was transferred to the intensive care unit in critical condition. Client 1's Operative/Procedure Report, dated 12/26/14, indicated Client 1 had a laparotomy (open exploration of the abdomen under general anesthesia), peritoneal lavage (flushing the area with fluid; used to help determine if intra-abdominal injury existed and whether surgery was required), and a gastrostomy. The pre and postoperative diagnoses included acute peritonitis and gastrostomy complication. The findings included, "widespread peritonitis, over 2 [liters] of cloudy watery fluid, extensive proteinaceous (resembling a protein) coating on all surfaces, malpositioned gastrostomy with stomach partly pulled away from [abdominal] wall..." A Critical Care Consultation, dated 1/5/15 at 12 a.m., indicated Client 1 "underwent PEG-tube replacement and was discharged home. [Client 1] did have the PEG-tube fall out and it was replaced in the home. Unfortunately, it appears that it was placed intraabdominal (in the abdomen), not intragastrically (in the stomach) and [Client 1] was fed. [Client 1] developed peritonitis, presenting to the [emergency room with] hematemesis (blood in vomit) and respiratory distress. [Client 1] was intubated (placed on a breathing machine) and noted to have evaluation that demonstrated both the peritonitis and [PEG-Tube] in the malpositioned state." Client 1's Discharge Summary, dated 1/7/15 at 4:56 p.m. included the following hospital course: "...Admitted here with acute [respiratory] failure requiring intubation and mechanical ventilation, thought to represent an aspiration event. [Client 1] was also found to have peritonitis and underwent laparotomy with peritoneal washout, with findings of retained gastric content in peritoneal space. A new gastrostomy was placed. Patient remained in intensive care throughout, and could not be weaned from ventilator and could not tolerate tube feeding. After 2 weeks in intensive care the care team determined that further efforts at weaning and feeding would not be successful, so in consultation with representatives of [Regional Center, Client 1] was transitioned to comfort care and extubated (breathing tube removed) on the afternoon of [1/7/15]. [Client 1] expired at [3:10 p.m.] on [1/7/15]." The Discharge Summary listed Client 1's cause of death as follows: "Cause of death: acute respiratory failure (days) due to aspiration pneumonia (days)." "Other significant factors contributing to demise (death): acute chemical peritonitis." A publication from the Centers for Medicare & Medicaid Services (CMS), Health and Human Services (HHS) titled "Late Accidental Dislodgement of a [PEG-Tube]", dated 5/2/11, indicates, "If accidental dislodgement occurs before maturation of the gastro cutaneous fistula tract [entry portal for the PEG-Tube], significant morbidity [illness or disease] and even mortality [death] may occur...Most of these complications are peritonitis requiring laparotomy [abdominal surgery]...and peritoneal cavity irrigation [wash out]...premature removal is defined as occurring less than 7 to 14 days after initial placement...the most clinically significant dislodgements occur early, before a mature gastro cutaneous fistula..." An on-line publication titled "A Clinician's Guide: Caring for people with [PEG-Tubes] and devices," undated, defines an immature stoma tract as "less than six weeks since insertion." Under "Important Considerations," the guide directs, "If the [PEG-Tube] or device is accidentally pulled...in an immature stoma tract the patient should present to the emergency department. A radiological contrast study or endoscopy should be performed." A publication from the American Medical Directors Association titled "Clinical Practice Guideline," dated 2003, defines an immature abdominal wall tract (entry portal for the PEG-Tube), as "less than 30 days old." The Department determined that the facility failed to access and transfer Client 1 to the General Acute Care Hospital to ensure prompt medical care and treatment when his PEG-Tube became dislodged. The Registered Nurse (RN) directed a Licensed Vocational Nurse (LVN) and a Licensed Psychiatric Technician (LPT) to continue attempting to re-insert a PEG-Tube when they met resistance and had a return of blood in the tube. The RN failed to conduct an assessment or notify the physician of the significant findings. The Department determined that the facility failed to assess and transfer Client 1 to the General Acute Care Hospital to ensure prompt medical care and treatment when his PEG-Tube became dislodged. The Registered Nurse (RN) directed a Licensed Vocational Nurse (LVN) and a Licensed Psychiatric Technician (LPT) to continue attempting to re-insert a PEG-Tube when they reported meeting resistance and had a return of blood in the tube. The RN failed to conduct an assessment or notify the physician of the significant findings. 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 was a direct proximate cause of the death of the patient. |
| 100000814 |
Wagner Heights Nursing and Rehabilitation Center |
030012583 |
B |
20-Sep-16 |
292L11 |
3780 |
California Health and Safety code, 1418.91 (a) A long-term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the department immediately, or within 24 hours. (b) A failure to comply with the requirements of this section shall be a class "B" violation. The following citation is written as a result of complaint #CA00498378. An unannounced visit was made to the facility on 8/10/16 to investigate an allegation of abuse. The Department determined the facility failed to: Report suspected abuse of Patient A by Patient B within 24 hours as required, when Licensed Nurse (LN) 1 walked over to Patient A the evening of 8/8/16 and noticed her face and clothes were wet with mocha and Patient B was still yelling at her. This violation potentially placed facility patients at risk for continued abuse. Patient A was a 55 year-old admitted to the facility in early 2015 with diagnoses which included dementia (decline in memory and thinking skills), cognitive deficits (trouble remembering, learning new things, concentrating, and making decisions) following cerebrovascular disease (stroke), and anxiety disorder. Her Minimum Data Set, (MDS-a standardized assessment tool) dated 6/29/16, documented Patient A had severe cognitive impairment [decline in memory and thinking skills]. Patient B was a 68 year-old admitted to the facility in early 2015 with diagnoses which included dementia, anxiety disorder, and cognitive deficits following cerebrovascular disease. Her MDS dated 6/17/16, documented Patient B had moderate cognitive impairment. On 8/8/16 at 9:42 p.m., LN 1 initiated a change in condition evaluation form for Patient B. The change in condition form was initiated due to Patient B "Cursing other Patient [A], throws mocha to Patient [A]." On 8/8/16 at 10:15 p.m., Licensed Nurse (LN) 1 initiated a change in condition evaluation form for Resident A. The change in condition form was initiated due to "Patient A was thrown [sic] a cup of mocha in her face by another Patient [B]." During an interview with LN 1, on 8/11/16, at 4:20 p.m., he stated, LN 1 walked over to Patient A the evening of 8/8/16 and noticed her face and clothes were wet with mocha and Patient B was still yelling at her. When asked if this was abuse, LN 1 said yes. LN 1 stated he was instructed by the Assistant Director of Nursing to complete a change in condition report. LN 1 said he did not notify the police, ombudsman, and the California Department of Public Health. There was no documented evidence the facility reported the suspected abuse of Patient A by Patient B to the Department of Public Health. During an interview with the Administrator (ADM), on 8/10/16, at 1:35 p.m., when asked why he or his staff did not notify the California Department of Public Health he stated, "Welfare and Institution Codes said if a patient cannot form intent then it is not abuse." The ADM also said, "It was not abuse because Patient B could not form intent, she has dementia." The facility policy and procedure entitled "Abuse Prevention, Intervention, Investigation, & [and] Crime Reporting Policy" revised December 2012, indicated, "6. Reporting-Regulations require employees that provide services to elderly persons or dependent adults (mandated reporters) to report instances of suspected or allegations of abuse, neglect, or misappropriation of resident property to the local ombudsman or local law enforcement agency and to the State Licensing and Certification immediately or as soon as practically possible within 24 hours of detection. ..." Therefore, the Department determined the facility failed to report an allegation of abuse within 24 hours as required, when Patient B threw hot mocha in the face of Patient A on 8/8/16. |
| 100000039 |
Windsor Hampton Care Center |
030012720 |
B |
10-Nov-16 |
4BL611 |
10117 |
F323 Free of Accident Hazard/Supervision/Devices The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. The following citation is written as a result of an investigation of facility reported incident #CA00480131. An unannounced visit was made to the facility on 3/18/16. The Department determined the facility failed to: Provide adequate supervision to ensure Resident A was free from accidents and injuries when she sustained a severe injury and amputation to her left fifth fingertip (little finger) as she opened and closed the door of Shower Room 2. Resident A was admitted to the facility 11/19/15. She had multiple diagnoses including generalized muscle weakness, repeated falls, and dementia. Resident A had a care plan, initiated on 12/15/15, which indicated under focus, "The resident is dependent on staff for activities, cognitive stimulation, social interaction, risk for leaving the building, running into others, grabbing them or objects around her [wheelchair] and risking hurting herself or others. Needs close monitoring throughout the day [related to] severe cognitive deficits and motor restlessness." Interventions included: Escort and sit with the resident once in scheduled activities, and [Resident] needs to be closely monitored when up in [activity] room [due to] fall risk and wandering." The care plan did not quantify how closely Resident A should be monitored. Resident A had a care plan, initiated on 12/22/15, which indicated under focus, "Resident A at risk for elopement [related to] dementia." The care plan indicated under interventions, "Monitor resident whereabouts frequently." The care plan did not specify and/or quantify how often Resident A should be monitored. Resident A had a care plan, initiated on 2/19/16, which indicated under focus, "Resident at risk for skin tears and injury related to poor safety awareness and banging herself to objects." A quarterly Minimum Data Set (MDS, an assessment tool), dated 2/25/16, indicated Resident A was rarely or never understood and rarely or never understood others. Resident A had short-term and long-term memory problems. Her cognitive skills for daily decision making were severely impaired. The MDS also indicated Resident A had physical behavioral problems directed towards others (e.g. hitting, kicking, pushing, scratching, grabbing...) and wandering (which occurred 4 to 6 days a week, but less than daily). Resident A required extensive assistance of one person with activities of daily living. Resident A had a care plan, initiated on 3/6/16, which indicated under focus, "Resident having increased motor restlessness as evidenced by continuous elopement attempts." Resident A's Progress Note, dated 3/12/16, indicated Licensed Nurse (LN 1) saw Resident A at 10:25 p.m. at the East Station shower room, opening and closing the shower room door. The Note indicated, "When charge nurse LN 1 came to bring her away from the door, [there were] blood streaks noted on the left door frame and blood drops on floor next to her wheelchair. When examined by charge nurse, the very distal tip of the [left] small finger was severed in slanted direction. Wet to dry gauze was [immediately] placed on the finger to control bleeding. [There] was a moderate amount of bleeding...The severed tip of finger was found on the floor in the space [where] the door hinges are." The Progress Note indicated Resident A was given Percocet (pain medication) prior to transfer to the emergency room. Resident A's hospital visit information sheet, dated 3/12/16, indicated, in part, "Finger Tip Amputation, Open [Treatment]... suture removal in approximately 7-10 days. Clindamycin (antibiotic) has been prescribed for prophylaxis since there is a concern for possible bony involvement of the amputation...You have cut off the tip of your finger...there is skin missing and the wound cannot be fully covered by sewing the edges together...it will take from 2-6 weeks for the wound to fill in with new skin." Resident A had a care plan, initiated on 3/13/16, which indicated under focus, "Resident has injury to [left] distal tip of small finger [related to] severing." Resident A had a second care plan, initiated on 3/13/16, which indicated under focus, "The resident has actual impairment to skin integrity at 5th left finger [related to] amputation secondary to trauma." An interview was conducted with LN 1 on 3/18/16 at 10:15 a.m. LN 1 said he heard the sound of a door opening and closing back and forth while he was passing medications in a room adjacent to the nursing station on 3/12/15 around 10:30 p.m. LN 1 pushed the medication cart to the nurses' station and saw Resident A sitting next to Shower Room 2. He noted Resident A was facing the door. Her hands and the wheelchair were in contact with the door. Resident A's left hand was toward the left where the door handle was located. LN 1 reported there was no staff at the nurses' station or in sight at the time. LN 1 noted blood smears on the door below the handle, on the floor next to the door, and on Resident A's hands and shirt. LN 1 indicated he cleaned up Resident A's hands and noted the left fifth fingertip and nail was missing. LN 1 looked around and found the missing portion of the finger on the floor at the right corner of the hinge of Shower Room 2's door. LN 1 said he was not sure if Resident A was in pain, but he administered Percocet 1 tablet by mouth. LN 1 notified the physician and sent Resident A to the emergency room. LN 1 indicated Resident A always wandered about the facility when she was up in her wheelchair, wandered into other resident's rooms at times, and was always seeking the exit doors, attempting to open them. An observation was conducted of Resident A on 3/18/16 at 10:40 a.m. Resident A was observed in the hallway near the East Nurses' Station sitting up in her wheelchair sleeping. An alarmed self-releasing belt (a seat belt which the resident can release, that alerts the staff if the resident attempts to get up independently) was placed across her lap. Resident A's left fifth finger (little finger) was wrapped in a dressing. A family member was sitting next to her. An interview was conducted with Resident A's family member on 3/18/16 at 10:45 a.m. He indicated she had severely injured her finger while trying to open and close the shower room door near the East Station. Her family member reported he had seen the amputated left little fingertip at the local hospital where she was referred to after the incident. Her family member stated, "I felt sorry for her." An interview was conducted with Certified Nursing Assistant (CNA) 1 on 3/18/16 at 11:10 a.m. She indicated Resident A wandered into other resident's rooms and about the facility and opened doors with one hand as she moved along. CNA 1 indicated staff tried to re-direct her, but it was difficult because she couldn't stay in one area. CNA 1 reported Resident A ran into other residents' wheelchairs, walkers, and objects as she wandered. She had no safety awareness. A change of the wound dressing was observed with Registered Nurse (RN) 1 on 3/18/16 at 11:48 a.m. Resident A was observed in her room sitting in her wheelchair with the alarmed self-releasing seatbelt placed across her lap. Her family member was at her bedside. The left fifth fingertip was noted amputated and the nail was missing. There were 3 sutures (stitches) to the finger area. RN 1 reported Resident A crushed her left fifth finger as she opened and closed the shower room door on 3/12/16 and was taken to the emergency room where the area was sutured. RN 1 indicated the wound dressing was being changed twice daily. RN 1 reported Resident A had behaviors of wandering. An interview was conducted with CNA 2 on 3/18/16 at 1:45 p.m. She indicated Resident A wandered all over the facility, grabbed onto objects like wheelchairs and walkers, and opened doors in an attempt to exit the facility. An interview was conducted with LN 2 on 3/18/16 at 1:50 p.m. LN 2 was asked what behaviors Resident A displayed. LN 2 indicated Resident A went into other peers' rooms, attempted to exit the facility, grabbed on wheelchairs, grabbed door handles, and wandered about the facility. An interview was conducted with CNA 3 on 3/22/16 at 4:10 p.m. She indicated she left Resident A in front of the East Nurses' Station on 3/12/16 around 10 p.m. after she provided care to her. CNA 3 then went to assist another resident. CNA 3 indicated there were 3 nurses sitting at the East Nursing Station. CNA 3 indicated Resident 3 wandered about the facility and always had bruises from banging into objects. An interview was conducted with LN 3 on 3/23/16 at 7:30 a.m. He indicated Resident A was unable to follow safety instructions, tried to go into other peers' rooms, sought exits, bumped into other peers' wheelchairs and the medication cart, and attempted to open doors and exits located in the front lobby and therapy room. LN 3 indicated Resident A was started on one to one supervision on 3/13/16 after she injured her finger when opening and closing the shower room door on 3/12/16. An interview was conducted with the Director of Nursing (DON) on 3/18/16 at 1 p.m. The DON indicated Resident A was at risk of elopement and wandered about the facility. When asked about the supervision provided to Resident A to ensure her safety, the DON indicated all staff were aware of her behaviors and were responsible to monitor her closely. The DON indicated the facility had no policy and procedure specific to prevention of accidents and supervision. Therefore, the Department determined the facility failed to: Provide adequate supervision to ensure Resident A was free from accidents and injuries when she sustained a severe injury and amputation to her left fifth fingertip (little finger) as she opened and closed the door of Shower Room 2. This violation had a direct relationship to the health, safety, or security of long-term care facility patients. |
| 030000046 |
Windsor El Camino Care Center |
030012832 |
B |
30-Dec-16 |
KQ4H11 |
12438 |
F314 Treatment/cvcs to Prevent/heal Pressure Sores 483.25 (c)Based on the comprehensive assessment of a resident, the facility must ensure that a resident who enters the facility without pressure sores does not develop pressure sores unless the individual's clinical condition demonstrates that they were unavoidable; and a resident having pressure sores receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing. The following citation is written as a result of complaint #CA00481554. An unannounced visit was made to the facility on 4/7/16 to investigate patient care allegations of pressure ulcer (injury to the skin and/or underlying tissue as a result of pressure) development and progression. The Department determined the facility failed to: 1. Prevent Resident 1 from developing a pressure ulcer; and 2. Promote the healing process in accordance with the resident's comprehensive care plan. This failure resulted in Resident 1 developing a Stage IV pressure ulcer (full thickness skin and tissue loss) that exposed bone. Resident 1 was initially admitted to the facility on xxxxxxx from the acute hospital for aftercare of a neck fracture due to a fall. After the initial admission, Resident 1 was transferred back to the hospital on xxxxxxx due to a fall that occurred in the facility and readmitted to the facility on xxxxxxx. Review of Resident 1's clinical records indicated the facility identified Resident 1 was at high risk for developing pressure ulcers upon the initial admission due to her immobility, bladder incontinence, and impaired cognitive function (trouble remembering, learning new things, concentrating, or making decisions) as evidenced by the "Admit/Readmit Assessment v1.0," (initial nursing assessment), dated 1/18/16, which indicated: -Incontinent bladder function "c. Resident is wet during: Day and Night time" -Extensive assistance for bed mobility; -Total dependence in toilet use, personal hygiene, and bathing; -Alert and Oriented to person only Resident 1's MDS (Minimum Data Set, an assessment tool), dated 1/24/16, identified Resident 1 was at risk for developing pressure ulcers and had no "Unhealed Pressure Ulcer(s)". Care plans developed based on the initial assessment included: -1/18/16 "Functional bowel/bladder incontinence" which directed Certified Nurse Assistants (CNA) to "Monitor and document intake and output [fluid consumed and fluid eliminated] as per facility policy." -1/19/16 "Activities of Daily Living" which directed CNAs to perform a "...SKIN inspection q [every] shift. Observe for redness, open areas, scratches, cuts, bruises and report changes to the Nurse." -1/19/16 "...dehydration or potential fluid deficit r/t [related to] Poor intake..." directed LN [Licensed Nurse] to "Monitor and document intake and output as per facility policy." -1/19/16 "High risk/potential for pressure ulcer development r/t...Dehydration, Immobility, Incontinence," directed CNAs to "Follow polices/protocols for prevention/treatment of skin breakdown at all times." A "Skin/Wound Note," dated 1/19/16, indicated, "No pressure related wound noted" upon admission. Resident 1's clinical record contained no documented evidence that the "Pressure Ulcer Risk Assessment" was completed for the first four weeks after the admission between 1/18/16 through 2/15/16 per facility policy. The facility's 6/23/16 policy, titled "Skin and Wound Management Program," stipulated "The Pressure Ulcer Risk Assessment" an assessment form, was to be completed "...weekly for the first four weeks after admission and re-admission..." There was no documented evidence a "CNA Daily Skin Check" to monitor for Resident 1's skin integrity was completed for January and February, 2016 per the 1/19/16 Activities of Daily Living care plan. There was no documented evidence a "Weekly Skin Review" was done by licensed staff for the weeks of 1/26/16, 2/2/16, and 2/16/16. A "Health Status Note," dated 2/18/16 (one month after admission) indicated, "Two open areas noted to coccyx [tailbone]." A "Wound Weekly Monitoring/Assessment" dated 2/24/16, indicated a pressure ulcer to, "Coccyx Pressure 2 cm [centimeter, 0.8 inches] x 1 cm [0.4 inches] Unstageable" [full thickness tissue (skin and the tissue under the skin) loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green, or brown) and/or eschar (dry, dark scab) in the wound bed] Review of Resident 1's February, 2016 Treatment Administration Records (TAR) indicated the following measures were implemented in an attempt to promote pressure ulcer healing: -2/18/16 "Apply barrier cream to the peri [groin]-area Q shift and PRN [as needed] for episodes of incontinence" to protect the skin from moisture. -2/29/16 "Resident must be toileted by staff or offered to toilet q 2 hours while awake and prn [as needed] using bedside commode or bathroom" to improve urinary incontinence and prevent moisture. -2/29/16 "Turn and position resident from side to side every q 2 hours and prn" [as needed] to relieve pressure. In an interview on 5/13/16 at 9:50 a.m., LN 1, a wound treatment nurse who assessed Resident 1's skin on 1/19/16, verified Resident 1 had no pressure ulcer upon initial admission. In an interview on 5/13/16 at 11:45 a.m., the Director of Nursing (DON) verified Resident 1 was identified at high risk for pressure ulcers but did not admit to the facility with pressure ulcers. In interviews on 5/13/16 at 10:25 a.m. and at 11:45 a.m., the Director of Nursing (DON) acknowledged Resident 1 was admitted to the facility without a pressure ulcer and developed one in the facility. The DON verified there was no documented evidence "The Pressure Ulcer Risk Assessment" was completed during the first four weeks after the resident was admitted. The DON confirmed there was no documented evidence the charge nurse's "Weekly Skin Review" for 1/26/16, 2/2/16, and 2/16/16 were done prior to Resident 1 developing the pressure ulcer. The DON stated the wound specialist had been taking care of the resident's pressure ulcer since 2/24/16. The DON verified there was no documented evidence of the "CNA Daily Skin Check" for January and February, 2016 and stated when CNAs did not document the skin checks every shift, it was inconsistent with the resident's care plan. Resident 1's Wound Care Consultant "Physician's Progress Notes" indicated the following: -2/24/16 "Location: Sacrum [lower back]/Coccyx...Pressure ulcer of sacral region, unstageable...Contributing factors-malnutrition and incontinence" -3/1/16 "Pressure ulcer of sacral region, unstageable...Contributing factors-malnutrition and incontinence" -3/9/16 "Pressure ulcer of sacral region, stage 3...Contributing factors-malnutrition and incontinence" A Care plan for Resident 1 was developed to promote healing for the 2/18/16 pressure ulcer to Resident 1's coccyx on 3/18/16 (one month after the open wound was noted). Resident 1's "Health Status Notes" indicated Resident 1 was hospitalized and readmitted to the facility as follows: -3/14/16 "...found resident on the floor on her left side next to her w/c [wheelchair]...resident transferred to [Name of Hospital]" -3/17/16 "Admitted resident at around 1600 [4 p.m.] from [Name of Hospital]" Review of Resident 1's March, 2016 TAR indicated skin care/pressure ulcer prevention interventions were discontinued on 3/14/16 when Resident 1 was transferred to the hospital. The facility did not reinstate the following orders when Resident 1 returned to the facility from the hospital on 3/17/16: -"Apply barrier cream to the peri [groin] - area Q shift and PRN [as needed] for episodes of incontinence" to protect the skin (original order 2/18/16) -"Resident must be toileted by staff or offered to toilet q 2 hours while awake and prn using bedside commode or bathroom" to improve urinary incontinence (original order 2/29/16). Review of Resident 1's care plans for "...high risk/or at risk for pressure ulcer..," dated 3/18/16, indicated "Identify/document potential causative factors and eliminate/resolve where possible" and the care plan for "...has a pressure related wound to the coccyx..," dated 3/18/16, indicated the resident's goal was, "Affected area to heal with no issues...prevent further skin integrity issues." Post hospitalization, Resident 1's Wound Care Consultant "Physician's Progress Notes" indicated: -3/23/16 "Resident returns from hospital. Overall the wound looks better...I don't think it will be any deeper than stage III [stage 3-Full thickness tissue loss; subcutaneous (under the skin) fat may be visible but bone, tendon or muscles are not exposed]...Contributing factors-malnutrition and incontinence" -3/30/16 "...it is now down to bone...Pressure ulcer of sacral region, stage 4 [full thickness tissue loss with exposed bone, tendon or muscle]...Contributing factors-malnutrition and incontinence" -4/6/16 "...Pressure ulcer of sacral region, stage 4" "Contributing factors-malnutrition and incontinence" Review of physician orders, indicated Resident 1 had a physician order, dated 3/29/16, after the resident's pressure ulcer worsened from stage III to stage IV, for an indwelling catheter (a tube inserted and remaining in the bladder to drain urine to the outside of the body) to "Promote Wound Healing." In an interview on 5/13/16 at 11:26 a.m., LN 1, a wound treatment nurse, acknowledged that had the skin inspection been completed every shift, earlier signs and symptoms of the pressure ulcer could have been noted for Resident 1. In interview 5/13/16 at 1 p.m., the DON acknowledged that one of the contributing factors for Resident 1's pressure ulcer to the coccyx was urinary incontinence. The DON verified Resident 1 was transferred to the hospital with a stage III pressure ulcer and returned to the facility with a stage III pressure ulcer as assessed by the wound specialist. The DON acknowledged Resident 1's pressure ulcer got worse and reached Stage IV in the facility; and on 3/29/16 an indwelling catheter was placed to assist with the resident's incontinence. The DON acknowledged that the facility could have promoted Resident 1's pressure ulcer healing process had the toileting program and the skin barrier cream application been reinstated upon returning to the facility and/or had the indwelling catheter been placed earlier to relieve the resident's urinary incontinence. The facility's 6/23/06 policy, titled "Skin and Wound Management Program," stipulated the residents were to receive care and service necessary to promote and maintain optimum skin integrity, and the facility was to complete the following: -"Body check will be performed by CNAs daily" and to document on the "CNA Daily Skin Check." -"Charge Nurses will perform weekly skin evaluation and document findings on the Weekly Skin Review" Review of the facility's 11/2012 policy, titled "Catheters, Urinary..." stipulated "All types of urinary catheters will be used or discontinued based on medical need, physician's orders..." The "Skin and Wound Management Program" policy further stipulated, "Predictive and preventive measures outlined in the Clinical Practice Guideline Number 3 - Pressure Ulcers in Adults: Prediction and Prevention published by the Agency for Health Care Policy and Research will be used as the minimum standard of practice for all [corporate name] facilities." Predictive and preventive measures outlined in the "Clinical Practice Guideline Number 3 - Pressure Ulcers in Adults: Prediction and Prevention," published by the Agency for Health Care Policy and Research (Publication No. 92-0047 May 1992), indicated in pertinent part: "All individuals at risk should have a systematic skin inspection at least once a day...Results of skin inspection should be documented...5. Minimize skin exposure to moisture due to incontinence...Topical agents that act as barriers to moisture can also be used...9. Interventions and outcomes should be monitored and documented." (Retrieved from http://files.eric.ed.gov/fulltext/ED357247.pdf on 11/30/16 at 5:45 p.m.) Therefore, the Department determined the facility failed to: 1. Prevent Resident 1 from developing a pressure ulcer; and 2. Promote the healing process in accordance with the resident's comprehensive care plan. These violations had a direct or immediate relationship to the health, safety, or security of Long Term Care patients or residents. |
| 100000029 |
Wine Country Care Center |
030013415 |
B |
9-Aug-17 |
RUB211 |
3733 |
California Health & Safety Code 1418.91
(a) A long-term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the department immediately, or within 24 hours.
(b) A failure to comply with the requirements of this section shall be a class "B" violation.
The following citation is written as a result of an investigation of entity reported incident #CA00539169. An unannounced visit was made to the facility on 6/21/17 to initiate investigation of an allegation of abuse that occurred on 6/7/17.
The Department determined the facility failed to report an allegation of abuse within 24 hours as required, when the Certified Nursing Assistant 1 (CNA 1), who witnessed the alleged abuse, did not report it to the department.
Patient 1 was admitted to the facility in early 2012 with diagnoses which included dementia without behavioral disturbance. The most recent Minimum Data Set (MDS, an assessment tool) dated 3/11/17, indicated Patient 1"is rarely/never understood" and is "moderately impaired" in making decisions regarding tasks of daily life.
A review of the nurse's notes for Patient 1 dated 6/9/17 at 2:30 p.m., indicated her responsible party was notified of the bruise on Patient 1's right eye, and the investigation into the cause.
During an observation of Patient 1 with Licensed Nurse 1 (LN 1) on 6/21/17 at 2:30 p.m., Patient 1 was noted with skin discoloration of yellow to reddish-purple on her right lower eye.
During an interview with LN 1 on 6/21/17 at 2:40 p.m., LN 1 stated she first observed the skin discoloration of Patient 1 on 6/9/17.
In an interview with CNA 3 on 6/21/17 at 2:45 p.m., CNA 3 stated CNA 1 told her on 6/8/17 that another CNA (CNA 2) had punched Patient 1 on the face. CNA 3 stated she had not witnessed the incident but had been aware and did not report it.
In an interview with CNA 1 on 6/21/17 at 3:50 p.m., CNA 1 stated "I witnessed [first name of CNA 2] punched [first name of Patient 1] on [the] face." CNA 1 stated, the incident happened on 6/7/17 between 9 p.m. and 9:30 p.m. CNA 1 stated as she was walking down the hallway towards the nursing station she heard Patient 1 screaming and she peaked through Patient 1's door. CNA 1 described, the door was slightly opened and the privacy curtain drawn. When asked what Patient 1 and CNA 2 were doing in the room, CNA 1 stated Patient 1 was on the sit-to-stand lift (a mechanical device use to assist in transfer) while CNA 2 was standing in front of Patient 1 trying to assist Patient 1 with transfer from her wheelchair to her bed. According to CNA 1, she observed Patient 1 trying to bite CNA 2 on his left arm and CNA 2 struck Patient 1 on the face with his right hand. CNA 1 stated she was scared to report the incident to the management but had mentioned the incident to another CNA (CNA 3) on 6/8/17.
A review of the undated facility policy titled, "Abuse, Prevention Of," directed "Administrator shall report all incidents of alleged abuse or suspected abuse to DHS [Department of Health Services] within 24 hours."
In an interview with the Director of Nursing (DON) on 6/21/17 at 4:10 p.m., the DON explained, all staff was mandated reporters and any suspected abuse should be reported within 24 hours to the state agency. The DON acknowledged, the facility failed to report the abuse allegation within 24 hours as required, due to the failure of CNA 1 to notify the facility staff members.
Therefore, the Department determined the facility failed to report an allegation of abuse within 24 hours as required, when the Certified Nursing Assistant 1 (CNA 1), who witnessed the alleged abuse, did not report it to the department. |
| 040001040 |
WILLOW CREEK HEALTHCARE CENTER |
040008876 |
B |
03-Jan-12 |
W6QY11 |
6742 |
CLASS B CITATION -- PATIENT CARE Title 22 DIV5 ART3 Nursing Services 72311 (a) (2) Nursing Services(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 planOn 9/28/11 at 1:50 p.m., an unannounced visit was made to the facility to investigate an Entity Reported Incident of a fall with injury, CA 00284984. Based on observation, resident and staff interview, clinical record and administrative document review, the facility failed to implement Patient 1's "Fall" Care Plan #11. The goal was to prevent falls. The approach to prevent falls was to secure the self-release belt while up in a wheelchair to prevent Patient 1 from leaning forward. Certified Nurse Assistant (CNA)1 failed to apply the self-release belt and as a result Patient 1 resulted in a fall. Review of Patient 1's "Face Sheet" indicated she was an 87 year old female admitted to the facility on 6/1/11 with diagnosis of muscle weakness general. The Minimum Data Set Assessment(MDS)validated a history of multiple falls with prior fracture. Patient 1's MDS dated 8/25/11 indicated "Balance: surface to surface transfer was not steady, only able to stabilize with human assistance." The physician progress notes dated 8/19/11 added a diagnosis which included, Dementia (a loss of brain function occurring in certain diseases that affects memory, thinking, language, judgment, and behavior). Patient 1's "Fall" care plan #11 dated 8/5/11 indicated Patient 1 had poor safety awareness.On 9/27/11 at 10:20 a.m., during an interview, CNA 1 stated she sat Patient 1 in her wheelchair inside of Patient 1's room after taking the patient to the bathroom.CNA 1 stated she left Patient 1 by the bathroom door, turned her back against the patient and went back in the bathroom. CNA 1 stated Patient 1 then fell out of the wheelchair, face to the floor, and sustained an injury. CNA 1 stated "Her [Patient 1's] seatbelt was not locked when I left her. It should have been. I knew I must lock [the] seat belt but [I] didn't." On 9/28/11 at 1:50 p.m., during a concurrent observation and patient interview, Patient 1 was noted to have several steri-strips (thin adhesive strips which can be used to close small wounds, generically known as butterfly stitches) over a cut on the bridge of the nose. The cut that measured 1-2 cm. (centimeters) had dried blood surrounding the wound. Patient 1 had purplish blue discoloration to her left periorbital area (pertaining to the area surrounding the eye socket). Her left eyelid was swollen. Patient 1 was wearing a removable left wrist splint and had swelling to her left hand. Patient 1 attempted to rotate her left thumb and was unable to do so fully. Patient 1 stated she could not move her thumb well. On 9/29/11 at 9 a.m., during an interview, Registered Nurse (RN) 1 stated Patient 1 had sustained a fracture to her nose as well as other bruises and scrapes from the fall which occurred on 9/27/11.RN 1 stated CNA 1 had left Patient 1 sitting in her wheelchair outside the bathroom door then turned her back against Patient 1 to go back in the bathroom without first securing Patient 1's self-release belt. Patient 1 then fell face forward to the ground, injuring her face. RN 1 stated "blood was gushing" from Patient 1's face. RN 1 stated Patient 1 also complained of right shoulder pain at that time. RN 1 described Patient 1's position after the fall as "face on the floor with both knees on the floor."RN 1 stated Patient 1's other injuries from the fall included bruises to her left arm, swelling to her left thumb, and abrasions (also known as grazes or scrapes) to both knees. RN 1 continued, "[It- the seatbelt] should have been [in place], that's one of the interventions because she tends to lean forward and already had falls in the facility."On 9/29/11 at 10:20 a.m., during an interview, CNA 1 stated by a review of a signed written declaration, dated 9/29/11 at 11 a.m., "...I took my patient [Patient 1] to the bathroom, after that... brought back to out of bathroom (sic)...She was out of the bathroom & (and) notice that I left the water running, quickly I went to shut the water off. In that quick moment [Patient 1] lean forward and fell down face down (sic)... My mistake was that I forgot to put her belt on...." On 10/3/11 at 9:05 a.m., during an observation, six days after the fall, Patient 1 had a blue to yellowish green discoloration on the left side of her face. Her left periorbital(area surrounding the eye)area had a fading purple to green discoloration.Patient 1's readmission, "FALL RISK ASSESSMENT," dated 8/5/11, indicated Patient 1 had a score of 16. The fall risk assessment indicated, "... If the total score is 10 or greater, the resident should be considered at HIGH RISK for potential falls. A prevention protocol should be initiated immediately and documented on the care plan." Reassessments were done on on 8/8/11, 8/11/11, and 9/27/11 with the scores all above 15 which indicated Patient 1 was a high risk for falls. Patient 1's current "Patient Care Plan on FALLS," initiated on 8/5/11, "At risk for Falls: Secondary to: History of Falls prior to admission [in the] Last 30 days..." The indicated goal was "The resident/ patient will: Have no injuries related to Falls..." On 8/12/11 indicated, "... Approaches/needs or preferences. The staff will...[use] self release belt when up in Kw/C to keep upright position (sic)..." Patient 1's Interdisciplinary Team (IDT) Notes dated 8/12/11 indicated, "Resident incident of fall on 8/11/11... A High risk of fall.... Fall risk assessment score 16 placing her a high risk for fall.IDT Recommendations... Review use of self release belt..." The facility failed to ensure the Care Plan #11 for Patient 1, who had a history of falls with injuries, was implemented. CNA 1 failed to secure the self-release belt prior to leaving Patient 1 unattended in her wheelchair. This failure resulted in a fall in which the resident sustained a non-displaced (a broken bone that has not moved from it's normal anatomical position) fracture to the nose, bruises, swelling of the left thumb and abrasions to both knees. Patient 1 was immediately taken by ambulance to the Emergency Room where a CT (Computerized Tomography-A computerized X-ray that can Display Anatomies not seen on Conventional X-rays.) revealed a fracture to the nose as well as soft tissue swelling, scrapes and bruises. Patient 1 was treated for pain which she described as a 5 using a pain scale rated from 1-10. The above violation had a direct or immediate relationship to Patient 1's health and safety and therefore constitutes a Class 'B' Citation. |
| 100000038 |
Windsor Post-Acute Healthcare Center of Modesto |
040009117 |
B |
15-Mar-12 |
QT9S11 |
4754 |
72517 Staff Development (a) Each facility shall have an ongoing educational program planned and conducted for the development and improvement of necessary skills and knowledge for all facility personnel. Each program shall include, but not be limited to: (5) Accident prevention and safety measures. The facility failed to provide a staff educational program for the safe use of shower gurneys which included the manufacturer's precautions of not using the side rails as grab bars, which resulted in Resident 1's fall and subsequent injuries. On 8/24/11, 9/15/11, and 12/28/11, unannounced visits were made to the facility to investigate Complaint #278548 regarding Quality of Care/Treatment - Resident Safety/Falls. Review of Resident 1's face sheet indicated he was readmitted to the facility on 4/19/10, with diagnoses that included old cerebrovascular accident, chronic back pain, and senile dementia. The Minimum Data Set (MDS) assessment dated 7/28/11, indicated Resident 1 had a functional impairment in his lower extremity that required the use of a wheel chair and extensive assistance by staff. The Medical Director discharge note dated 8/22/11 indicated Resident 1 was "grossly obese (221 pounds) and non-ambulatory." On 9/15/11, Licensed Nurse 2, the Director of Continuous Quality Improvement (DCQI), provided a "shower" policy and procedure dated 4/11, devoid of the shower gurney manufacturer's operation instructions. A copy of manufacturer's operation instructions was not provided.On 12/28/11 at 11:30 a.m., Certified Nursing Assistant 1 (CNA 1) stated when she needed to wash Resident 1's back, the resident assisted by grabbing the right side rail of the gurney with his left hand, to turn onto his right side away from CNA 1. CNA 1 stated she assisted him into position by lifting up his left leg. The right side rail fell down, Resident 1's lower body slid off the gurney, followed by the upper body and his head, onto the tiled floor of the shower stall, landing on the right side of his body, just in front of the low lying wall. CNA 1 stated there was no training in the classroom specific to the operation of a shower gurney.On 12/28/11 at 2:45 p.m., during an interview, Licensed Nurse 1, the Director of Staff Development (DSD), stated training for the shower gurneys was done during orientation "on the floor" and learned "hands-on" with a staff CNA. The DSD stated her expectation when cleaning a resident's back on a shower gurney, included asking the resident to "hold on to the side rails of the gurney to turn, just long enough to wash and spray off, to quickly do the back."The DSD stated there was no specific shower gurney policy and procedure. The DSD stated she did not know about manufacturer's specification to not use the side rail as a grab bar. A review of the manufacturer's specifications for the "OPERATION INSTRUCTIONS" dated 1/30/07, revealed "PRECAUTIONS: Do not use siderail as grab bar." On 3/1/12 at 9:35 a.m., during a telephone interview, the Manufacturer's Representative (MR) stated the side rail was "not sturdy/stable enough to use as a grab bar..." The acute hospital's "Pre-Hospital Care Report" dated 8/5/11 contained documentation that Resident 1 was transferred to the acute hospital on 8/5/11 at 10:43 a.m. The acute hospital's "ED (Emergency Department) PRIMARY" form contained documentation that Resident 1's diagnoses included: "fractured thoracicspine w/o (without) cord injury, fractured femoral neck (hip), concussion (jarring injury of the brain), intracranial bleed (bleeding inside the skull), syncope (fainting) and seizure." The "Orthopedic Consultation" report dated 8/5/11 at 4:30 p.m., contained documentation that Resident 1 was "status post fall earlier today while doing a transfer. He has fairly severe pain in the right hip and groin area which is somewhat masked by the severe pain in his lower back. He rates the pain as moderate, worse with any movement." The facility failed to provide a staff educational program for the safe use of shower gurneys which included the manufacturer's precautions not to use the side rails as grab bars. This failure resulted in Resident 1's fall and subsequent injuries: - The femoral neck (hip) fracture required a surgical procedure "Open Reduction Internal Fixation of the Right Hip." - The thoracic spine fracture without cord injury required Resident 1 to don a Thoraco-Lumbar-Sacral Orthotic (TLSO), a body brace restricting movement worn when up in wheel chair.- Concussion, intracranial bleed, syncope, and seizure. - Resident 1 rated his pain as moderate, worse with any movement.The above failures had a direct or immediate relationship to patient health, safety, or security, and therefore constitutes a Class 'B' Citation. |
| 100000038 |
Windsor Post-Acute Healthcare Center of Modesto |
040009912 |
A |
20-May-13 |
VJJQ11 |
12769 |
483.25(m)(2) Residents Free of Significant Med Errors The facility must ensure that residents are free of any significant medication errors. The facility violated the regulation by failing to ensure Resident 1 was free from a significant medication error when Morphine Sulfate (MS) (a medication to control pain) was not administered as prescribed and policies and procedures were not in place to protect resident safety. Resident 1 had been prescribed 5 milligrams (mg) of MS for pain control. Resident 1 had been given 100 mg of MS, an overdose 20 times the ordered dose, in error by the facility's licensed vocational nurse (LVN 1). Resident 1 developed respiratory distress and became unresponsive as a result of the overdose of medication. Resident 1 died as a direct result of MS toxicity. Review of Resident 1's clinical records on 11/6/12 indicated Resident 1 had been admitted to the facility on 12/3/10. He had diagnoses that included Chronic Obstructive Pulmonary Disease (a disease that decreases the ability of the lungs to breathe effectively) and colon cancer with metastasis [extended to] the liver and the lung. Resident 1 had received hospice services beginning 8/7/12 at the facility for comfort and pain control. The hospice staff on 10/22/12 described Resident 1 as alert and oriented, minimally responsive verbally and required total assistance for basic care and nutrition needs. Resident 1 was described by hospice staff as "unable to take medication(s) unless administered by someone else."Resident 1's physician orders dated 10/16/12 indicated, "Morphine Sulfate (Concentrate) 20 mg/ml (milliliter) Solution by mouth. Dose Ordered: 0.25 ml/5 mg PO [by mouth] q [every] 6 h [hours] ATC [around the clock] 6 am 12 pm 6 pm 12 MN for Pain." On 1/9/13 at 10:50 a.m., during a telephone interview, LVN 1 stated on 10/26/12 at 12 noon she went into Resident 1's room. Resident 1 was awake and alert and able to respond appropriately to her questions with "yes" or "no." LVN 1 stated on 10/26/12 at 12 noon she had poured the liquid morphine into a plastic cup to measure the dose. LVN 1 stated she administered 100 mg (5.0 ml) of morphine instead of 5 mg (0.25 ml) to Resident 1. LVN 1 stated she realized her error when she documented the MS administration on the "Drug Accountability Record" (a document that tracks the time and amount of each dose of morphine given to every resident) after giving Resident 1 the medication. LVN 1 stated she then notified the Director of Nursing (DON), the hospice nurse and the resident's family of the error at 1 p.m.Review of professional reference, "Davis's Drug Guide for Nurses, Eleventh Edition," identified MS as a "High Alert" medication. The guide indicated, "Some medications, because of a narrow therapeutic [effective] range or inherent toxic nature, have a high risk of causing devastating injury or death if improperly ordered, prepared, stocked, dispensed, administered or monitored....they require special attention due to the potential for serious, possibly fatal consequences. These have been termed high-alert medications to communicate the need for extra care and safeguards." Davis's guide for MS "Nursing Implications" indicated: "High Alert...clarify doses that greatly exceed normal range. Have second practitioner independently check original order and dose calculations...administer oral solution with properly calibrated measuring device...older adults are more sensitive to the effects of opioid analgesics and may experience side effects and respiratory complications more frequently." Davis's Guide indicated: "Morphine...usual starting dose for moderate to severe pain...30 mg q 3 to 4 hours... Review of professional reference, "Institute for Safe Medication Practices" website www.ismp.org dated 2012 included liquid concentrate narcotics on their list of "High Alert" medications. The website indicated, "High-alert medications are drugs that bear a heightened risk of causing significant patient harm when they are used in error. ...the consequences of an error are clearly more devastating to patients. We hope you will use this list to determine which medications require special safeguards to reduce the risk of errors."On 11/6/12 at 12:45 p.m., during an interview, the DON stated, Resident 1 had been given 100 mg of MS on 10/26/12 in error by a facility licensed nurse. The DON stated Resident 1 should have received 5 mg of morphine (0.25 ml), not 100 mg (5.0 ml).On 2/21/13 at 3:34 p.m., during an interview, the DON stated there was no policy or procedure for signing the drug accountability record before or after giving a narcotic medication such as MS. The DON stated the facility had no policy for licensed nurses to have a high alert medication double checked by another nurse prior to administration.On 2/21/13 at 4:20 p.m., during an interview, the Director of Staff Development (DSD) stated newly hired licensed nurses are provided orientation to medication administration, but not specifically to high risk narcotic administration. The DSD stated there had not been a system in place in October 2012 for double checking high alert medications.Review of facility document "Lesson Plan - Inservice, Title: Medication Administration" dated 9/11/12 did not indicate inclusion of safe guards for "High Alert" medications. Resident 1's nurse's notes dated 10/26/12 at 1:10 p.m. indicated Resident 1 was alert, blood pressure (B/P) was 121/67, heart rate (HR) was 117 and respiratory rate (RR) was 24. Resident 1's hospice notes dated 10/26/12 at 1:30 p.m. indicated Hospice Nurse (HN) 1 had arrived and assessed Resident 1. The hospice note indicated Resident 1 was not able to speak but was "able to track with eyes" in response to verbal stimulation. The document indicated Resident 1's blood pressure (B/P) had been 107/56, and heart rate (HR) 113 [high] and respirations (RR) were 20 per minute (within normal limits.)On 12/3/12 at 9:50 a.m. during a telephone interview, LN 2 stated she went into Resident 1's room on 10/26/12 at 2:15 p.m. LN 2 stated Resident 1 was not responding to her verbal questions or directions at that time. LN 2 stated the unresponsiveness was unusual for Resident 1 as normally he would respond with one or two word answers to her questions. LN 2 stated Resident 1 tried to open his eyes when she had then rubbed his legs.Resident 1's hospice note dated 10/26/12 at 3 p.m. indicated Resident 1 had responded "slower to verbal stimuli." The nursing note indicated Resident 1 no longer opened his eyes to verbal stimuli. On 11/27/12 at 7:05 a.m., during a telephone interview, HN 1 stated he had placed a needle into Resident 1's vein (IV) on 10/26/12 at 3 p.m. in order to administer Narcan [a narcotic antagonist] (a medication to reverse the effects of morphine) 0.2 mg I.V. HN 1 stated Narcan had been ordered by the hospice physician due to the change in Resident 1's ability to respond to stimulation after the administration of MS at noon on 10/26/12. HN 1 stated after Resident 1 had received the dose of Narcan he then began to speak in response to questions asked. Resident 1 then had followed activity with his eyes and nodded his head in response to questions as well as responded with one word answers.HN 1 stated when he had left the facility at 5 p.m. Resident 1 had been sleeping, was easily awakened by verbal stimuli and opened his eyes but did not verbalize. At this time the hospice notes indicated Resident 1's B/P was 109/77, HR was 96 (per minute), and RR had been 20 (per minute). HN 1 stated prior to leaving the facility he instructed LN 2 to monitor Resident 1's condition closely and HN 1 had notified Resident 1's daughter of his condition.On 12/3/12 at 9:50 a.m., during a telephone interview, LN 2 stated she went into Resident 1's room on 10/26/12 at 6 p.m. LN 2 stated Resident 1 had loud, wet sounding breathing that she could "hear across the room without a stethoscope [instrument for amplification to listen to breath sounds]." LN 2 stated Resident 1 had not responded to her voice. Resident 1's vital signs had changed to a B/P of 86/47 [low] HR had increased from 96 to 142/minute and had a RR of 21/minute. LN 2 stated Resident 1 did not have the use of supplemental oxygen at that time. LN 2 stated she then measured Resident 1's oxygen saturation level (a test that shows how much oxygen is transported by the blood to the tissues in the body) and it was "very low" at 37%. LN 2 stated she then called for a second nurse who placed an oxygen mask on Resident 1. LN 2 stated she then phoned and asked a hospice nurse to return to the facility due to the decrease in Resident 1's level of consciousness and significant decrease in the oxygen saturation level which now had required the administration of supplemental oxygen.Review of professional reference, "Mosby's Diagnostic and Laboratory Test Reference, Ninth Edition" indicated, "oxygen saturation... normal findings 95% or greater...critical values 75% or less...causes of low oxygen saturation levels...severe hypoventilation (e.g. oversedation)." On 11/27/12 at 7:07 a.m., during a telephone interview, HN 2 stated she had been called to the facility to check on Resident 1 on 10/26/12 and had arrived shortly after 6 p.m. HN 2 stated Resident 1 at that time had not responded to her questions and would not follow her verbal directions. Resident 1's breathing rate had increased to 30 to 40 times per minute, and Resident 1 had foam around his mouth and was diaphoretic (sweaty). HN 2 stated this had been a definite change in Resident 1's condition compared with earlier visits. HN 2 stated she had then notified Physician 1 of Resident 1's change in condition. HN 2 stated Resident 1 was then transferred to the acute care hospital at 7:25 p.m. by ambulance. Review of the acute hospital emergency room notes dated 10/26/12, indicated Resident 1 arrived to the hospital emergency room on 10/26/12 at 7:29 p.m. and had been described as "unresponsive to verbal/tactile stimuli." The emergency room physician's documentation for Resident 1 dated 10/26/12 at 7:45 p.m. indicated Resident 1's status was "not responsive." The physician notes indicated Resident 1's breath sounds were loud and wet sounding with wheezes though out his lungs. The physician note indicated Resident 1 had been evaluated by the emergency room physician and had received supplemental oxygen by mask, and treatments to ease his breathing.Resident 1's emergency room nurse's notes dated 10/26/12 at 11:12 p.m. indicated the facility had been notified of the hospital's plan to transfer him back to the facility and of Resident 1's condition. Resident 1's condition was described in the nursing notes as "still having difficulty breathing, congested, unresponsive to verbal and tactile stimuli." The notes indicated the emergency room physician and Resident 1's family had agreed to the transfer of Resident 1 back to the facility. On 12/3/12 at 9 a.m., during a telephone interview, Licensed Nurse (LN) 3 stated she had been on duty in the facility on 10/27/12 at 12:20 a.m. when Resident 1 returned from the emergency room. LN 3 stated Resident 1 had returned wearing an oxygen mask and described his breathing as fast and labored. Resident 1 did not respond to any verbal questions or follow verbal directions. Resident 1 did not make any purposeful movement when moved from the transport stretcher to the bed. LN 3 stated the resident's oxygen saturation was "very low" at 50%. LN 3 stated she left Resident 1's room to obtain an oxygen tank which would deliver a high percentage of oxygen. LN 3 stated when she returned to the room minutes later, Resident 1 had not been breathing and no pulse could be found. LN 3 stated she then called the house supervisor to assess the resident. LN 3 stated the house supervisor pronounced Resident 1 dead at 12:55 a.m. LN 3 stated she then notified the hospice staff and Resident 1's family of his death.On 3/7/13 at 12 noon. during a telephone interview, the Facility Consultant Pharmacist (FCP) confirmed 5 ml of Roxanol 20 mg/1 ml would have been 100 mg, not 5 mg. The FCP stated he had not seen a dose that large (l00 mg) routinely given.The toxicology report dated 10/30/12 indicated Resident 1's morphine level was recorded as 0.40 mg/L (Effective Level: 0.01-0.12 mg/L [Liter] and potentially Toxic 0.15-0.5 mg/L).The Coroner's report dated 11/27/12 indicated, " CAUSE OF DEATH: Morphine Intoxication." These violations, either jointly or separately, presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result and was a direct proximate cause of the death of the patient and therefore constitutes a Class "AA" Citation. |
| 040000074 |
WISH-I-AH HEALTHCARE & WELLNESS CENTER |
040011140 |
A |
26-Nov-14 |
3C3011 |
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
CLASS A CITATION INFECTION CONTROL
F 441: CFR 483.65 Infection Control
The facility must establish and maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection.
CFR 483.65(a) Infection Control Program
The facility must establish an Infection Control Program under which it
(1) Investigates, controls, and prevents infections in the facility;
(2) Decides what procedures, such as isolation, should be applied to an individual resident; and
(3) Maintains a record of incidents and corrective actions related to infections.
CFR 483.65(b) Preventing Spread of Infection
(1) When the Infection Control Program determines that a resident needs isolation to prevent the spread of infection, the facility must isolate the resident.
(2) The facility must prohibit employees with a communicable disease or infected skin lesion from direct contact with residents or their food, if the direct contact will transmit the disease.
(3) The facility must require staff to wash their hands after each direct resident contact for which hand washing is indicated by accepted professional practice.
CFR 483.65(c) Linens
Personnel must handle, store, process, and transport linens so as to prevent the spread of infection.
On 10/8/14 at 2 p.m., an unannounced visit was made to the facility to investigate an Entity Reported Incident # CA00414392 regarding a resident outbreak of gastroenteritis (nausea, vomiting, and/or diarrhea).
The facility failed to establish and maintain an effective infection control program to prevent resident infections when the facility failed to identify a foodborne gastrointestinal outbreak which affected 12 of 80 residents. Resident 1 and 8 had laboratory confirmed Salmonella infection. Ten additional residents (Residents 6, 9, 10, 11, 12, 13, 14, 15, 16, and 17) were identified with signs and symptoms of gastroenteritis. Resident 1's positive blood culture for Salmonella was confirmed prior to Resident 1's death. Facility failures included:
1. Kitchen sanitation procedures not maintained to minimize resident exposure to foodborne illness.
2. Facility staff returned to work after illness while still infectious.
3. Facility bathrooms were maintained in a safe, functional, and sanitary manner.
4. Facility ice machine not cleaned and sanitized according to manufacturer's recommendations.
5. Facility staff did not maintain contact isolation precautions when caring for a symptomatic resident.
6. Facility linen not available for residents.
7.Resident 1 contracted sepsis (a serious systemic infection) secondary to Salmonella infection. Resident 1 was sent to the hospital where she expired 7 days after admission.
8.Facility failed to maintain its sewage treatment system. Facility staff removed and disposed of raw sewage without appropriate personal protective equipment (PPE) and without a designated washing facility.
These failures exposed residents and staff to gastrointestinal illness which resulted in harm to twelve residents. Two residents (Resident 1 and 8) had laboratory confirmed Salmonella infections. Ten additional residents (Resident 6, 9, 10, 11, 12, 13, 14, 15, 16, and 17) were identified with symptoms of gastrointestinal illness, and placed on contact isolation precautions, which deprived them of social interaction and freedom of movement within the facility, and contributed to a diminished quality of life.
On 9/24/14 at 7:53 a.m., the California Department of Public Health (CDPH) Licensing and Certification Unit (L&C) received notification from the facility via facsimile of a gastrointestinal illness affecting five residents and seven staff. Review of facility document titled, "Line Listing Report, Gastroenteritis Illness, Staff" indicated Staff 1, a male working in the Dietary department, was symptomatic with diarrhea (D) on 9/17/14 for one day. Staff 2, a male working in Dietary, was symptomatic with vomiting (V) and D on 9/19/14, lasting until 9/20/14. Staff 3, a female in the Social Services department, was symptomatic with V and D on 9/19/14, lasting until 9/21/14. Staff 4, a male working in Housekeeping was symptomatic with D on 9/23/14, lasting one day. Staff 5, a female working in Housekeeping was symptomatic with D on 9/23/14. No date was given of last symptoms. Staff 6,
040011140
the Director of Nursing (DON) was listed, but no symptom type was recorded. She was symptomatic on 9/20/14, lasting until 9/22/14. Staff 7, a female working as Minimum Data Set Coordinator (MDS), was symptomatic on 9/18/14, lasting until 9/19/14, no symptom type was recorded.
Review of the facility document titled, "Infection Control Surveillance" indicated Resident 8 became symptomatic with gastrointestinal (nausea, vomiting, and/or diarrhea) symptoms on 9/23/14, and was placed on contact isolation precautions (procedures which reduce the risk of spread of infection through direct or indirect contact). Resident 9 became symptomatic on 9/23/14, and was placed on isolation precautions. Resident 6 became symptomatic on 9/23/14, and placed on isolation precautions. Resident 10 became symptomatic on 9/23/14 with symptoms, and place on isolation precautions. Resident 11 became symptomatic on 9/23/14, and placed on isolation precautions. All resident infections were coded as Healthcare Associated Illness (HAI), (acquired while in the facility).
On 9/26/14 at 10:26 a.m., CDPH L&C received an anonymous complaint from a facility staff person regarding Resident 1, which indicated, "Resident was living at the facility and was sent to [hospital] for possible sepsis (a serious systemic infection)."
Review of the facility document titled, "Line Listing Report, Gastroenteritis Illness" submitted to CDPH L&C unit, received 9/29/14, indicated Resident 12 was symptomatic with date of onset 9/24/14, and Resident 13 was symptomatic with date of onset 9/25/14. Both were placed on contact isolation precautions. Both were coded as HAI Infections by the facility.
Review of the facility document titled, "Line Listing Report, Gastroenteritis Illness" submitted to CDPH L&C unit, received 10/2/14, indicated Resident 14 was symptomatic and placed on contact isolation precautions, with date of onset 10/2/14.
Review of Resident 1's facility clinical record indicated Resident 1 was admitted to the facility on 4/26/14 with diagnoses which included breast cancer. Nursing notes dated 9/21/14 indicated Resident 1 was found unresponsive by facility staff and transferred by ambulance to the hospital emergency room on 9/21/14 at 3:56 p.m.
Review of Resident 1's hospital clinical record conducted on 10/3/14, indicated Resident 1 was examined and found unresponsive to commands. She was admitted with diagnoses including confusion, pneumonia (infection of the lungs), and dehydration (inadequate fluid intake). Resident 1's laboratory tests indicated blood cultures were drawn in the emergency room on 9/21/14. Laboratory results dated 9/23/14 at 12:09 p.m. indicated, "Preliminary ...Salmonella species. Organism sent to [local] County Dept. of Public Health." Resident expired on 9/28/14 at 7:23 p.m.
Review of "Diagnosis and Management of Foodborne Illnesses," Morbidity and Mortality Weekly Report, April 16, 2004, indicated under Background, "Specifically, this guide urges physicians and other health care professionals to realize that many but not all cases of foodborne illness have gastrointestinal tract symptoms....Appreciate that any patient with foodborne illness may represent the sentinel case of a more widespread outbreak... Foodborne illness is considered to be any illness that is related to food ingestion; gastrointestinal tract symptoms are the most common clinical manifestations of foodborne illnesses." Under Clinical Considerations it indicated, "...Bacterial agents most often identified in patients with foodborne illness in the United Stated are...Salmonella." Under Recognizing Foodborne Illness it indicated,"...Every outbreak begins with an index patient who may not be severely ill. A physician or health care professional who encounters this person may be the only one with the opportunity to make an early and expeditious diagnosis. Thus, the physician or health care professional must have a high degree of suspicion and ask appropriate questions to recognize that an illness may have a foodborne etiology.....Because infectious diarrhea can be contagious and is easily spread, rapid and definitive identification of an etiologic agent may help control a disease outbreak. Early identification of a case of foodborne illness can prevent further exposures."
Review of the facility document titled, "Line Listing Report, Gastroenteritis Illness" submitted to CDPH L&C unit, received 10/6/14, indicated Resident 15 was symptomatic with date of onset 10/4/14, and Resident 16 symptomatic with date of onset 10/5/14. Both were placed on contact isolation precautions.
Review of the facility document titled, "Line Listing Report, Gastroenteritis Illness" submitted to CDPH L&C unit, received 10/19/14, indicated Resident 17 was symptomatic and placed on contact isolation precautions with date of onset 10/11/14.
On 10/21/14 at 2:30 p.m., the CDPH L&C received notification from the facility regarding additional staff symptomatic with illness. Review of facility document titled, "Line Listing Report, Gastroenteritis Illness, Staff," indicated Staff 8, a female working as a Certified Nursing Assistant (CNA) became symptomatic with V on 10/6/14. Staff 9, a female working as
a CNA became symptomatic with D on 10/7/14. Staff 10, a female working in Dietary, became symptomatic with D on 10/14/14, and returned to work on 10/15/14. Staff 11, a female working as a CNA, became symptomatic with V and D on 10/12/14.
1. On 10/6/14 at 3:30 p.m., during an interview with the [local] Department of Public Health (LDPH) Communicable Disease Specialist (CDS), she stated she and an Environmental Health Specialist (EHS) had conducted a source investigation site visit to the facility on 10/1/14. She stated the EHS conducted a sanitation inspection of the facility kitchen.
On 10/7/14 at 8:30 a.m., during an interview with EHS 1, the facility's inspection report was requested.
Review of LDPH document titled, "Official Food Facility Inspection Report" dated 10/1/14, indicated, "Joint inspection was conducted in this facility with [CDS] due to GI outbreak: 6 residents and 7 staff (2 of them are kitchen employees)....Upon my inspection I noted following violations: ...6. Provide towels in dispenser for kitchen hand washing sink at all times. Observed towels next to the hand washing sink...Employees working in the kitchen are using restroom located close to the entry of the building. This restroom has only cold water at 77 degrees. Employees need to open 3 doors, to walk through the building and return back to the kitchen... [indicating a risk for cross contamination of food due to the risk of kitchen employees handling doors after hand washing] on return to the kitchen] 43. Employee shall wash their hands after the restroom in warm water at 100 degrees F (Fahrenheit). 21. Provide warm water for the restroom at 100 degrees F...I was unable to detect QT sanitizer [Quaternary sanitizer, a chemical mixed with water in a concentration to sanitize kitchen utensils and food preparation surfaces]. It was not pumped properly into sink. Provide sanitizing solution to sanitize large utensils in the utensils sink at all times...21. Provide hot water for kitchen sink at 120 degrees F. Water recorded at 108 112 degrees..."
On 10/8/14 at 8:30 a.m., during an interview with EHS 2, she stated it took one and one half hours for the kitchen staff to fix the sanitizer pump problem. The EHS 2 stated, "The sanitizer is pumped through a long white tube which drains down into the sink."
On 10/8/14 at 2:25 p.m., during an initial kitchen observation and interview with the Dietary Services Supervisor (DSS 2) and the Registered Dietician (RD), DSS 2 was asked about the type of sanitizer used in the kitchen sink. DSS 2 stated the kitchen used chlorine and pointed to a long white tube which extended down into the base of the 2 compartment sink. She was corrected by the RD who stated, "That is Quaternary solution." A small red bucket was observed sitting below the food preparation sink, filled with liquid. On inquiry, DSS 2 stated they were using premixed bleach solution from the bucket to sanitize their countertops.
On 10/9/14 at 10 a.m., during an interview with DSS 2, the facility kitchen sanitation and temperature logs were requested for September and October 2014.
Review of the facility document titled, "2 COMPARTMENT SINK LOG (Chemical sanitation)" dated October 2014, indicated a Quat (Quaternary ammonia) monitoring test strip result of 200 parts per million (ppm) at Breakfast, Lunch, and Dinner, the same day LDPH found the Quaternary solution pump at the 2 compartment sink non functional.
On 10/9/14 at 10:50 a.m., during a concurrent observation and interview with DSS 2 and Dietary Consultant 1 (DC 1), kitchen sanitation logs were reviewed. DC 1 stated the handwritten log, "Pot and Pan Sink sanitizer log" and the 2 Compartment sink log were for the same sink and time period. DC 1 stated the sanitizer log referenced the sanitation bucket used on food preparation surfaces. DC 1 stated both the sanitizer bucket and the 2 compartment sink were filled with Quaternary ammonia solution. When asked how the bucket could measure 100 ppm at the same time the 2 compartment sink measured 200 ppm, DC 1 stated, "We have had problems with the sanitizer in the kitchen." On inquiry regarding whether the bucket sanitizing log indicated a measurement too low to sanitize, DC 1 did not answer. On inquiry regarding how long the deficient sanitation level had been deficient in the kitchen, she stated, "I don't know how long it was measuring 100 [ppm]." DC 1 could not answer how long deficient sanitizer levels would be monitored before a request for repair would be initiated. DSS 2 then admitted she had altered a Sanitizer log by hand writing "Pot and Pan Sink" at the top of a sanitizer bucket log sheet, because she could not find the sanitation log requested.
On 10/9/14 at 11:05 am, during an interview with the RD regarding staff explanation of deficient sanitizer levels in the bucket coming from the Quat dispenser unit at the 2 compartment sink, he stated, "They probably didn't put the test strip in the solution long enough." On inquiry as to whether 100 ppm was a satisfactory level for Quat in a sanitation bucket, he replied, "No. I can't explain that." He was unable to state why there were two separate logs kept for the sanitation bucket in the kitchen.
Further review of the sanitation logs indicated at the bottom of each page, "Note: If sanitizer in NOT in the appropriate range DO NOT USE TO SANITIZE. Contact your supervisor immediately. If supervisor unavailable, contact Maintenance Department for assistance with correction."
On 10/9/14 at 11:10 a.m. during an interview with the Administrator (ADM) regarding the sanitation logs, and the explanations given by dietary staff regarding the differing levels of sanitation levels between the bucket and the 2 compartment sink, she stated, "I don't understand it ...they are supposed to be using bleach solution on the countertops."
On 10/20/14 at 3:45 p.m., during a concurrent observation and interview on kitchen tour, a role of paper towels was observed sitting on the window shelf located to the right of the hand washing sink. The RD stated, "Yes, the towel dispenser is broken."
Review of Control of Communicable Diseases Manual, 19th Edition, David L. Heymann, MD, Editor, 2008, indicated under Salmonellosis, p. 536, "5. Mode of Transmission Ingestion of the organisms in food derived from infected animals, contaminated by feces or an infected animal or person....Epidemics are usually traced to foods such as: processed meat products, inadequately cooked poultry/poultry products; undercooked or lightly cooked foods containing eggs/egg products;...dairy products...and foods contaminated by an infected food handler. Epidemics may also be traced to foods such as meat and poultry products processed or prepared with contaminated utensils or on work surfaces contaminated in previous use." Under 9. Methods of Control A. Preventive Measures: " 4) Educate all food handlers about the importance of a) handwashing before, during and after food preparation; ...d) avoiding recontamination within the kitchen after cooking is completed; and e) maintaining a sanitary kitchen and protecting prepared foods...8) Exclude individuals with diarrhea from food handling and from care of hospitalized patients, the elderly, and children ... "
2. On 9/24/14 at 7:53 a.m., the CDPH L&C received notification from the facility via facsimile of a gastrointestinal illness affecting five residents and 7 staff. Review of a facility document titled, "Line Listing Report, Gastroenteritis Illness, Staff," indicated Staff 1, a male working the Dietary department became symptomatic with D on 9/17/14, lasting one day. Staff 2, a male in Dietary, became symptomatic with V and D on 9/19/14, lasting until 9/20/14.
On 10/8/14 at 3:00 p.m., during a concurrent observation and interview, two male staff members were observed sitting at a table outside the main kitchen area. Staff I introduced himself and stated he was a facility Cook (Cook 1).
On 10/8/14 at 3:45 p.m., during an interview with Director of Admissions (DOA), time clock data was requested and produced for facility nursing and dietary staff for the months of September and October 2014. The DOA stated staff time was recorded by time clock, so all entries were recorded. The DOA stated his records were the final time keeping records for the facility, and were correct.
On 10/9/14 at 10:10 a.m., during an interview with Cook 1, he stated the evening of 9/16/14 his wife prepared undercooked baked chicken for his family, "It was red all around the bone." The following morning (9/17/14) he came to work at the facility kitchen, severely nauseated, stating, "I only stayed a couple of hours and went home ... I started vomiting." Cook 1 further stated he notified DSS 1 of his illness, and was told he could return to work when he felt better. Cook 1 stated his symptoms subsided the morning of 9/18/14, so he returned to work the same day.
10/9/14 at 3 p.m., during an interview with the ADM, the facility sick leave policy was requested. An employee handbook was produced. The ADM stated this was what she knew of regarding return to work policy for ill employees.
Review of the facility document titled, "[Facility] Employee Handbook" revised 12/12, indicated under ILLNESS AND RETURN TO WORK, "If you are absent from work, because of illness, injury or for other health reasons for three (3) or more consecutive scheduled days, or if you have had surgery or have been hospitalized, you will need a written release from your physician in order to return to work. Employees injured on the job have a responsibility to attend all follow up appointments and inform their supervisor of any work restrictions." There was no documented evidence of a restricted time period to return to work following symptoms of illness.
Review of "Employee Health and Personal Hygiene Handbook," adapted from the 2005 FDA (Food and Drug Administration) Food Code, indicated under Introduction, "Proper management of a food establishment involves ensuring that food employees do not work when they are ill and having procedures for identifying employees who may transmit foodborne pathogens to food, other employees, and customers...A correlation between the severity of a food employee's clinical illness and the level of exclusion and restriction required to eliminate the risk has been established...The 2005 FDA Food Code recognizes the increased risks of foodborne illness in highly susceptible populations such as...older adults and those with compromised immune systems. Food establishments in health care...are required to take additional precautions to prevent the transmission of foodborne illness."
On 10/9/14 at 5 p.m., during an interview with the ADM, she stated she was aware of Cook 1's illness as DSS 1 informed her the same day Cook 1 was ill. She stated the facility did not have a return to work policy in place for ill kitchen workers at that time. She stated the facility still had no return to work policy in place for ill kitchen staff. The ADM stated they had not followed CDC (Centers for Disease Control and Prevention) guidelines.
Review of facility time clock records indicated Cook 1 clocked in and out of the facility on the following dates and times: On 9/17/14, he clocked in at 5:44 a.m. and out at 8:54 a.m. On 9/18/14 he clocked in at 5:32 a.m. and out at 9:30 a.m., clocked back in at 10 a.m. and out at 1:40 p.m., back in at 4:16 p.m. and out at 8:33 p.m. On 9/19/14 he clocked in at 5:52 a.m. and out at 9 a.m., clocked back in at 9:30 a.m. and out at 1:30 p.m.
On 10/12/14 at 2:05 p.m., during an interview with Dietary Aide 1 (DA 1) regarding his illness, DA 1 stated he became ill with nausea and diarrhea on 9/19/14. He stated he called DSS 1 to report his illness and inability to work, and was told to return to work when he felt better. He stated the ADM was aware of his illness, as she phoned him back on the same day. DA 1 stated his job duties included driving prepared food to the Bo Hin Tow building and taking it to the kitchen area of the building. He further stated, "I make each person's plate in the dining room, put the silverware on the tray, I do everything." He stated his job included opening resident beverages if required. On inquiry to other kitchen duties he stated, "I also do the evening snacks ...I make sandwiches ...I make 12 for the Admin building, 6 for Bo Hin Tow and 6 for Canyon View, so if someone wants a snack they can have a sandwich." He stated he prepared Bologna sandwiches or peanut butter and jelly ...I also do the desserts and drinks sometimes."
Review of facility time clock records indicated DA 1 clocked into and out of the facility on the following dates and times:
Date InOut InOut
9/17/14 1:31 p.m. 4:10 p.m. 4:40 p.m. 8:54 p.m.
9/18/14 1:30 p.m. 6:30 p.m. 7:00 p.m. 9:00 p.m.
9/20/14 1:32 p.m. 6:45 p.m. 7:15 p.m. 8:48 p.m.
9/21/14 1:31 p.m. 6:19 p.m. 6:49 p.m. 9:01 p.m.
On 10/12/14 at 2:15 p.m., during an interview with the ADM, she stated DSS 1 worked at the facility between 8/15/14 and 10/2/14. She stated DSS 1's kitchen duties during that time was ordering and staffing in the kitchen. During this period of time there was no dietary staff to oversee the kitchen. She stated DSS 1 had no formal dietary training.
Review of Control of Communicable Diseases Manual, 19th Edition, David L. Heymann, MD, Editor, 2008, indicated under Salmonellosis, p. 536, "5. Mode of Transmission Ingestion of the organisms in food derived from infected animals, contaminated by feces or an infected animal or person....Epidemics are usually traced to foods such as: processed meat products, inadequately cooked poultry/poultry products; undercooked or lightly cooked foods containing eggs/egg products;...dairy products...and foods contaminated by an infected food handler. Epidemics may also be traced to foods such as meat and poultry products processed or prepared with contaminated utensils or on work surfaces contaminated in previous use." Under 9. Methods of Control A. Preventive Measures: " 4) Educate all food handlers about the importance of a) handwashing before, during and after food preparation; ...d) avoiding recontamination within the kitchen after cooking is completed; and e) maintaining a sanitary kitchen and protecting prepared foods...8) Exclude individuals with diarrhea from food handling and from care of hospitalized patients, the elderly, and children ..."
3a. On 10/6/14 at 3:30 p.m., during an interview with the LDPH Communicable Disease Specialist (CDS), she stated she and an EHS had conducted a source investigation site visit to the facility on 10/1/14. She stated the EHS conducted a sanitation inspection of the facility kitchen.
On 10/7/14 at 8:30 a.m., during an interview with EHS 1, the facility's inspection report was requested from the LDPH.
Review of LDPH document titled, "Official Food Facility Inspection Report" dated 10/1/14, indicated, "Joint inspection was conducted in this facility with [CDS] due to GI outbreak: 6 residents and 7 staff (2 of them are kitchen employees)....Upon my inspection I noted following violations:...6. Provide towels in dispenser for kitchen hand washing sink at all times. Observed towels next to the hand washing sink...Employees working in the kitchen are using restroom located close to the entry of the building. This restroom has only cold water at 77 degrees. Employees need to open 3 doors, to walk through the building and return back to the kitchen [indicating a risk for cross contamination of food due to the risk of kitchen employees handling doors after hand washing] ....43. Employee shall wash their hands after the restroom in warm water at 100 degrees F (Fahrenheit). 21. Provide warm water for the restroom at 100 degrees F...I was unable to detect QT sanitizer [Quaternary sanitizer, a chemical mixed with water in a concentration to sanitize kitchen utensils and food preparation surfaces]. It was not pumped properly into sink. Provide sanitizing solution to sanitize large utensils in the utensils sink at all times..."
On 10/8/14 at 8:30 a.m., during an interview with EHS 2, she stated the facility contained a bathroom next to the kitchen but it was locked. She stated staff told her they were not supposed to use it and the door was boarded shut. She further stated it took one and one half hours for the kitchen staff to fix the sanitizer pump problem, stating, "The sanitizer is pumped through a long white tube which drains down into the sink." EHS 2 stated kitchen staff had to call a repair man to fix the sanitizer pump.
On 10/8/14 at 2:25 p.m., during an initial kitchen observation and interview, DSS 2 was asked about the type of sanitizer used in the kitchen. She stated the kitchen used chlorine and pointed to the white tube extending into the sink. She was corrected by the RD who stated, "That is Quaternary solution."
On 10/8/14 at 2:35 p.m., during an initial kitchen tour observation, a back door located adjacent to the dish machine was opened. A large hand washing sink was observed against a back wall, a second door was observed closed and bolted. The hand washing sink contained no soap in the dispenser or towels in the dispenser. The sink bowl was heavily coated with brown and rust colored organic matter. On inquiry as to whether the sink was functional, the Maintenance Supervisor (MS) stated, "We don't use that sink." The bolted door was opened by the MS who stated, "We don't use this toilet ...it works." The toilet was observed to contain thick brown and black organic matter, climbing the sides of the bowl to the rim. The MS flushed the toilet. Large brown pieces of organic matter broke away from the bowl and circulated in the water. On inquiry as to why this bathroom was not used by kitchen staff, the MS stated, "Administration told me to bolt the door because they said it was unsanitary to have a bathroom so close to the kitchen...they said the staff could use the one downstairs."
On 10/8/14 at 2:45 p.m., during a concurrent downstairs bathroom observation and interview, an indirect light was observed shining from the end of a short hallway. The Special Projects Maintenance Worker (SPMW) entered the facility from the outside, walked to the end of the hallway, and entered the lighted room. He then backed out of the doorway, shut the room door, and left the facility through the same doorway he entered. On entering the hallway a closed door was observed to the left, and opened by the MS. A small unkempt bathroom was observed. Pieces of bathroom tissue lie on the floor in the corner adjacent to the toilet. Thick black organic matter was observed covering the interior of the toilet bowl, rust colored organic matter was noted clinging to the bowl under the surface of the water. The black organic matter was observed climbing from the front interior of the bowl to the outer front edge under the seat. A filled seat cover holder was placed on the wall above the toilet tank. A filled toilet paper dispenser was observed affixed to the wall on the left side facing the bowl. A filled hand towel dispenser was placed on the wall above the toilet paper. A hand washing sink covered with brown, black and rust colored organic matter was observed on a wall adjacent to the toilet. The left handle of the faucet was broken and hanging to the left of the fixture from the bottom half of the handle. A small steady stream of water was observed running down the left side sink. A small trash can located on the floor to the right of the sink was observed overflowing with used paper towels. Used plastic gloves were observed on the floor next to the trash can. A functional filled soap dispenser was found on the wall behind the entrance door. On entry to the bathroom DSS 2 stated, "This is gross." The RD stated, "This is not being used." On inquiry regarding why an unused bathroom would be fully stocked with an overflowing trash can, he placed his palms out in front of his chest and stated, "I don' t know anything about this."
On 10/8/14 at 3:00 p.m., during a concurrent observation and interview, two male staff members were observed sitting at a table outside the main kitchen area. On inquiry regarding their knowledge of who was using the bathroom downstairs, Cook 1 replied, "We all do ...dietary, nursing, everybody." The second staff person nodded in agreement and stated, "Everybody."
On 10/8/14 at 3:15 p.m., during an interview with the SPMW regarding the condition of the downstairs bathroom, he stated, "I don't want to waste my time...You can't clean that.... We're going to replace it [the toilet and sink]."
On 10/8/14 at 4 p.m., during an interview with the Nurse Consultant (NC) regarding the downstairs bathroom, she acknowledged the condition of the bathroom and stated the facility would work to improve its condition.
On 10/19/14 at 12:53 p.m., during an environmental tour, the SPMW was asked to measure the water temperature of the downstairs bathroom used by kitchen staff. The hot water handle was turned on and sink was observed backing up with standing water pooling in the sink. SPMW stated he was notified by kitchen staff earlier in the day of the sink backing up, and stated, "They (kitchen staff) told me it backed up, that's why the other sink (now replaced) looked black." He further stated he would fix the sink back up. He attempted to wash his hands above the standing water, but cross contaminated his hands in the standing water when he washed them. He then stated, "I'm gonna fix it...I have to take it apart." Ascending the stairs to the back entrance of the kitchen, numerous soiled brooms and mop items were stored against the wall. A soiled floor mop bucket was placed outside the closet.
On 10/19/14 at 1:05 p.m., during an observation and concurrent interview, the SPMW was observed walking down a road behind the Administration (Admin) building, with a drill in his left hand. He stated he fixed the bathroom sink by drilling a hole in the pipe screen.
On 10/19/14 at 1:10 p.m., during an environmental tour of the Admin building, Housekeeper 1 (HK 1) was observed standing outside Room 2, waving a plastic caution sign toward the interior of the room. On inquiry, HK 1 stated, "We're having problems with the toilet in here, its overflowed all over the floor." The resident room floor was observed visibly wet under the beds and around the bathroom door. HK 1 stated the overflow problem had occurred since his hire date, 8 days ago. |
| 040000074 |
WISH-I-AH HEALTHCARE & WELLNESS CENTER |
040011141 |
A |
26-Nov-14 |
3C3011 |
19334 |
One citation was issued for 2 linked Complaints: CA00414179 and CA00414770 On 9/15/2014 an investigation was conducted of Complaints CA00414179 and CA00414770 Quality of Care. The facility failed to provide necessary care and services to ensure the resident maintained the highest practicable physical mental and psychosocial well-being when: 1. The facility failed to provide trained and qualified Licensed Nurses (LNs) to care for Resident (Res.)1's Negative Pressure Wound Therapy ([NPWT], used as a negative pressure device for severe wounds to assist in healing) without obtaining an adequate assessment, care plan, policy and procedure or method of monitoring. NPWT dressing was not changed for twenty-five days, from 7/11/14 until 8/6/14. 2. The Surgeon's orders, for Resident 1, from the acute hospital, dated 7/11/14 were not implemented. There was no written evidence of an evaluation or follow up care documented by a surgeon on Resident 1 after her discharge from the acute hospital on 7/11/14. The attending Physician, MD [Medical Doctor] 2 wrote orders on 8/1/14 which were not implemented until 8/6/14.3. The orders for laboratory samples for Res 1 were not drawn as ordered and lack of results were not monitored from 8/4/14 until she was transported, in septic shock (life-threatening bacterial infection), to an acute care hospital on 9/21/14. These failures put Resident 1 at risk for a life threating infection. 1. Resident 1 was a 75 year old female admitted to the facility on 4/26/12. MD 1's order indicated Res. 1's diagnoses included cellulitis secondary to Klebsiella (bacterial invasion and inflammation of skin and underlying tissues), and breast cancer. A radical mastectomy (surgical removal of an entire breast, including all the lymph nodes) was performed on 6/3/14. Res 1 returned to the acute hospital on 7/3/14, for a revision of the right breast mastectomy wound and a negative pressure wound therapy device (NPWT, commonly called a "wound vac" or "Vacuum Assisted Closure") was placed following the revision.Res. 1 was re-admitted to the facility on 7/11/14, with a NPWT device. There was no documented evidence an assessment of the chest wound had been done until 8/6/14 (twenty-five days after readmission. Review of Minimum Data Set (MDS) assessment (tool used to identify physical function and psychological and social function) dated 7/25/14 indicated Resident 1 had a surgical wound. On 9/15/14, at 2 p.m., in a concurrent observation and interview, Res 1 was in bed, thin, pale and awake making eye contact. Res 1 was guarding (covering) the wound site of her right breast mastectomy site on the right chest wall, using both hands and arms. Resident 1's surgery site dressing was attached to a NPWT. The tubing connecting the dressing to the vacuum pump had scant pink drainage. The collection device was a 1000 milliliter (ml) canister, half full. There was an occlusive (contained the wound, created a seal for moisture and air) transparent dressing covering the right chest and a crescent shape piece porous black foam dressing material visible through the transparent dressing. The date was written on the transparent dressing in black ink: "9/11" and was initialed by LN 1. There was no description, time, measurement, or sponge count to signify the number of pieces of sponge used in the wound written on the transparent dressing. Res. 1 stated she had pain and soreness in her shoulder and her back. Res. 1 stated she did not want the wound touched, she had pain of 7 (pain scale of 0-10, used to measure pain intensity where zero is no pain and 10 is the worst pain ever experienced). Resident 1 was observed to flinch when two Certified Nursing Assistants (CNAs) tried to reposition her in bed. On 9/15/14 at 6 p.m., in an interview, LN 1 stated Res 1's dressing change of the "wound vac" was supposed to be done on the day shift. LN 1 stated there had been no training and no written instructions provided on the wound vacuum care and dressing change. LN 1 stated when she removed the dressing on 9/11/14 the clear dressing material was marked with black ink indicating the last dressing change was 9/5/14, five days prior. LN 1 stated the Resident 1 flinched with a light touch on her skin. LN 1 stated there had been difficulty with the dressing change and she had reported to the Administration this fact. LN 1 stated the wound had been "reinforced" (new, clean dressing materials placed over existing, soiled dressing to increase absorption) but not changed.Review of nurses notes dated 9/11/14 at 7:30 p.m. indicated,"...writer checked if there's [was] leaking and found out the machine is not suctioning. The resident was "crying out loud with no apparent reason...This...dressing stick very tight on pt.'s [patient's] skin. ...I left the upper part of the dressing undone and I only reinforce the lower part of the dressing..." Review of training records indicated LN 1 was observed by the Director of Nurses (DON) when LN 1 changed the "wound vac" dressing on 9/16/14, one week after first changing the dressing on 9/11/14. LN 1 stated there had not been written instructions or training given before she first changed the dressing. Review of Res. 1's care plan, dated 7/12/14, titled, "Infection." The care plan had no documented intervention of the procedure or instructions for monitoring the wound dressing, or the wound site. There was no associated Care Area Assessment (CAA) or care plan specific to Res.1's NPWT device. On 9/16/14 at 8:30 a.m., during an interview, LN 2 stated his only training on the wound vacuum device had been during his military service many years ago, and he had received no further training on the NPWT device. LN 2 stated he had performed the majority of the dressing changes for Res. 1. LN 2 stated he used only black foam in the wound and he used one or two pieces. LN 2 stated during the last week the resident was in the facility, the black foam had broken into small fragments. LN 2 stated he tried to take out some of the sponge pieces using a pair of tweezers after he took out the larger pieces. LN 2 stated he had not counted or documented the sponge count. On 9/17/14, at 2 p.m. during a concurrent observation and interview LN 2 stated he had used black foam to pack Res 1's wound. LN 2 stated the wound required two or more pieces of the porous black foam, cut to size. LN 2 was holding a clear plastic bag of supplies, he identified as the materials provided for the NPWT device. The bag contained a large piece of black foam approximately10 inches by 4 inches, (to be cut to size for wounds), a white piece of foam (to be used for the wound bed), a 20 X 20 inch piece of plastic drape and a "Foam Quantity Label" to document the date, time, initial and sponge count. He stated the procedure he used to change the dressing was to take out the soiled dressing materials, clean the wound with normal saline, cut and place black granufoam and place on wound bed, apply large piece of the clear plastic covering with an adhesive backing, used to create an airtight seal ("drape") and the connecting tubing, set the electronic controller at 100 -150 millimeters of mercury (mm HG, a metric measurement of pressure, based on the rise and fall of mercury in a cylinder.) LN 2 did not use the Foam Quantity Label; he used the surface of the clear plastic drape and wrote his name and date in black marking pen. He could not identify the manufacturer's intended use of the white foam to the dressing procedure. LN 2 did not know if there should have been any protective covering over the wound bed. On 9/22/14 at 1 a.m., during an interview, LN 2 stated the NWPT had developed intermittent pressure leaks beginning 9/11/14 and included 9/13/14, 9/14/14 and 9/15/14. LN 2 stated he reported the pressure leaks to the DON on the morning of 9/15/14. On 9/15/14 LN 2 ordered a new "wound vac" machine due to the repeated incidents of pressure leaks. LN 2 stated the new machine arrived on 9/16/14, by a currier, without instructional materials. LN 2 stated he downloaded a pamphlet on 9/13/14 with the procedure and instructions when the first machine began to malfunction. LN 2 stated he had not been provided instructional materials or training from the facility, the Director of Staff Development (DSD) or the DON, and held up a brochure, titled, "V.A.C. [vacuum assisted closure] Therapy Clinical Guidelines." LN 2 stated the brochure was the only instruction he had for Res 1's NPWT device. LN 2 stated he was the primary nurse responsible for performing the "wound vac" dressing change as he had prior experience 7 years ago in the military. On 9/30/14 at 10:30 a.m., during an interview, the DSD stated she had not developed a teaching module for care or dressing change of the NPWT device. The DSD stated she did not know how to change a "wound vac" dressing and had not felt comfortable developing a teaching module and "would not even try." On 10/1/14 at 12:40 p.m., in an interview, the DON stated the facility did not have a policy and procedure, a teaching module or a care plan for the NPWT device. On 10/1/14, at 12:40 p.m., in an interview, the ADM. stated there was no learning/teaching module for the NPWT device. The ADM. stated there was no care plan specific to Res 1's wound care, and there was no policy and procedure. The ADM. stated the form that was in use did not have the capacity for documenting the size, shape, appearance, drainage (amount or color) or progress of Res 1's wound. In an interview on 10/1/14 at 2:30 p.m., LN 2 stated during the last dressing change on 9/20/14 before Res 1 went to the acute hospital, he removed a large piece of foam 4 inches long and a small piece of foam 2 inches long with some small pieces of black foam "debris" with a tweezer. LN 2 stated the foam overlapped the skin, and had caused maceration (tissue tearing and deterioration). Review of "V.A.C. Therapy Clinical Guidelines" published by [...], copyright 2014, indicated the procedure for dressing application on page 36: Review of manufacture's guidelines titled "V.A.C. Therapy System and Safety Information", published by ..., copyright 2014, submitted on 10/01/14 at 12:45 a.m. by the DON (as the policy to be implemented by nursing staff) indicated: "WARNINGS: Always ensure that dressings do not come on contact with vessels or organs...if a thick layer of natural tissue is not available, multiple layers of fine-meshed, non-adherent material... may be consider an alternative. Foam Placement: ... Do not place any foam in blind, unexplored tunnels...White Foam dressings may be more appropriate for use with explored tunnels...document the foam quantity (on the provided "Foam Quantity" label) and dressing change date on the drape (clear occlusive plastic covering with an adhesive backing, used to create an airtight seal) or foam quantity label, and in patient's chart... Foam Removal: V.A.C. Foam dressings are not bioabsorbable (not able to be absorbed in to body). Always count the number of pieces of foam removed from the wound and ensure the same number of foam pieces are removed as were placed. Foam left in the wound for greater than the recommended time period (two to three days) may foster ingrowth of tissue into the foam, create difficulty in removing foam from wound or lead to infection or other adverse events... Review of the "Nurses Weekly Skin & Wound Progress" notes, dated 8/6/14 through 9/20/14 indicated on 8/6/14 the initial assessment was done. The documentation indicated the wound measurements were recorded on: 8/6/14, 8/12/14, 8/18/14, 8/25/14, 9/6/14 and 9/20/14. The last two dates recorded were fourteen days apart. There was no documentation that indicated the number of pieces of foam used or documentation of a dressing change performed. Review of the physician's orders dated 7/11/14 indicated, "...Change [wound dressing] 2-3 times per week and prn (as needed) if soiled/dislodgement..." Review of Res. 1's MD orders, from the document titled, "Routine Treatment Administration Record" dated 8/1/14: "Cleanse wound to right breast with normal saline, skin prep periwound (a barrier lotion put on to protect the skin surrounding the wound), lightly pack with foam [non adherent white foam] to tunnel and areas with undermining, cover with black foam and apply NPWT to low suction at 100-150 mm [millimeters] HG [Hemoglobin]. Review of Routine Treatment Administration Record dated 9/14 indicated LN initials on 9/1/14 through 9/14/14, 9/16/14 and 9/20/14. Wound dressing was documented as changed in four days, 9/16 to 9/20/14. On 10/2/14 at 2 p.m. LN 4 stated she had changed the wound dressing on 9/5/14. LN 4 stated she could not recall how many pieces of foam were cut to place into the dressing. LN 4 stated the dressing was marked with a "sharpie" (black permanent marking pen) which indicated the date and the initials. LN 4 stated there had been no previous documentation how many pieces of foam had been placed into the dressing, the dimensions or appearance. On 10/8/14, at 3:30 pm, during an interview, LN 5, stated she had been the nurse that received Res. 1 as an inpatient in the acute care hospital. LN 5 stated she removed the "wound vac" dressing on 10/8/14 at 11:02 a.m. LN 5 stated she removed the black granufoam and rinsed the wound with normal saline. LN 5 stated the wound bed looked dark red, upon digital (use of hands to assess) inspection; the tissue had overgrown some retained black granufoam, and could not be removed without further tissue damage using any non-surgical intervention. This assessment was confirmed by MD 3 in the Physician's Progress notes, dated 9/24/14. Review of Resident 1's clinical record from the acute care hospital, titled, "Ostomy/Wound Progress Note," entry dated 9/22/14, by LN 5 indicated, "...Pt [patient] also admitted with NPWT (Negative Pressure Wound Treatment) device to the right breast ... Upon removal of old drsg [dressing], noted malodor from drsg, as well as black granufoam embedded into the wound bed that is unable to be removed with neither forceps, gauze, nor hemostat. MD 3 at bedside to assess. Will d/c [discontinue] wound vac. at this time and perform NS [normal saline] wet to dry TID [three times per day] in attempts to remove foam from wound bed. Wound measures 4 x 8.2 x 0.5. [Centimeters (cm) one inch = 2.54 cm)]. There is also maceration noted to the wound edges, with foam over the surrounding skin noted with removal of drsg..." 2. Review of Res, 1's physician's orders dated 7/11/14 indicated, "...Change [wound dressing] 2-3 times per week and prn (as needed) if soiled/dislodgement. For any irresolvable NPWT complications over 2 hours, remove entire dressing. Apply moist-to-moist dressing and reapply NPWT and as soon as possible. In unable to obtain NPWT apply aquacell (absorbent non - adherent wound dressing) wound drsg. [dressing] or equivalent and change 2-3 times per week and PRN soiled/Dis.[dislodged]."Review of Res. 1's clinical record revealed there was no documented evidence MD orders written on 7/11/14 were implemented prior to 8/6/14.Review of MD orders, from the document titled, "Routine Treatment Administration Record" dated 8/1/14 revealed, "Cleanse wound to right breast with normal saline, skin prep periwound (a barrier lotion put on to protect the skin surrounding the wound), lightly pack with foam [non adherent white foam] to tunnel and areas with undermining, cover with black foam and apply NPWT to low suction at 100-150 mm HG.Review of Physicians order dated 8/1/14 indicated this entry was the first documented by the attending physician in Res.1's chart, since 7/3/14, when she went to the acute hospital.On 9/30/14 at 10 a.m., during a telephone interview, MD 1 stated he had not been notified of any serious problems for Res. 1, until she went to the acute hospital with the diagnosis of sepsis. MD 1 stated he did not remember seeing Res 1's wound, and couldn't give a description. On 10/9/14, at 8:25 a.m. during an interview, MD 2 stated she could not remember Res 1's wound, or details about the NPWT. MD 2 stated she believed a surgeon was following Res. 1. MD 2 stated, upon receiving the information the surgeon "signed off" [relinquished the care to another MD] Res 1's care and referred her to an oncologist at the time of her re-admission, MD 2 stated, "There should have been a surgeon consulting for her (Res 1's) complex wound." Review of "V.A.C. Therapy Clinical Guidelines" published by [...], copyright 2014, indicated the wound vacuum application for chronic wounds (wounds unlikely to heal) on page 53,..."Settings are continuous for first 48 hours then intermittent five minutes on and two minutes off. The guidelines indicate the pressure settings on the machine would be lower and dressing changes more frequent for wounds with poor prognoses. On page 37 of the same publication under the heading "When to Discontinue V.A.C. Therapy...The wound shows no progress for one to two consecutive weeks."Review of Res. 1's clinical record indicated no physical evaluation of the chest wound for progress of healing or plans to discontinue the wound vacuum therapy. 3. In an interview on 9/30/14 at 10 a.m. . the ADM stated Res 1's bloodwork for laboratory values as ordered by the physician had not been drawn from 8/1/14 through 9/21/14. The ADM stated, "We just missed it, I guess." Review of Resident 1's physician order dated 8/1/14 indicated blood work was to be drawn for "Digoxin level (heart medication), TSH (thyroid stimulating hormone), BMP (basic metabolic panel), CBC (complete blood count) next lab..."Review of Resident 1's clinical record from the hospital titled, "Blood Culture," collected on 9/21/14. On 9/23/14 preliminary results indicated, "Isolate. Gram Negative Bacilli from aerobic and anaerobic vials." The second vial Isolate indicated, "Coagulase negative Staphylococcus." (Both of these results indicate infectious process). "Blood Culture" report dated 9/23/14 identified both the aerobic and anaerobic (terms used to denote growth with oxygen and without oxygen) vials as a "Salmonella species." The "ED [Emergency Department] Physician Notes" dated 9/21/14 indicated Resident 1 had been admitted to the ED on 9/21/14. The Physician Notes indicated, "...She was found by staff to be less responsive than usual. She was found to have a fever and tachycardia (high heart rate)...on arrival here she was very lethargic (state of listlessness)..." Review of the final lab report from the acute hospital dated 9/24/14 indicated Resident 1 had been positive for gram negative bacteremia (bacteria found in blood) and septic (wide spread infection).Review of "Acute Communicable Disease Control Manual," revised 4/14, indicated on page 1 of the section titled "Salmonellosis: 1. Agent Salmonella, gram-negative (refers to color of stain [red] in the identification of this pathogen) bacillus (refers to the rod-like shape of the infectious agent)...2. Identification: a. Symptoms: Sudden onset of fever...abdominal pain, diarrhea...occasionally the clinical course is that of... septicemia...the organism may localize anywhere in the body causing abscesses..."The above violation presented an imminent danger of death or serious harm to the residents and therefore constitutes a Class A citation. |
| 100000038 |
Windsor Post-Acute Healthcare Center of Modesto |
040011219 |
B |
12-Jan-15 |
S2Z011 |
11997 |
Corrected 1/15/15 to include Regulation typeCFR 483.12 (b) (3) Permitting Resident to Return to Facility A nursing facility must establish and follow a written policy under which a resident whose hospitalization or therapeutic leave exceeds the bed-hold period under the State plan, is readmitted to the facility immediately upon the first availability of a bed in a semi-private room if the resident - (i) Requires the services provided by the facility; and (ii) Is eligible for Medicaid nursing facility services. The facility failed to follow the California Standard Admission Agreement (a skilled nursing facility's (SNF's) admission contract required by state law, which included admission and discharge rights, and other obligations of each person [or party] signing the admission contract), when Resident 1 was refused readmission to the facility, after 6 days of in-patient hospitalization and after being determined to be stable to return to the SNF. On 10/1/14, the [SNF] refused to readmit Resident 1 to the facility, after Resident 1 completed 6 days of in-patient hospitalization at a Behavioral Health Center (BHC - an adult in-patient center within a hospital, dedicated to treating individuals with acute [sudden] psychiatric impairment). As a result of the facility's refusal to readmit Resident 1, the Local Police Enforcement transported Resident 1 to a respite center (a short-term crisis housing for individuals with known or suspected to be experiencing mental illness, and who are at risk for homelessness), against Resident 1's will and without Resident 1's routine medications or treatments necessary for his mental, emotional, and physical well-being.On 10/2/14, an onsite visit was conducted to investigate Complaint number CA00415161. Concurrent clinical record and document reviews, and interviews conducted with affected facility and non-facility personnel or individuals, indicated the following:Resident 1 was a 68 year-old male who was admitted to the facility on 11/7/11, with diagnoses that included congestive heart failure (CHF) (the heart is unable to pump blood at an adequate rate resulting in congestion in the lungs), unspecified intellectual disability (below-average intelligence or mental ability and lack of decision-making skills), depression (sadness or feelings of worthlessness), and syncope and collapse (fainting or passing out). Resident 1's medications included Lasix 40 milligrams (mg) once a day (a water pill used to treat excessive fluid accumulation and edema [swelling] of the body caused by heart failure) and Lexapro 10 mg once a day for depression.The comprehensive annual Minimum Data Set (MDS) assessment (a federally mandated comprehensive assessment of residents in a skilled nursing facility to identify functional abilities and health problems) dated 11/24/13, indicated Resident 1 could not recall words or remember the correct day of the week. Resident 1 had no verbal or physical behavioral symptoms such as cursing, hitting, kicking, or grabbing that were directed toward others. The care plan with a revision date of 5/16/14, indicated Resident 1 "Is/has potential to be verbally aggressive related to ineffective coping skills, uses inappropriate language, and is easily annoyed." The interventions included medications, identifying triggers, and for staff to intervene before Resident 1's agitation escalated.The document titled "Report of Suspected Dependent Adult/Elder Abuse" dated 9/25/14, indicated, "On 9/25/14 at 10:20 a.m., Resident 1 was observed entering the library and appearing to be agitated. He became aggressive with another resident ...Police Department contacted ...police removed resident from facility '5150'..." (a section of the California Welfare and Institutions Code which authorizes a qualified officer or clinician to involuntarily confine a person suspected to have a mental disorder that makes him or her a danger to themselves, a danger to others, and/or gravely disabled).On 10/2/14 at 9:11 a.m., during a telephone interview, Social Services Worker 1 (SSW 1) from the Behavioral Health Center (BHC) stated Resident 1 was taken to the emergency room on 9/25/14, by the local law enforcement under 5150, after he was found "choking" another resident at the facility. SS 1 stated Resident 1 was admitted to BHC for further psychiatric evaluation and treatment. The BHC's History and Physical (H & P) dated 9/25/14, indicated Resident 1 required additional hospitalization for safety and stabilization as well as medication titration and would be discharged back to the facility.According to SSW 1, Resident 1 did not display physical aggression and did not make verbal threats towards anybody at the BHC during his admission on 9/25/14, and the following days thereafter. SSW1 stated, "On 9/26/14, I started discharge planning and contacted the Director of Nurses (DON). The DON told me Resident 1 could not return to the facility because he was taken out of the facility by the police. When I asked the DON where Resident 1 would return to, she told me to call the District Attorney's office."SSW 1 stated on 9/29/14, Resident 1 was deemed medically stable to return to the facility. SSW 1 stated, "I called the facility again and spoke with the administrator and the DON. I told them Resident 1 was deemed medically stable and ready for discharge. The administrator and the DON refused to readmit Resident 1. SSW 1 stated she then contacted other Board and Care (B & C - specially regulated homes providing assisted living services, living quarters, and proper care to less than 6 people), but (Resident 1) was adamant and repeatedly requested to go back to the facility where he lived for the past three years. "He kept on begging to be sent back home to the facility. He was upset and emotionally traumatized. I contacted (Resident 1's) brother, but he told me he could not care for the resident due to his own personal and health needs."The BHC's psychiatrist's progress notes dated 9/29/14, indicated "Patient has not exhibited any behavioral outbursts or aggression towards others for the past several days of his hospitalization. Patient appears to be at baseline and ready for discharge today, however, the skilled nursing facility was refusing to take the patient back."On 10/2/14 at 9:18 a.m., during a telephone interview, the Ombudsman (an advocate for residents or patients in a long-term health care facility) stated the facility's refusal to readmit Resident 1 back to the facility caused undue distress upon Resident 1 and put him at risk for "homelessness." The Ombudsman stated, "The respite center can only keep Resident 1 for 24-48 hours and after that, he has nowhere else to go and he will be homeless." The Ombudsman stated Resident 1 ended up in a "temporary" respite center against his will and without his routine medications necessary to treat his various illnesses including a heart problem.On 10/2/14 at 9:30 a.m., during an interview, the administrator stated Resident 1 was transported back to the facility on 10/1/14. He stated he came to the facility and refused to admit Resident 1 because he was a threat to the safety and well-being of all the residents at the facility. The administrator stated although Resident 1 had no prior incidents of physical aggression for the three years he lived at the facility, he acted out without reason or provocation and choked another resident in full view of the other resident's family. The administrator stated Resident 1's physician was at the facility on the day of the incident (9/25/14), and "verbally" told him Resident 1 was not appropriate for long term care at the facility.On 10/2/14 at 11:32 a.m., during an interview, the facility's Social Services Director (SSD) stated Resident 1 have lived at the facility for approximately three years and had no past, present, or future discharge plans prior to the incident on 9/25/14. The SSD stated, "Resident 1 had months upon months of angry verbalizations under his breath, but never struck out. He was seen by a mental health practitioner once a week on Thursdays and according to his reports, there were no indications Resident 1 would physically harm himself or other people."On 10/2/14 at 11:45 a.m. during an interview, the Director of Nurses (DON) stated Resident 1's physical aggression towards another resident on 9/25/14, was an isolated incident. The DON stated Police was called and escorted Resident 1 out of the facility. The DON stated, "I did not know where the police was going to take Resident 1, so I did not give a 7-day bed-hold notice." (A 7-day bed-hold notice is a written notice explaining the resident's right to have his/her bed held for up to seven days. The facility must readmit the resident if he/she returns within the 7 days, and allow him/her to return to the first available bed after the 7 days are up). When asked to describe Resident 1's known behavior(s), the DON stated, "Resident 1 was just generally a grumpy person. He cusses at others under his breath but he never hit, struck, or choked anyone. He made verbal threats but he was not assaultive or physically aggressive."The DON stated she received a phone call from SSW1 on 9/26/14, whereupon she was informed Resident 1 was admitted to the Behavioral Health Center (BHC). The DON stated, "I still did not send a 7 day bed-hold, we were not going to take him back. On 9/29/14, the administrator and I were on a conference call with SSW 1. She informed us Resident 1 was ready to be discharged from the BHC, and the administrator and I told her we will not readmit Resident 1 for safety reasons."On 10/2/14 at 2:00 p.m., during a clinical record review, Resident 1's physician's progress notes dated 10/2/14 (7 days after the incident), indicated " ... (Resident 1's name) with multiple medical problems is not appropriate for long term care at this time. He is dangerous to himself and other residents' safety and well-being."On 10/17/14 at 1:00 p.m., during a telephone interview, the Board and Care owner (BCO) stated, SSW 1 called her on 9/26/14 and 9/29/14, and inquired about placement of Resident 1 at her facility. The BCO stated, "On 9/30/14, I went to the Behavioral Health Center to evaluate Resident 1. I had a male bed available, however, he refusing to go with me and I wasn't going to force him and take him to my home against his will. He kept on telling me his home was the facility and he wanted to go back there." The BCO stated she received another call on 10/3/14, and was asked to pick up Resident 1 from the respite center. The BCO stated she picked up Resident 1 and took him to her Board and Care without any personal belongings, clothing, or medications (since 9/25/14, nine days). According to the BCO, Resident 1 was sad, upset, and had no interest to talk or eat. The BCO stated, "I was worried about him so I took him to a private medical group where they took blood tests and we are still waiting for his prescriptions to be filled as of today." When asked to speak with Resident 1, the BCO gave the phone to the resident who stated, "I want to go home... (name of facility)... please...."On 12/19/14, during administrative document review, the facility census list for 10/1/14, indicated there were 7 male beds open and available for admission). There was no documentation of 7 day bed hold offered or communicated to Resident 1 (self-responsible). The facility's refusal to readmit Resident 1 to the facility after he was deemed medically stable by the appropriate mental health practitioner and physician, resulted in Resident 1's transfer to a respite center against his will and without the medications or treatments necessary for his mental, emotional, and physical well-being. Resident 1 was placed in a situation of temporary homelessness, which affected his overall psychosocial and emotional well-being.This violation had a direct relationship to the health, safety, or security of Resident 1 and constitutes a Class B Citation. |
| 040001040 |
WILLOW CREEK HEALTHCARE CENTER |
040011572 |
B |
19-Jun-15 |
8RWH11 |
6088 |
F224 483.13 (c) - Staff Treatment of Residents - Physical, Mental Staff Treatment of Residents - Neglect or Misappropriation of Property, Mistreatment. Each resident has the right to be free from mistreatment, neglect and misappropriation of property. The facility must develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. "Misappropriation of resident property" means the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent. On 2/20/15 at 12:40 p.m., an investigation was conducted on Entity Reported Incident CA00432133 regarding resident abuse.The facility failed to ensure Resident 1 (Res) was free from misappropriation of resident property when the Social Services Director (SSD), who was unauthorized, requested a withdrawal of $300.00 from Res 1's trust account. The Business Office Manager did not obtain the authorized signature for the withdrawal and did not follow the facility's Resident Trust Fund policy and procedure and gave the SSD $300.00 in cash from Res 1's trust account. The SSD used the $300.00 to purchase items at a local department store for which Res 1 had not authorized.Resident 1 was admitted to the facility on 3/29/11. Res 1's Minimum Data Set (MDS - an assessment tool used to determine mental and physical ability) annual assessment dated 10/29/14 and a quarterly assessment dated 1/11/15 indicated her BIMS (Brief Interview for Mental Status - an assessment tool used to determine the cognitive level of residents) score was 15 of 15, which indicated she was mentally alert and oriented and able to make appropriate decisions regarding her care.On 2/20/15 at 12:40 p.m., during an interview, the Business Office Manager (BOM) stated she had worked at the facility for 7 years and understood the process of authorizing funds from resident accounts. The BOM stated on 10/21/14 she received a request from the SSD for funds from Res 1's trust account. The BOM stated it was "Not very common for [SSD] to request money." When questioned about the facility's Policy and Procedure the BOM stated, "I knew the policy... I trusted [SSD] so I just gave her the money." The BOM stated she gave $300.00 in cash to the SSD from Res 1's Trust Account on 10/23/14. The BOM stated she should not have given the money to the SSD.Review of the facility's Policy and Procedure titled, "Resident Trust Fund Policy and Procedure," dated 11/01/12 indicated, "Authorized Signatures on the Trust Fund Account are as follows: President, Chief Financial Officer, Vice President Operations, Administrator, Director of Nursing, MDS Nurse or Assistant Director of Nursing ...The following facility positions CANNOT be signers: all business office staff, social services and activities." On 2/20/15 at 10:25 a.m., during a concurrent interview and clinical record review, the Administrator stated on 2/10/15 Res 1's son arrived for a visit. The son of Res 1 stated he had received the quarterly statement for Resident 1's trust account and questioned the authorization to withdraw the $300.00. Res 1's son requested information and receipts on the $300.00 withdrawn from the trust account on 10/21/14. The receipt totaled $299.64 and listed several items purchased from a local department store on 11/06/14. Included in the purchase of items were several types of female underwear, including bikini-type (sub-total $42.56); a purse (sub-total $39.99); personal outer wear for legs (sub-total $8.00); and several blouses (sub-total $105.96), several pajama sets ($69.97) and other miscellaneous items.On 2/20/15 at 1:30 p.m., during an interview, Res 1 stated "... No, I did not authorize her [SSD] to take $300.00 and go shopping..." Res 1 stated regarding the items purchased: "I wouldn't have worn them (the clothes) to a dog fight! They said I OK'd it...[SSD] tried to get me to change my story. I wonder how many other times she has done this and gotten away with it..." Res 1 stated she did not wear female underwear but adult briefs. During this interview, Res 1 began to cry and clasp and unclasp her hands. Res 1 stated, "I would like to know why she [SSD] did it and if she would do it again? Someone asked me if I would like to talk to a psychiatrist and I said, No, I don't need one." Res 1 stated, "[SSD] stole $300.00 from me. I don't want to be questioned about it...That was financial abuse!" The clinical record titled, "Physician Notification of Change of Resident Condition," indicated on 2/10/15, "Resident [Res 1] was upset and emotional this afternoon about her missing belongings [$300.00]. She refused to eat dinner at social dining this evening." Res 1 was subsequently placed on closer observation due to the concerns of refusing to eat and to monitor Res 1 for behavioral changes. On 2/20/15 at 3 p.m., during an interview, the Dietary Service Supervisor (DSS) stated on 2/18/15 she was in the hall when she heard Res 1 crying. DSS entered the room and asked Res 1 what was wrong. Res 1 stated, "[SSD] stole $300.00 from me! I don't want to be questioned about it. I just want it to be left alone." On 2/20/15 at 1:05 p.m., during an interview, Certified Nursing Assistant (CNA) 1 stated she usually took care of Res 1. CNA 1 stated Res 1 continued to be irritated and upset about the $300.00 used from the trust fund.The facility failed to protect Res 1 from misappropriation of resident property when the BOM did not follow the Trust Fund Policy and Procedure and gave $300.00 of Res 1's funds to the SSD who spent the funds at a local department store without Res 1's authorization. As a result of this misappropriation of funds Res 1 exhibited behavioral changes such as wringing of hands, refusal to eat, and refusal to participate in social dining along with episodes of crying about the loss of property.This violation had a direct or immediate relationship to Resident 1's health, safety, or security, and therefore constitutes a Class "B" Citation. |
| 050001409 |
Windsor Terrace of Westlake Village |
050008821 |
A |
10-Jan-12 |
VFM611 |
5680 |
F323 483.25 (h) (h) Accidents - the facility must ensure that(2) Each resident receives adequate supervision and assistance devices to prevent accidents.During a complaint investigation the Department determined the facility failed to provide adequate supervision to prevent injury related to a fall for Resident A. The facility failed to implement interventions including two-person assistance for bed mobility and hygiene for Resident A. These failures resulted in Resident A falling from bed and sustaining a subdural hematoma and hospitalization.Resident A was admitted to the facility on November 24, 2009 with diagnoses including dehydration, other organic chronic psychotic conditions, Alzheimer's disease (progressive mental deterioration due to generalized degeneration of the brain), and chronic obstructive pulmonary disease (COPD-a disease involving constriction of the airways and difficulty or discomfort in breathing). Assessments completed on admission to the facility revealed Resident A's decision making skills and memory were severely impaired. Resident A was at high risk for falls, was taking a medication designed to thin the blood, and was dependent on staff for bed mobility, locomotion, dressing, eating, toilet use, personal hygiene, and bathing.Resident A sustained three un-witnessed falls from bed, without injury, between June 2010 and June 2011. On September 10, 2010 Resident A's fall risk care plan interventions were revised to include placing Resident A's bed in its lowest position as a fall precaution, but Resident A continued to fall. In February of 2011, the self-care plan of care revealed Resident A had declined in self-care functioning since the un-witnessed falls.On June 23, 2011 the fall risk care plan was revised to include interventions of placing a "bolstered bed cushion" in bed with Resident A and placing the bed in the lowest position. On August 31, 2011, Resident A's self-care functioning with activities of daily living (ADL) care plan was revised to include "two-person" assist with bed mobility, transfers and dressing instead of a one-person assist as previously required.On September 5, 2011, a certified nursing assistant, while attempting to change Resident A's brief, without the assistance of a second staff member, turned Resident A onto the right side. Resident A began to jerk and slid off the bed onto the floor head first. Resident A sustained injuries including a deep laceration and swelling at the left eyebrow, a skin tear on the left elbow, and a subdural hematoma (bleeding between the brain surface and the outer covering of the brain). Resident A required intensive care hospitalization for neurologic observation. Resident A remained in the hospital for nine days and was subsequently transferred back to the facility.During an interview with the staff developer on November 7, 2011 at 1:50 p.m. revealed that Resident A was included in the list, provided to staff, of residents who require a two-person assist. The list was in a binder at the nurse station and available to all direct care staff to review and refer to. The staff developer indicated direct care staff were always reminded to not work alone and to ask for help when working with residents identified as a two-person assist with ADL's. A concurrent record review confirmed Resident A on the two person assistance list. During a phone interview with the certified nursing assistant (CNA 1) on November 15, 2011 at 10 a.m., CNA 1 indicated while turning Resident A to the right side (away from CNA 1) during provision of care, Resident A began to jerk back and forth, rolled over the bolstered cushion and fell off the other side of the bed. CNA 1 admitted having knowledge Resident A required two- person assistance with transfers and locomotion but not during care that involved changing Resident A's brief. CNA 1 reported having always changed Resident A's briefs without the assistance of other staff and claimed not knowing Resident A needed two staff to be present when changing the brief.During an interview with a licensed nurse (LN 1) on November 15, 2011 at 2 p.m., and with LN2 on November 15, 2011 at 2:50 p.m., both confirmed having knowledge Resident A was a high risk for falls and needed total assistance with most ADL's. LN 2 clarified that Resident A needs two staff to be present when Resident A is turned or rolled on her side during brief change.LN 2 explained, on September 5, 2011 at 3 p.m., having reminded CNA 1 that Resident A was a two person assist and commented CNA 1 should have called for another staff to assist while changing Resident A's briefs.The facility was in violation of the above regulation when it failed to implement interventions to prevent injury related to a fall for Resident A. Resident A was cognitively impaired, was a two-person total assistance with her activities of daily living, had history of multiple falls and was identified to be at high risk for more falls. On September 5, 2011, Resident A fell from her bed when staff failed to implement two-person assistance for bed mobility while performing care. Resident A sustained injuries including lacerations to the head and a subdural hematoma requiring hospitalization. The facility knew or should have known Resident A required assistance from two staff for bed mobility and hygiene. The facility failed to provide adequate supervision which resulted in Resident A sustaining a laceration to the left eyebrow and a subdural hematoma requiring hospitalization. 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. |
| 050000688 |
WAVECREST HOME ICF/DD-H |
050009832 |
B |
14-Feb-14 |
JW8811 |
2160 |
California Health and Safety Code 1418.91 (a)(b) (a) A long term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the department immediately or within 24 hours. (b) A failure to comply with the requirements of this section shall be a class "B" violation.The Department determined that the facility was in violation of the above statute by its failure to report an allegation of abuse involving Patient 1 to the Department immediately or within 24 hours. Patient 1 was 18 years old, admitted to the facility with diagnoses including severe mental retardation, autism, and seizure disorder.During an interview on 5/4/11 at 3 p.m., Staff A and Staff C explained witnessing the facility manager pulling the face mask of Patient 1's helmet when Patient 1 failed to comply with the facility manager's requests or didn't move fast enough for facility manager.Staff A explained having observed Patient 1 standing near the exit door to the patio when the facility manager yelled at Patient 1, "Mooove!", then the facility manager took a plastic bag containing a nylon sling lift (a device used to support patients during mechanical transport) and hit Patient 1 on the right side of his head and face. Patient 1 was wearing his helmet with a full face mask.Staff A described the facility manager as usually forceful to Patient 1 to force him to comply. The facility manager was further described as frequently grabbing Patient 1's helmet facemask, shaking and pulling Patient 1 around holding the facemask to get him to obey her. Staff A explained, as a result, Patient 1 flinches and pulls away whenever a hand is moved toward his face. During an interview on that same day, Staff B explained the facility manager had shown Staff B the face grasp method to get Patient 1 to comply with requests. Staff A explained having had abuse training by the facility but was afraid to report the incident. The alleged abuse was not reported to the Department until 4/20/11, 16 days after the incident.The facility failed to report the alleged abuse of Patient 1 to the Department immediately, or within 24 hours. |
| 050000688 |
WAVECREST HOME ICF/DD-H |
050009833 |
B |
14-Feb-14 |
JW8811 |
2430 |
Welfare & Institutions Code 4502 (h) Patient Rights - Persons with developmental disabilities have the same legal rights and responsibilities guaranteed all other individuals by the United States Constitution and laws and the Constitution and laws of the State of California. No otherwise qualified person by reason of having a developmental disability shall be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity, which receives public funds. It is the intent of the Legislature that persons with developmental disabilities shall have the 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 Department determined that the facility is in violation with the above statute by failing to ensure a patient's right to be free from abuse.Patient 1 was 18 years old, admitted to the facility with diagnoses including severe mental retardation, autism, and seizure disorder.During an interview on 5/4/11 at 3 p.m., Staff A and Staff C explained witnessing the facility manager pulling the face mask of Patient 1's helmet when Patient 1 failed to comply with facility manager's requests or didn't move fast enough for the facility manager. Staff A explained having observed Patient 1 standing near the exit door to the patio when facility manager yelled at Patient 1, "Mooove!", then the facility manager took a plastic bag containing a nylon sling lift (a device used to support patients during mechanical transport) and hit Patient 1 on the right side of his head and face. Patient 1 was wearing his helmet with a full face mask.Staff A described the facility manager as usually forceful to Patient 1 to force him to comply. The facility manager was further described as frequently grabbing Patient 1's helmet facemask, shaking Patient 1 and pulling Patient 1 around holding the facemask to get him to obey her. Staff A explained, as a result, Patient 1 flinches and pulls away whenever a hand is moved toward his face. During an interview on that same day, Staff B explained the facility manager had shown Staff C the face grasp method to get Patient 1 to comply with requests. This violation caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety, or other emotional trauma to Patient 1. |
| 060000168 |
WINDSOR GARDENS CARE CENTER OF FULLERTON |
060010735 |
B |
21-May-14 |
NLW611 |
4554 |
The facility failed to manage Resident 9's pain and administer pain medication as prescribed by the physician. This resulted in Resident 9 experiencing severe pain, discomfort and interfered with the resident's ability to sleep. During initial tour on 4/8/14 at 1440 hours, Resident 9 stated she was admitted to the facility last night around 1915 hours from the acute care hospital for physical therapy following left knee replacement surgery. The resident stated she requested pain medication last night and did not receive any. The resident stated the licensed nurse told her the pharmacy was closed. Resident 9 stated she laid awake, in bed, all night, in pain, and "stewing" over not getting any pain medication. Resident 9 stated she called her family member in the morning to transfer her to another facility, but has since changed her mind. The resident stated she was very upset she did not receive her pain medication and did not want this to happen to anyone else.Clinical record review was initiated for Resident 9 on 4/8/14. Resident 9 was admitted to the facility on 4/7/14, with diagnoses including status post left knee replacement. Resident 9's MDS dated 4/10/14, showed the resident is cognitively intact. Resident 9's history and physical dated 4/8/14, shows Resident 9 has the capacity to understand and make decisions.Review of the MAR for April 2014 shows orders dated 4/7/14, for hydrocodone (narcotic pain medication) 7.5 mg/325 mg, two tablets every four hours as needed for severe pain, hydrocodone 7.5 mg/325 mg, one tablet every four hours as needed for moderate pain, and Tylenol (pain medication) 325 mg, two tablets every four hours as needed for mild pain. An order dated 4/8/14, shows Norco (narcotic pain medication) 5 mg/325 mg, one tablet, one time only, now for pain. The MAR shows Norco 5 mg/325 mg was administered on 4/8/14 at 1130 hours for pain.On 4/8/14 at 1505 hours, a concurrent interview and clinical record review was conducted with LVN 4. LVN 4 verified Resident 9's first dose of pain medication since her admission on 4/7/14 at 1915 hours, was Norco 5 mg/325 mg administered on 4/8/14 at 1130 hours, 16 hours after her admission. There was no documentation showing Resident 9 received hydrocodone 7.5 mg/325 mg or Tylenol 325 mg as prescribed by the physician. When LVN 4 was asked why Resident 9 did not receive her pain medication when she requested it on 4/7/14, she stated she did not know.Review of the Pain Assessment completed 4/7/14 at 2135 hours, shows Resident 9 has had frequent pain over the last 5 days, affecting her ability to sleep at night. The Pain Assessment showed the resident has been experiencing moderate pain with a numeric rating of 5 (based on a scale of 0-10 with 0 being no pain and 10 the worst possible pain).Review of the nurse's note date 4/7/14 at 2225 hours, shows Resident 9's pain was 2/10.During an interview with Resident 9 on 4/10/14 at 0845 hours, Resident 9 stated her pain was 10/10 on the night of her admission. According to the facility's P&P regarding pain management dated 11/2012, medications and non-drug treatment interventions will be administered promptly as needed according to the physician's orders and the resident's plan of care. On 4/9/14 at 1530 hours, a concurrent interview and clinical record review was conducted with LVN 5. LVN 5 verified the documentation in the clinical record showed Resident 9 complained of pain on 4/7/14; however, the LVN was not able to produce documentation showing why pain medication was not administered to the resident. LVN 5 verified the facility's emergency drug kit does not contain hydrocodone 7.5 mg/325 mg. The LVN verified pain medications should be available to the resident within four hours of the time ordered by the physician. LVN 5 verified there was no documentation in the clinical record showing the nurse on the PM shift (1500-2300 hours) on 4/7/14, or the night shift (2300-0700 hours) on 4/7/14, attempted to call the physician to request an order for a pain medication contained in the emergency drug kit. LVN 5 confirmed there was no documentation in the clinical record showing the pharmacy was contacted to determine the status of the hydrocodone 7.5 mg/325 mg delivery. The facility's failure to provide Resident 9 with pain medication as prescribed by the physician resulted in Resident 9 experiencing severe pain, discomfort and interfered with the resident's ability to sleep. This failure has a direct and immediate relationship to the health, safety, and security of the resident. |
| 060000168 |
WINDSOR GARDENS CARE CENTER OF FULLERTON |
060012254 |
A |
17-May-16 |
MJLN11 |
13639 |
Windsor Gardens Care Center of Fullerton Provider Number 055689 Exit Date: 4/7/16 Complaint No: CA00480287 Class A Citation F323: 42 CFR 483.25 Accidents (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 failed to ensure adequate supervision while Resident 1 was eating when Resident 1 was at a high risk for food aspiration (inhalation of some foreign material). Resident 1 was left alone in his room to feed himself his dinner meal on 8/31/15. As a result, the resident aspirated his food and was found unresponsive, pulseless, and not breathing. The licensed vocational nurse (LVN) 1 performed the Heimlich maneuver after discovering food in the resident's mouth, initiated CPR (cardiopulmonary resuscitation, a procedure to restore life), and called 911. Resident 1 was transported to an acute care hospital emergency department (ED) via paramedics where he was found to have cardiopulmonary arrest and a partially blocked airway, requiring mechanical ventilation. During the hospitalization, he was found to have anoxic brain damage and a collapsed lung due to food impaction. He subsequently died on 9/9/15, nine days after the incident. The Orange County Sheriff-Coroner's report dated 9/11/15, showed Resident 1's cause of death was "anoxic brain injury due to aspiration of food contents." Failure to adequately supervise Resident 1 during meal time resulted in aspiration of food, a collapsed lung, cardiopulmonary arrest, anoxic brain damage, and subsequently death. Closed clinical record review for Resident 1 was initiated on 3/24/16. Resident 1 was readmitted to the facility on 8/25/15, with diagnoses including dementia with behavioral disturbances and esophageal reflux. The care plan was the same as his prior admission care plan from 5/11/15. Review of Resident 1's hospital's history and physical examination dated 8/11/15, showed his diagnoses included dementia, a history of a brain tumor in 2004 and a stroke in 2011.Review of Resident 1's Minimum Data Sets (a standardized tool used to assess resident's functional capabilities) dated 5/11/15 and 8/30/15, showed the resident had severe cognitive impairment and required limited assistance from one staff member for eating (resident highly involved in the activity, with staff providing guided maneuvering of limbs).Review of Resident 1's Admit/Readmit Assessment form dated 8/25/15, showed the resident required supervision from staff for eating.Review of Resident 1's care plan dated 8/26/15, to address his impaired activities of daily living skills showed an intervention to assist the resident with meals as needed. (Care Plan, Interventions/Tasks, page 6).Review of Resident 1's Speech Therapy Initial Evaluation dated 8/28/15, showed the reason for the referral was due to the resident being observed to have cognitive impairment which hindered his ability to safely communicate as well as having signs and symptoms of aspiration while he was drinking thin liquids. The Assessment Summary showed Resident 1 had dysphagia concerns and would benefit from treatment in learning strategies to improve his swallow safety.Review of Resident 1's Speech Therapy Progress Note dated 8/28/15, showed the resident was observed having signs and symptoms of aspiration with large, consecutive swallows of thin liquids and required minimum cues to take small sips. The ST (Speech Therapist) also documented "Nursing informed of swallow recommendation and sign posted on wall."Review of the Speech Therapy Progress Note dated 8/31/15 at 1214 hours, showed Resident 1 was observed sitting upright at bedside during breakfast, was observed eating rapidly with large bites of food, had inadequate chewing, and was drinking a whole cup of liquids quickly. The ST documented the resident required moderate to maximum verbal and tactile cues to slow down to improve safety of swallow function during meals. Documentation in the Speech Therapy Progress Note showed the ST recommended staff continue monitoring for signs and symptoms of aspiration and teaching of strategies such as small bites, altering liquids/solids, and swallowing small bites/sips before taking another. Additional review showed the ST documented the above findings were communicated to the resident, and nursing department approximately five hours prior to the staff finding Resident 1 alone in his room and unresponsive, with food in his mouth.Review of the resident's plan of care and progress notes found no documented evidence staff implemented the ST's recommendations as documented on 8/28/15 and on 8/31/15 at 1214 hours, regarding aspiration precautions.Review of the Neuropsychological Consultation note dated 8/31/15, showed Resident 1's insight/judgment was impaired. On the section for "Discussion/Recommendations," the psychologist documented Resident 1 required a structured and supervised environment to remain safe.Review of the Progress Notes for Resident 1 showed a late entry dated 8/31/15 at 1800 hours. Documentation showed at 1710 hours, when LVN 1 was passing medications, a code blue was called in Resident 1's room. LVN 1 documented the following: resident was unresponsive and his mouth was full of food. In addition, LVN 1 documented that the Heimlich maneuver was repeated on the resident and a mouth sweep was performed. LVN 1 was able to remove unchewed food from Resident 1's mouth.Review of Resident 1's Nursing Home to Hospital Transfer Form dated 8/31/15, showed the resident needed assistance with eating Review of the paramedic report dated 8/31/15, showed the facility called the paramedics at 1731 hours. The paramedics arrived at the facility at 1750 hours and found Resident 1 unconscious/unresponsive, pulseless, and not breathing. The paramedic documented the resident had partial airway obstruction and had food in his mouth/throat.Review of Resident 1's ED Report dated 8/31/15, showed the following: * At 1759 hours, the resident was unable to be intubated (place a plastic tube through the mouth or nose into the throat to provide oxygen) due to his throat being impacted full of rice; * At 1800 hours, the resident was manually ventilated (given oxygen via a mask), after dislodging some of the impacted rice; * At 1802, code blue (resuscitation) was called; and * At 1810, Resident 1 was intubated and transferred to the Intensive Care Unit.The ED physician documented Resident 1's Primary Impression was Cardiac Arrest Aspiration.Review of Resident 1's hospital Discharge Summary dated 9/21/15, "as the days continued, it became clear that the resident had severe anoxic brain injury related to the cardiopulmonary arrest and given the resident's poor neurologic prognosis, the family withdrew Resident 1's ventilator support and focuses on comfort measures only." On 9/9/15 at 0700 hours, Resident 1 had expired. The physician documented the "discharge diagnoses included anoxic brain injury, cardiopulmonary arrest secondary to aspiration of food contents and left lung collapse secondary to food impaction." During an interview on 3/24/16 at 1232 hours, CNA 1 stated Resident 1 was not able to verbalize his needs. CNA 1 stated the resident did not need assistance with eating and he always ate in his room. CNA 1 stated Resident 1 was on limited assistance with eating. When CNA 1 was asked what kind of assistance she provided to Resident 1 during meal time, she stated she would just place his tray on the over bed table, open his milk carton, and apply butter on his bread.On 3/24/16 at 1252 hours, an interview with the Assistant Director of Nursing (ADON) was conducted. She stated on 8/31/15 at 1710 hours, LVN 1 was the nurse who found Resident 1 unresponsive with a mouth full of food. The ADON stated LVN 1 performed the Heimlich maneuver on Resident 1, conducted a mouth sweep to determine if additional food was in the resident's mouth and suctioned the resident's mouth. The ADON stated that CPR was initiated to Resident 1 at 1717 hours. The ADON stated there was no facility code blue sheet to document the steps the staff had taken during the code blue. The ADON was unaware if Resident 1 had episodes of choking.On 3/24/16 at 1345 hours, the Director of Nursing (DON) was interviewed. When asked about the incident involving Resident 1, the DON stated on 8/31/15, Resident 1 was found face down on the side of his bed while the resident was eating dinner and CPR was started. She stated Resident 1 had not completed his dinner as the meal tray still had food on it. The DON stated Resident 1 had severe cognitive impairment and was confused.During a telephone interview on 3/25/16 at 1307 hours, Resident 1's family member stated he had visited Resident 1 at the facility and noticed the resident had no supervision while eating. He stated when Resident 1 was at other facilities, he was never left alone to eat; he had supervision while eating. A telephone interview was conducted on 4/4/16 at 1350 hours, and a follow-up phone call on the same day at 1402 hours was conducted with LVN 1. LVN 1 stated on 8/31/15, while he was administering the medications to another resident, he heard an overhead page for Rapid Response (emergency response) to Resident 1's room. LVN 1 stated when he entered Resident 1's room; he observed Resident 1 had "a lot of food in his mouth." LVN 1 stated Resident 1 was unresponsive, so he performed the Heimlich maneuver on the resident and the resident expelled the food from his mouth.During a telephone interview on 4/4/16 at 1611 hours, the Dietary Supervisor confirmed on 8/31/15, Resident 1 was given rice with his meal per the resident's request for his evening meal. She stated the resident was served steamed rice most of the time.During a telephone interview on 4/4/16 at 1700 hours, with CNA 2, she stated on 8/31/15, she was assigned as the caregiver for Resident 1. CNA 2 stated she started passing the residents' dinner trays between 1630 to 1700 hours. CNA 2 stated she did not stay in Resident 1's room after he received his dinner tray. CNA 2 stated Resident 1 was independent with eating. CNA 2 stated the charge nurse did not instruct her that Resident 1 required supervision when he was eating. When CNA 2 was asked if she was aware of a sign posted on the wall in Resident 1's room to address the resident's need for supervision while eating, she stated no.On 4/5/16 at 1645 hours, a telephone interview was conducted with ST 2. She stated Resident 1 was observed to have cognitive impairment which hindered his ability to safely communicate, in addition to having signs and symptoms of aspiration when he was drinking liquids. When ST 2 was asked to define signs and symptoms of aspiration, she stated "coughing during the swallowing process." ST 2 stated Resident 1 was observed chugging down his drinks which placed the resident at a high risk for aspiration. ST 2 stated Resident 1 needed to take small sips of liquids with cueing and needed supervision. When ST 2 was asked if the nursing staff were aware of Resident 1's high risk for aspiration, she stated "yes." In addition, ST 2 stated she had posted a sign above Resident 1's bed on 8/28/15 that read "Aspiration precautions: Patient instructed to take small sips, supervision required." When ST 2 was asked to clarify "supervision required," she stated a staff member needed to stay with Resident 1 while he was eating or drinking to provide him cues verbally and/or physically to slow down. ST 2 stated Resident 1 ate very rapidly.Review of the Orange County Sheriff Coroner's report dated 9/11/15, showed Resident 1's cause of death was "anoxic brain injury due to aspiration of food contents." Further review of the coroner's report showed the following: * On 9/9/15 at 0451 hours, the coroner received a call from the acute care hospital's RN and was informed Resident 1 was admitted to the hospital on 8/31/15, after being found pulseless and having rice in his mouth/throat. The paramedics report identified the resident's airway had a partial obstruction; he was resuscitated and transported to the emergency department on 8/31/15, where they were initially unable to intubate the resident because the resident's throat was full of rice, but eventually the resident was intubated but never regained consciousness.* On 9/9/15 at 0840 hours, the coroner called the facility and was informed Resident 1 was last seen on 8/31/15 at 1630 hours, when the staff brought the resident his food to his room. The facility's staff informed the coroner on 8/31/15 at 1710 hours, a code blue was called to Resident 1's room after he was found unresponsive with a mouth full of rice.* On 9/9/15 at 0854 hours, the coroner received a call from the acute care hospital's admitting physician. The physician confirmed the resident came in the hospital with an airway obstruction and noted to have either rice or some sort of pasty type food. The physician stated the family had expressed concerns with the facility's lack of monitoring or placing Resident 1 on a special diet.Failure to supervise Resident 1 during meal times as recommended resulted in aspiration, food impaction, a collapsed lung, hospitalization and respiratory failure requiring mechanical ventilation, cardiopulmonary arrest, and anoxic brain damage, which contributed to his death nine days later.These violations presented either an imminent danger that death or serious physical harm would result or a substantial probability that death or serious physical harm would result. |
| 070000094 |
Watsonville Post Acute Center |
070009073 |
B |
07-Mar-12 |
0F7711 |
12355 |
F329 - 483.25(I) Drug Regimen Is Free From Unnecessary Drugs Each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used in excessive dose (including duplicate therapy); or for excessive duration; or without adequate monitoring; or without adequate indications for its use; or in the presence of adverse consequences which indicate the dose should be reduced or discontinued; or any combinations of the reasons above.Based on a comprehensive assessment of a resident, the facility must ensure that residents who have not used antipsychotic drugs are not given these drugs unless antipsychotic drug therapy is necessary to treat a specific condition as diagnosed and documented in the clinical record; and residents who use antipsychotic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs. The facility failed to ensure Resident 1's drug regimen was free of unnecessary drugs when the facility administered psychoactive medications (used to manage mood and behavior) which included Risperdal (an antipsychotic medication used to manage psychosis and disordered thinking); Risperdal Consta, (a long acting injectable form of Risperdal); and both oral and injectable routes of Haldol (an antipsychotic medication used to manage psychosis, aggression, and agitation); and Xanax (an anti-anxiety medication) without adequate monitoring or indication for use and in the presence of possible adverse reactions. Resident 1 developed increased sleepiness, sedation and lethargy, difficulty in walking and incontinence following the administration of antipsychotic medications. The resident's physician failed to evaluate the resident or conduct a review of his medication when staff informed him of the change in condition. In addition, staff continued to administer Xanax in the presence of adverse reactions. These failures placed the resident at risk for increased sedation and decline in physical functioning.Resident 1 was an 87 year old male admitted to the facility on 7/5/09 with diagnoses that included dementia with behaviors and a healing Stage IV pressure ulcer to the coccyx (tailbone area). Acute care hospital skilled nursing facility admission orders documented medication orders that included Risperdal 0.5 milligram (mg) by mouth twice a day (no indication); Haldol, one mg by mouth three times a day as needed for severe agitation; Xanax, one mg by mouth three times a day, hold if sedated and Ambien (a medication used to treat insomnia) 10 mg by mouth at bedtime. The "Nursing Admission Assessment Form," dated 7/5/09, indicated that Resident 1 was steady on his feet, did not use any assistive devices, and was continent of both bowel and bladder. The assessment noted Resident 1 had intermittent confusion and was at risk for elopement. The "Licensed Personnel Weekly Progress Notes" dated 7/5/09, indicated that Resident 1 was oriented to person and place, confused to time and was "difficult to re-direct at times." A physician's telephone order dated 7/5/09, from Physician B, Resident 1's attending physician in the facility, repeated the hospital admitting orders for Risperdal 0.5 milligram (mg) by mouth (no indication found in the medical record), and Haldol one mg by mouth, three times a day as needed related to severe agitation, Xanax 1 mg PO three times a day, hold if somnolent and Ambien 10 mg by mouth at hour of sleep for insomnia.A nursing progress note, dated 7/7/09, indicated that Resident 1 was alert, confused, spit out medications, and attempted numerous times to leave the facility. An addendum at 8 p.m., noted that Resident 1 refused his night care and medications. The on-call physician ordered Haldol, one mg administered via injection, every four hours as needed for agitation.On 7/8/09 at 3:15 p.m., a nursing progress note indicated that Resident 1 continued to be at risk for increased episodes of elopement. Licensed staff notified Physician B of this assessment and received a telephone order, dated 7/8/09 for Risperdal Consta, 25 mg via muscular injection every two weeks (for increased episodes of elopement). The physician ordered to discontinue the injectable Haldol and the .5 mg oral Risperdal.The manufacturer's indications for the use of Risperdal and Risperdal Consta identified that Risperdal is not approved for the treatment of dementia related psychosis. Side effects that could result from the use of Risperdal are: *Akathisia (inability to sit or stay still); *Somnolence (excessive sleepiness); *Dystonia (prolonged, repetitive muscle contractions that may cause twisting or jerking movements); *Neuroleptic malignant syndrome (catatonic rigidity, stupor, unstable blood pressure, fever, profuse sweating, incontinence) and; *Cerebral Vascular Accident or stroke, sudden death The manufacturer guidelines for Haldol identified that Haldol is not approved for the treatment of dementia related psychosis. The following are the side effects associated with the use of Haldol: *Severe extrapyramidal reactions (tremor, slurred speech, restlessness, severe agitation, poor muscle tone); *Tardive Dyskinesia (movement disorder that includes involuntary rolling of the tongue and twitching of the face, trunk, or limbs); *Sedation; *Lethargy. Manufacturer guidelines for Xanax identified that side effects related to Xanax can include extreme drowsiness, sedation, problems with speech, and problems with balance or coordination. The July, 2009 Medication Administration Record (MAR) documented Resident 1's psychoactive medication regimen was as follows: On 7/7/09 at 1:30 p.m., Resident 1 received one mg of Haldol, by mouth for agitation.On 7/7/09 at 8:30 p.m., Resident 1 received one mg of Haldol, via muscular injection. On 7/7/09, Resident 1 received a total of one mg Risperdal by mouth. On 7/8/09, Resident 1 received a total of 0.5 mg of Risperdal by mouth and 25 mg of Risperdal Consta via muscular injection. On 7/7/09 and 7/8/09 the resident received one mg Xanax three times per day, as ordered at 9 a.m., 1 p.m. and 5 p.m. On 7/8/09 at 10 p.m., a nursing progress note documented that Resident 1 was confused and had developed a "very unsteady" gait.On 7/9/09 (the day after receiving the injection of Risperdal Consta), a nursing progress note (no time) indicated that Resident 1 was very sleepy and had trouble walking. The nurse documented that the resident, "continues with confusion, having trouble walking, speech garbled." On 7/10/09 at 10 p.m., a nurse's note indicated that Resident 1 continued to be "very sleepy all shift." The nurse documented that Resident 1 was "awakened for dinner - sat up at the edge of the bed and fed per staff." After eating "25 percent" the resident went back to sleep and medications were held due to "somnolence." A "Change in Condition Assessment" dated 7/10/09, indicated that upon admission, Resident 1 was continent of both bowel and bladder and that as of 7/10/09, the resident required incontinence briefs due to "accidents" and trouble walking. The registered nurse also assessed that Resident 1 was disoriented and confused, had impaired balance, and was very sleepy. The assessment identified Resident 1's behaviors as disoriented, combative, resistive, and that Resident 1 wanders.A fax communication from the facility to Physician B, dated 7/10/09, noted that the resident had been very sleepy since receiving the Risperdal Consta injection on 7/8/09. The faxed communication requested the physician to review the resident's medications and advise the facility what to do for Resident 1. The fax also indicated that the resident had a new blister to the left hip. The physician responded via fax with an (undated) order for the blister on Resident 1's hip, but gave no advice or instructions to the facility regarding the resident's changed condition or evaluation of the medication regimen.Nursing notes, dated 7/10/09 and 7/11/09, continued to document the resident's increased sleepiness, lethargy and poor meal intake. There was no documentation that the physician responded to the facility's request to evaluate the resident regarding his changed condition and to evaluate the resident's medication regimen. There was no documentation that facility staff followed up with the physician when the physician did not respond to the fax dated 7/10/09. A nurse's note, dated 7/11/09 at 11:30 p.m., documented that at 9 p.m. that evening, the resident's temperature was elevated at 102.1 degrees Fahrenheit (F) (a normal oral temperature is 98.6 degrees F). At 11:30 p.m., the resident's temperature was 100 degrees. The nursing note documented that the resident slept all shift and his medications were held due to lethargy.The July, 2009 MAR documented that staff held the resident's 1 p.m. Xanax on 7/9/09 and both the 1 p.m. and 5 p.m. doses on 7/10/09, 7/11/09, and 7/12/09 due to the resident's increased sedation. The MAR indicated that the resident continued to receive the 9 a.m. dose of Xanax 7/09/09, 7/10/09, 7/11/09, 7/12/09, and 7/13/09, when nursing staff documented that the resident had increased sedation.On 7/13/09, at 4 p.m., a nursing note contained documentation that Resident 1 continued to be "groggy" and had developed "jerking movements, tremors" and "currently needing assistance for everything." The nurse's note also indicated that Resident 1 was no longer able to turn and position himself in bed and required turning every one to two hours.A nursing note, dated 7/13/09, at 5:20 p.m., documented that 911 was called and that paramedics transferred Resident 1 to the hospital due to an increased temperature, and altered level of consciousness. During an interview on 8/3/09 at 1 p.m., Physician A stated that both he and Physician B had treated Resident 1 in the past, but they did not share a medical practice. He stated initially there was confusion regarding Resident 1's assigned physician while in the facility. Physician A stated he saw Resident 1 for the first time (since his admission to the facility) on 7/12/09 and facility staff had not notified him regarding Resident 1's change of condition or the resident's elevated temperatures. During an interview on 8/4/09 at 11:10 a.m., the Director of Nursing (DON) stated staff could have contacted the facility's medical director when they did not receive a response from Physician B regarding the resident's changed condition.During a telephone interview on 4/20/10 at 11 a.m., the DON verified that Resident 1, when admitted on 7/5/09, was alert and oriented to self and family and was able to walk independently despite anxious behaviors. The DON also verified that Resident 1 was at risk for elopement. The DON confirmed that the administration of the psychoactive medications may have contributed to the adverse consequences experienced by Resident 1. These adverse consequences included difficulty walking, garbled speech, tremors, and sedation. The facility's policy and procedure titled "Psychotropic Medication Management," dated 9/02 identified that the facility was to administer and monitor the effects of psychotherapeutic medications in such a manner as to assist the resident in "achieving or maintaining his/her highest functional level. The policy specified that anti-psychotics "should not be used" for conditions that included restlessness, uncooperativeness, anxiety, wandering, impaired memory, insomnia. The facility failed to ensure Resident 1's drug regimen was free of unnecessary drugs when the facility administered psychoactive medications without adequate monitoring or indication for use and in the presence of possible adverse reactions. Resident 1 developed increased sleepiness, sedation and lethargy, difficulty in walking and incontinence following the administration of antipsychotic medications. The resident's physician failed to evaluate the resident or conduct a review of his medication when staff informed him of the change in condition. In addition, staff continued to administer an anti-anxiety medication, Xanax in the presence of adverse reactions. These failures placed the resident at risk for increased sedation and decline in physical functioning.The above violations had a direct or immediate relationship to the health, safety, security of residents. |
| 070000036 |
WHITE BLOSSOM CARE CENTER |
070009349 |
B |
04-Jun-12 |
VGCQ11 |
3693 |
Health and Safety Code 1418.91(a) (a) A long-term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the department immediately, or within 24 hours. The facility failed to report an incident of suspected abuse to the California Department of Public Health (CDPH) immediately or within 24 hours after the alleged theft of Patient 1's ring on 2/1/12.Patient 1's clinical record was reviewed on 4/27/12. Patient 1 was admitted with diagnoses including high blood pressure. An acute care hospital emergency room note dated 2/1/12 indicated the patient was alert. Patient 1's ring was inventoried and documented in his "Inventory of Personal Effects" dated 1/28/12. During an interview on 4/27/12 at 8:25 a.m., Patient 1's family member (FM) stated when Patient 1 was admitted to the facility, the admitting nurse asked her to remove his wedding ring to take it home. The FM stated Patient 1's fingers had calcium deposits on his knuckles and the ring could not be removed without cutting it off or hurting the patient.During an interview on 5/16/12 at 4:10 p.m., certified nurse assistant A (CNA A) stated she assisted with Patient 1's admission to the facility and observed Patient 1's ring. She stated she asked the nurse if the family could take the ring home for safety. CNA A further stated the FM told her Patient 1 never removed his ring as it was too tight. During an interview on 5/16/12 at 3:10 p.m., licensed nurse C (LN C) stated she was with Patient 1 and the FM on 2/1/12 when another family member noticed Patient 1's ring was missing from his hand. Patient 1 also pointed to his ring finger which now had no ring on it.During an interview on 4/27/12 at 1:40 p.m., Patient 1's FM stated Patient 1 kept looking for his ring and was very upset.LN C further stated the social service director (SSD) took over the complaint. During an interview on 5/16/12 at 3:27 p.m., licensed nurse D (LN D) stated on 2/1/12 as Patient 1 was being transferred to the acute care hospital, his FM asked where was Patient 1's wedding ring and stated he had been wearing his wedding ring. The FM asked LN D to call the police. LN D called the social service director (SSD) and informed her of the missing ring. During an interview on 5/16/12 at 3:30 p.m., the SSD stated she assisted Patient 1 and the FM on 2/1/12 between 3 and 5 p.m. when Patient 1's wedding ring was reported missing.During an interview on 5/17/12 at 8:27 a.m., the SSD stated a police report for Patient 1's missing wedding ring was filed on 2/3/12 during business hours.However, the California Department of Public Health, Licensing and Certification Program received no notification of the allegation of the missing ring.During an interview on 5/21/12 with a police officer at the local police department, the investigative sergeant stated the police report for Patient 1's ring was filed by facility staff on 2/3/12 at 8:37 a.m.The facility's policy, "Reporting Abuse to Facility Management" (revised April 2010) indicated, "It is the responsibility of our employees, facility consultants, Attending Physicians, family members, visitors etc., to promptly report any incident or suspected incident of neglect resident abuse, including injuries of unknown source, and theft or misappropriation of resident property to facility management." The facility's policy, "Abuse and Neglect - Clinical Protocol" (revised October 2010) indicated, "The management and staff, with the support of the physicians, will address situations of suspected or identified abuse and report them in a timely manner to appropriate agencies, consistent with applicable laws and regulations." |
| 070000093 |
Watsonville Nursing Center |
070009408 |
B |
20-Jul-12 |
5DYX11 |
4042 |
F 223, 483.13(b), 483.13(c)(1)(i) FREE FROM ABUSE/INVOLUNTARY SECLUSION The resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion.The facility must not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion. The facility failed to ensure residents were free from sexual abuse when on 7/6/12 an employee exhibited sexually inappropriate behavior while providing therapy for one of four sampled residents (1). Resident 1 was admitted for rehabilitation therapy due to chronic pain syndrome related to advanced Parkinson's disease (disorder in the brain that causes shaking or tremors, difficulty in walking and movements, lack of coordination). The Minimum Data Set (MDS, an assessment tool) dated 6/29/12 indicated Resident 1 was alert, oriented, able to make her needs known and was responsible for her own health care. During an interview with Resident 1 on 7/11/12 at 9:08 a.m., she stated that since 6/26/12 a male staff had been providing therapy including stretching and massage, etc., for 60-75 minutes each time. Resident 1 stated on 7/6/12 around 9:30 a.m., the same male staff came to her room and started therapy including massaging her foot going up to her legs and she said it felt good because it reduced pain and spasms. Resident 1 said the male staff then touched her breasts, unzipped his pants and began to massage himself. Resident 1 said he rubbed his private part on her left arm and took her hand and laid it on his private part. She said "he was cursory and subtle and then he left shortly afterwards without saying a word through the sliding door out my room." "It was not unpleasant until he exposed himself." Resident 1 stated, "It worries me because he was predatory, he might violate other women with his disgusting behavior. I felt helpless and violated. He was in a position of trust and it was a grave attack upon my dignity."Resident 1 said, "he touched my breast at least three times in the past" but she did not want confrontation for fear of retaliation. She stated it was when he exposed himself that she got angry, but before she could say anything, he was gone. "I reported this to the director of rehabilitation immediately." During an interview on 7/11/12 at 9:45 a.m. with the director of rehabilitation (DOR), she stated the male staff was a physical therapy assistant (PTA). DOR stated the PTA had been suspended since 7/6/12 pending investigation. The scheduled appointments were reviewed with DOR, and the PTA performed services to Resident 1 on the following dates: June 26, 27, 28 and 29, 2012; July 2, 3, 4, and 6, 2012 for a total of eight days of therapy. DOR stated that massage was used during treatment to reduce pain, increase circulation and prepare the area of the body to be worked on. DOR stated however, there was no therapeutic reason to touch the pubic/vaginal area nor the breasts. The therapists in the facility were contract employees assigned to this particular facility only including the PTA. During an interview on 7/11/12 at 1:25 p.m. with the PTA, he admitted he was not truthful to the people who interviewed him including the DOR, the administrator (ADM) and the regional director of rehabilitation (RDOR). PTA said he did something terribly wrong by touching her breasts several times during the course of treatment. PTA claimed he could not remember the exact dates but at least on three different sessions since 6/26/12 to 7/6/12. PTA stated "I confess and I want to make it right. I am sorry for what I did." The facility's undated policy, "Abuse Prevention" indicates the policy of the facility is to protect its residents from acts of abuse, prevent mistreatment, and neglect and abuse of residents. The facility failed to implement their abuse policy and procedure to ensure Resident 1 was free from sexual abuse. This event caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety or other emotional trauma. |
| 070000097 |
WILLOW GLEN CENTER |
070010190 |
B |
14-Oct-13 |
BCY511 |
4540 |
72527(a)(9) Patients' Rights (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (9) To be free from mental and physical abuse. The facility failed to ensure Patient 1 was free of physical abuse when during the noon meal on 10/2/13 at 12:30 p.m., witnesses indicated they saw restorative nurse assistant 1 (RNA 1) slap Patient 1's face. Patient 1 was noted in his health record as alert and needed extensive assistance in his activities of daily living, such as eating his meals. A restorative nurse assistant (RNA, a certified nurse assistant (CNA) trained by therapy staff) supervised Patient 1 during his meals. During an interview on 10/4/13 at 12:15 p.m., the speech therapist (ST) stated she was in the dining room located between Station #2 and Station #3 on 10/2/13 at 12:30 p.m. The ST stated RNA 1 and Patient 1 were arguing in the dining room. Patient 1 grabbed RNA 1's arm and RNA 1 got annoyed. RNA 3 came to separate the two and wheeled Patient 1 to another table. The ST stated RNA 1 went to the table where Patient 1 was, and struck Patient 1's face. The ST stated another patient (Patient 2) saw RNA 1 strike Patient 1 and asked the ST why. During an interview on 10/4/13 at 1:30 p.m., Patient 2 stated he was seated in the corner of the dining room and saw the events that occurred on 10/2/13 at 12:30 p.m. Patient 2 stated Patient 1 was shouting profanity at RNA 1. Patient 2 stated he saw RNA 1 deliberately hit Patient 1's face. Patient 2 stated the hit was not an accidental swipe of Patient 1's face, but a deliberate punch at Patient 1's face. During a telephone interview on 10/7/13 at 7:20 a.m., certified nurse assistant 2 (CNA 2) stated she was in the dining room on 10/2/13 at 12:30 p.m. CNA 2 stated RNA 1 was seated on a stool and was in a verbal altercation with Patient 1. The altercation became heated so she asked RNA 3 to separate the two males. RNA 3 wheeled Patient 1 to another table. Then RNA 1 got up from his stool, went to Patient 1 and slapped his face. CNA 2 stated the slapping was definitely deliberate, and not an accidental swiping. During a telephone interview on 10/7/13 at 7:35 a.m., RNA 3 stated Patient 1 and RNA 1 were arguing and Patient 1 was using profanity at RNA 1. RNA 3 wheeled Patient 1 to another table, and as he was wheeling him, Patient 1 was kicking at RNA 1's legs. No sooner had he brought Patient 1 to the table when RNA 1 followed and suddenly slapped Patient 1's face on the left cheek. RNA 3 stated the slapping occurred so fast, but his impression was RNA 1 intentionally slapped Patient 1's face, rather than accidentally swiped it. During a telephone interview on 10/7/13 at 8:30 a.m., RNA 1 stated Patient 1 was seated at the wrong table and was blowing kisses at female staff. RNA 1 counseled him, but Patient 1 started using profanity at him. RNA 1 stated he asked RNA 3 to wheel Patient 1 to another table. As Patient 1 was being wheeled, he started kicking at RNA 1's legs and grabbed RNA 1's arm. RNA 1 stated during the scuffle with Patient 1, the back of his hand brushed against the cheek of Patient 1's face. RNA 1 stated onlookers who saw the incident got an impression that he slapped Patient 1 intentionally. RNA 1 stated he accidentally touched Patient 1's face on the cheek, rather than intentionally slapped it. The facility investigation report dated 10/4/13 and signed by the abuse coordinator (the administrator) indicated the ST, CNA 2, and RNA 3 stated in their interviews, they saw RNA 1 hit Patient 1's face, after RNA 3 had already moved Patient 1 away from RNA 1. However, RNA 1 indicated in his interview, he accidentally hit Patient 1's face when he pulled his arm away from Patient 1. The facility abuse policy/procedure defined abuse as physical abuse, neglect, fiduciary abuse, abandonment, isolation, abduction, or other treatment with resulting physical harm or pain or mental suffering, or the deprivation by a care custodian of services that are necessary to avoid physical harm or mental suffering. The above violations caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety or other emotional trauma to patients. |
| 070000906 |
WREN HOUSE |
070011001 |
B |
11-Sep-14 |
ZMPE11 |
6696 |
Title 22 76918 Client's Rights Each client shall have those rights as specified in Sections 4502 through 4505 of the Welfare and Institutions Code and Sections 50500 through 50550, Title 17, California Administrative Code. Welfare and Institutions Code 4502(h) Persons with developmental disabilities have the same legal rights and responsibilities guaranteed all other individuals by the United States Constitution and laws and the Constitution and laws of the State of California. No otherwise qualified person by reason of having a developmental disability shall be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity, which receives public funds. It is the intent of the Legislature that persons with developmental disabilities shall have rights including, but not limited to, the following:(h) A right to be free from harm, including unnecessary physical restraint, or isolation, excessive medication, abuse, or neglect. The Department determined the facility failed to ensure a written policy and procedure that prohibits neglect of clients was implemented for one of one sampled client (1) when Client 1 was not supervised during "drop off" from the bus resulting in a blunt fall and Client 1 sustained facial and nasal fractures. This failure increased the risk of injury to the clients.On 8/8/14 during record review of Client 1's CFA (Comprehensive Functional Assessment) dated 1/2014 it indicated Client 1 had severe intellectual disabilities and had no safety awareness. Client 1 had the behavior of moving her wheelchair by pushing her body forward and using her legs to advance her wheelchair instead of propelling the wheels with her hands. Client 1 also had a self-injurious behavior (SIB) of throwing herself to the ground when upset. Record review of the facility's "Special Incident Report" (SIR) dated 8/6/14 indicated the client fell from the bus on 8/5/14 as the client arrived to the facility at approximately 1:50 p.m. The facility staff called 911 and Client 1 was transferred to the emergency department (ER) of a local hospital. Client 1 sustained a facial fracture. The treatment included Zithromax (antibiotic, an agent that kills bacterial infection) and referral to an oralmaxillofacial surgeon (surgical specialist for face, mouth, and jaw surgery).Record review of Client 1's head CT scan report (a computed tomography scan, an imaging method that uses X-rays to create pictures of cross-sections of the body) dated 8/5/14 revealed a "left maxillary (jawbone) wall fracture (a medical condition in which there is a break in the continuity of the bone)/non-displaced incomplete fracture left lateral orbital rim" (orbit, rigid bony cavity in the skull which contains an eyeball). The report also had a finding of "mildly depressed left nasal bone fracture" and a clinical exam indicating "severe periorbital (situated around the orbit of the eye) swelling along with multiple abrasions."During an observation of Client 1 on 8/8/14 at 7:35 a.m. in the dining room, the client was alert and friendly but confused. The following skin discolorations (bruises) were observed:1. Client 1 had a blue to purple skin discoloration on the left middle forehead approximately two by three centimeters (cm, a unit of measurement) spreading down in between the eyebrows.2. The left eyebrow was covered by scattered red to blue skin discolorations that extended approximately a half cm up to the left forehead.3. Blue to purple skin discolorations around both eyes more prominent on the left eye, similar to a black eye.4. The left side and below the nose had an irregular shaped red skin discoloration fused together to a large curved scrape and red skin discoloration spreading up to the cheek bone like a blushed cheek.5. The left side of the lips had purple discoloration spread to the left side of the chin. 6. There was a black skin discoloration approximately dime sized on the left hand and the right hand had red discoloration approximately quarter sized.In summary, the entire left side of Client 1's face was severely bruised. A concurrent interview was attempted with Client 1. Client 1 could not describe her pain and stated she fell. Client 1 could not engage in a long conversation. During an interview on the same day at 8:00 a.m. with the qualified intellectual disabilities professional (QIDP), he confirmed the facility had no policy and procedure for neglect of the client ("Picking up and Dropping off Clients") in the facility. The QIDP stated when he came to the facility on the day of the incident, the client had been assessed by the licensed nurse and the paramedic took over.During an interview with direct support professional A (DSP A) on the same day at 9:45 a.m., DSP A said the staff do not wait outside at the curbside for the bus to arrive. She said the bus driver (BD) should honk the horn and call to let staff know that the bus arrived but he did not do so. During an interview with the BD on 8/8/14 at 11:15 a.m. he admitted he did not honk the horn because it was not working and could not remember since when it stopped working. The BD stated on 8/5/14 he unstrapped the safety belt straps to the steel strapping plate of the bus from Client 1's wheelchair before staff was present and proceeded to telephone staff to come to the curbside. The BD stated he had his back to the client while telephoning the facility staff. The BD stated he saw Client 1 fall forward in the wheelchair from the bus door steps. The BD also said he should not have left Client 1 alone and unstrapped in her wheelchair because it happened so fast he could not prevent the fall.On 9/2/14 at 8:40 a.m. during observation of the BD, he picked up Client 1 from the facility. DSP A wheeled Client 1 out of the facility to the curbside onto the open ramp of the bus. DSP A locked the wheelchair and the BD held the wheelchair from the back while the ramp was raised. The BD was not observed using the ramp safety belt on the siderail. The BD unlocked the wheelchair, pulled Client 1 inside the bus and attached the safety belt inside the bus to the wheelchair and locked the wheelchair to the bus strap.During interview with the BD on the same day at 9:00 a.m., he said he was aware of the bus ramp safety belt but did not use it. Concurrent interview with the director of the Day Program (DDP) was done. She said the BD should use the ramp safety belt.On further review, there was no written evidence there was a facility policy and procedure developed to guide staff in a safe transfer procedure.This failure had a direct or immediate relationship to the health, safety, or security of clients. |
| 070000041 |
WINDSOR MONTEREY CARE CENTER |
070011377 |
B |
14-Apr-15 |
HN4Q11 |
3781 |
F223 - 483.13(b), 483(c)(1)(i) Free From Abuse/Involuntary Seclusion The resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion.The facility must not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion. The facility failed to ensure residents were free from physical and verbal abuse when on 3/19/15, certified nurse assistant A (CNA A) was observed forcibly trying to pry open Resident 3's eyelids, hitting Resident 3's forehead with her open hand and later yelling at the resident while complaining about having to clean her up after toileting. The 1/8/15 minimum data set (MDS, an assessment tool) indicated Resident 3 had long and short term memory problems with moderately impaired decision making capabilities. The MDS also indicated Resident 3 was dependent on staff for transfer, mobility, bathing, dressing and eating. A review of Resident 4's clinical record indicated she was alert and oriented. The 2/18/15 MDS indicated she had the BIMS score (a brief interview for mental status) of 14 (on a scale of 0-15). During an interview on 4/3/15 at 8:45 a.m., Resident 4, who was Resident 3's roommate, stated on 3/19/15 she saw CNA A enter the room and yell at Resident 3 to open her eyes. With the privacy curtain halfway drawn, Resident 4 saw CNA A attempt to forcibly open Resident 3's eyes. When Resident 3 would not open her eyes, CNA A struck Resident 3's forehead using the right heel of her open palm. On the same day towards the end of the morning shift, Resident 4 stated CNA A was making her final rounds when she saw Resident 3 had a bowel movement. CNA A appeared mad and frustrated and yelled at Resident 3 twice about how she had a big bowel movement and she had to clean her "kootchi." Resident 4 stated CNA A had always been assigned to Resident 3. Resident 4 stated CNA A was very loud, was always yelling at Resident 3 and was abrupt, impatient and very demeaning to her. During the same concurrent interview, Resident 4 stated she did not voice her concerns to the administrator regarding CNA A until 3/21/15. A record review on 4/2/15 indicated the responsible party (a person responsible or liable in making medical and/or financial decisions for an individual), attending physician, ombudsman and the California Department of Public Health were notified on 3/21/15. During an interview on 4/2/15 at 1:45 p.m., the responsible party stated she visited Resident 3 after she was notified of the incident. Resident 3 hardly talked, appeared afraid and flinched whenever somebody came near her. During a review of the investigation report on 4/2/2015, it was documented CNA A was suspended from 3/21/15 through 3/24/15. CNA A was given the notice of termination on 3/25/15, after the investigation report was completed. A review of the facility's 3/2013 policy, "Abuse Prevention, Investigation and Reporting," indicated each resident has the right to be free from verbal, sexual, physical, mental abuse, corporal punishment and involuntary seclusion. 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, family members or legal guardians, friends, or other individuals. The facility failed to ensure residents were free from physical and verbal abuse when on 3/19/15, CNA A was observed forcibly trying to pry open Resident 3's eyelids, hitting Resident 3's forehead with her open hand and later yelling at the resident while complaining about having to clean her up after toileting. Physical abuse can cause pain and injury and verbal abuse can cause mental anguish as well as a decrease in self-esteem. |
| 070000097 |
WILLOW GLEN CENTER |
070011655 |
B |
17-Aug-15 |
009P11 |
5297 |
F225 - 483.13(c)(2) Investigate/Report Allegations/Individuals The facility must ensure 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 failed to report a witnessed incident of verbal abuse within 24 hours to the California Department of Public Health (CDPH), the local law enforcement agency and the local ombudsman as required by law and in accordance with the facility policy. Failure to report the abuse in a timely manner prevented an analysis of the occurrence to determine any necessary changes to prevent abuse in the future and potentially allowed the abuse to continue. Resident 14's clinical record was reviewed on 8/3/15. A progress note dated 5/14/15 at 8:23 a.m., indicated licensed vocational nurse M (LVN M) noticed at 1 a.m., the resident was very agitated, was jumping from his bed, going toward Resident 12 and stating he would kill Resident 12. The social service director (SSD) arrived and immediately placed the resident on one-to-one monitoring and escorted the resident back to bed until the police arrived. The police placed Resident 14 on a psychiatric hold and removed him from the facility. Resident 12's clinical record was reviewed 7/27/15. His minimum data set (MDS, an assessment tool), dated 5/18/15, and indicated he had no cognitive impairment. A progress note dated 5/14/15 at 3:18 a.m., authored by the SSD, indicated the charge nurse advised the SSD Resident 14 had threatened to "kill" his roommate. The note indicated the SSD arrived at the facility and observed Resident 14 hitting the wall next to his bed and grasping the bed side rail. When the SSD asked Resident 14 how he could help him, Resident 14 responded, "Give me a rifle."The progress note indicated the certified nurse assistant (CNA) assigned to monitor the resident on a one-to-one basis stated Resident 14 was extremely combative and would hit and/or kick any staff who attempted to assist him. The note further indicated the SSD called the local police department to initiate a psychiatric hold. The police arrived at the facility to assist with Resident 14's transfer to the local county hospital via an ambulance.The progress note indicated the psychiatric hold was initiated because of Resident 14's anxiety, psychosis (severe mental disorder characterized by a disconnection from reality) and behavioral disturbances manifested by his threat to "kill" his roommate with intent. The note indicated the SSD informed the attending physician by pager, Resident 14's family member, the director of nurses (DON) and the administrator (ADM) of the incident.During an interview on 8/3/15 at 7:35 a.m. with Resident 12, he stated on 5/14/15 at approximately 1 a.m. he was in his wheelchair sitting adjacent to Resident 14's floor mat. Resident 14 moved from his bed onto his floor mat and threatened to kill Resident 12. Resident 12 stated, "I was scared!" During an interview on 8/3/15 at 2 p.m. with LVN M, she stated she observed Resident 14 after a CNA informed her the resident was trying to jump out of bed. LVN M stated she observed Resident 14 holding the side rail of the bed, moving onto the mattress on the floor, yelling and kicking his legs and scooting on his back towards Resident 12 who was sitting in his wheelchair. LVN M stated Resident 14 was very agitated and stated he was going to try to kill Resident 12. She further stated Resident 12 was in distress after Resident 14 threatened to kill him. During an interview on 8/3/15 at 2:15 p.m. with the SSD, he stated he received a telephone call from LVN M stating Resident 14 was having a psychotic break and was combative. The SSD stated he called the local police department to initiate a psychiatric hold because he considered Resident 14 a danger to himself. During an interview on 8/3/15 at 3 p.m. with the SSD, he stated if he had known Resident 12 had heard the threat from Resident 14, he would have notified the CDPH. The SSD stated he was unaware of LVN M's observation of the incident and he did not know Resident 14 had threatened his roommate.Review of the facility's 2/6/13 policy, "Abuse, Prevention of," indicated each resident had the right to be free from verbal, sexual physical and mental abuse and all health practitioners and all employees in a long-term healthcare facility were mandated reporters. If abuse was suspected, the suspected abuse should have been reported. If the suspected abuse did not result in serious bodily injury, the mandated reporter must report the incident by telephone within 24 hours to the local law enforcement agency (911) and send a written report within 24 hours to the local law enforcement agency, the CDPH and the local ombudsman. The social service designee should investigate any suspected or alleged abuse and assure the reporting of the incident had been made to the local ombudsman, the local law enforcement agency and the CDPH. The violation of this regulation had a direct or immediate relationship to the health, safety, or security of residents. |
| 070000906 |
WREN HOUSE |
070011930 |
B |
29-Dec-15 |
YWEJ11 |
10300 |
Welfare and Institutions Code 4502(h) Persons with developmental disabilities have the same legal rights and responsibilities guaranteed all other individuals by the United States Constitution and laws and the Constitution and laws of the State of California. No otherwise qualified person by reason of having a developmental disability shall be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity which receives public funds. It is the intent of the Legislature that persons with developmental disabilities shall have rights including, but not limited to the following:(h) A right to be free from harm, including unnecessary physical restraint, or isolation, excessive medication, abuse, or neglect. The facility failed to ensure Client 1 was protected from harm including neglect when she was punched in the nose by Client 2 who had a history of assaultive behavior by hitting peers. The facility staff failed to prevent such an incident when the staff did not provide the appropriate interventions and the behavior management protocols after Clients 1 and 2 had a verbal altercation resulting in a physical assault.1. Client 1's Comprehensive Functional Assessment (CFA), dated 7/27/15, indicated she was able to communicate her needs clearly enough to be understood by an unfamiliar person. She needed to be monitored for behavioral problems (screaming, use of foul language, and disciplining peers) secondary to a diagnosis of bipolar disorder (a brain disorder causing unusual shifts in mood, energy, and activity levels). The quarterly behavior data report, dated 10/31/15, indicated Client 1's behavior of using foul language, disciplining, and directing peers had escalated. 2. Client 2's CFA, dated 9/25/15, indicated he was able to communicate his needs/wants adequately. He required monitoring for his behavior of inappropriate verbal expression (swearing) and a history of hitting peers. He had a diagnosis of impulse control disorder (a psychiatric disorder characterized by a failure to resist a temptation, urge or impulse that may harm oneself or others). Client 2's impulse control disorder care plan, dated 9/9/15, indicated the approach of client safety would be maintained. The intervention was to redirect the client by watching television, listening to music and providing a functional activity. This intervention was not implemented. Client 2's Behavior Program Plan, dated 3/25/15, indicated when the client displayed a warning behavior such as a verbal altercation with others, the prevention technique was to encourage/coach, redirect client to task, separate the client from others, and/or consider relaxation behaviors to calm him down. The quarterly interdisciplinary team report (Human Rights Committee), dated 7/27/15, indicated Resident 2's assaultive behavior had escalated during the past three months. The interdisciplinary team recommended continuing to redirect the client as needed in order to assist in decreasing the incidents. The Special Incident Report (SIR), dated 11/10/15, documented Client 2 "struck [Client 1] via punch on her face specifically on her nose" on 11/9/15. The injury flow sheet, dated 11/10/15, indicated the licensed vocational nurse (LVN) was called from the day program to look at Client 1's bruise located on the bridge of her nose. The bruise was described as a purple-red color, but there was no description of the size and extent of the bruise. The monthly behavior observation baseline data collection record (with the antecedent behavior of swearing, yelling, and hitting) for the month of November 2015 indicated Client 2 had six episodes of hitting peers with the antecedents of yelling and swearing. The intervention was to redirect the client to a functional activity. According to the facility staff, the documented episodes of hitting during November 2015 were an attempt to hit peers and not actual hitting.The monthly data collection for the incident of assaultive behavior (hitting peers) indicated Client 2 had four episodes of attempting to hit peers for the month of November 2015. The interventions were corrective feedback and redirect the client to a functional activity. During an observation on 12/9/15 at 9:05 a.m., Client 1 was seated on the couch and was not involved in any type of activity. Client 2 was in the living room walking back and forth with staff assistance. During a telephone interview on 12/9/15 at 3:30 p.m., direct care staff A (DCS A) stated on 11/9/15 during the afternoon shift she was in the kitchen preparing meals and getting dinner ready for the clients. She stated Clients 1 and 2 were seated next to each other in the dining area. While they were waiting for their meals, both clients were observed arguing, yelling, and swearing at each other. She stated after hearing several arguments, she approached both clients and told them to stop. DCS A stated both clients stopped and she returned to the kitchen to prepare the food. She stated while she was in the kitchen, she intermittently heard Clients 1 and 2 continue to argue, yell, and swear at each other. DCS A stated while she was warming up the food, she heard Client 1 yell and state, "[name] punched me." DCS A stated she did not see it happen because she was in the kitchen. When asked, she stated she did not immediately separate the clients while they were arguing but instead she repeatedly instructed both of the clients to stop the arguments. DCS A stated she was aware Client 2 had a history of yelling at peers and becoming agitated. She was also aware of Client 2's behavior episodes of attempting to hit peers. When asked, DCS A stated the incident could have been prevented if she had removed Client 2 from the dining area during the verbal argument with Client 1. During a telephone interview on 12/9/15 at 4 p.m., DCS B stated on 11/9/15 at around 4 p.m., Clients 1 and 2 were seated next to each other in the dining area waiting for their dinner. She stated Clients 1 and 2 had been arguing for quite some time at the beginning of the shift and the argument went on intermittently. DCS B stated Client 1 was directing and disciplining peers. She stated Client 2 became agitated and started to swear when Client 1 was talking too much and trying to imitate Client 2's swearing. DCS B stated at around 5 p.m., she was assisting one of the clients in the bathroom. While she was helping the client in the bathroom, she could hear Clients 1 and 2 yelling and swearing at each other and she heard DCS A tell them to calm down. She stated after a few minutes she heard Client 1 yell, "[name] hit me in the face." She stated DCS A took Client 2 away from the dining area after the incident. DCS B stated Client 1 and 2 should not eat together in the dining area because Client 2 had an ongoing behavior of being argumentative, hitting objects, and attempting to hit peers. When asked if she had received training regarding client altercations, DCS B stated she did not remember receiving any training regarding client altercations but she had received training regarding Client 2's Behavior Program Plan after the 11/9/15 incident occurred. During an interview on 12/11/15, at 9 a.m., at the day program in the presence of the program director, Client 1 stated, "[name] hit me in the nose" (describing it with her left fist closed and moving her fist towards her nose) and said, "Like this, boom!" Client 1 stated, "It hurts". She could not recall when and where the incident occurred.During an interview on 12/11/15 at 9:15 a.m., the day program director (PD) stated Clients 1 and 2 were separated during meals and during activity. The PD stated because of their history of arguing and hitting, both clients needed to sit away from each other. The PD stated the staff did not follow the Behavior Program Plan developed for both clients. During another interview on 12/11/15 at 9:30 a.m., DCS D stated Clients 1 and 2 "always argue and fight" and needed to be separated at all times. During a telephone interview on 12/11/15, at 10 a.m., DCS C stated according to the facility protocol, when all of the clients were waiting for their meals, they should not be left alone at the dining table. DCS A stated one staff should stay with the clients while the other staff prepared the food.During an interview on 12/11/15 at 11:30 a.m., the qualified intellectual disabilities professional (QIDP) stated the staff did not provide immediate intervention to both clients when they had a verbal altercation the first time. The QIDP further stated both DCSs A and B were new to the facility and needed to be trained in dealing with the clients' inappropriate behaviors. He stated the incident could have been prevented if the staff had separated the clients during the verbal altercation episode. The QIDP stated the facility did not have a policy developed for the staff to follow during client-to-client altercations.A review of the facility's undated "In-Service" training binder did not indicate DCSs A and B received training regarding Client 2's behavior management program. The QIDP stated both DCSs A and B were not given training regarding the behavior management program but were provided training on 11/9/15 after the incident occurred.A review of the facility's undated policy, "Behavior Management Program", indicated each client's behavior management plan was incorporated in their individual service plan and was available to all facility staff, the client, and if appropriate, the client's representative. The QIDP should train all of the staff regarding the implementation of the behavior management techniques to be used. Both the QIDP and the facility manager should monitor the staff performance on a frequent basis. The facility failed to protect Client 1 from harm during a verbal altercation with Client 2 which resulted in a physical assault due to the staff's failure to immediately intervene and separate the clients during the altercation. The facility failed to implement the clients' behavior management programs. Client 1 sustained a bruise on the bridge of her nose when Client 2 after several arguments, hit her face with his fist. This violation had a direct or immediate relationship to the safety or security of Client 1. |
| 070000097 |
WILLOW GLEN CENTER |
070012004 |
B |
02-Feb-16 |
R0U211 |
2400 |
F226, 483.13(c) DEVELOP/IMPLEMENT ABUSE/NEGLECT, ETC POLICIES The facility must develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. The facility failed to implement their abuse policy for Resident 1 when an abuse allegation against a staff member was not reported to the California Department of Public Health (CDPH) within 24 hours, not investigated, and the staff member was not suspended.Resident 1's clinical record was reviewed. An interdisciplinary team meeting (IDT, representatives from all disciplines meet to discuss the care provided to the residents) occurred on 12/17/15.During an interview with the social services assistant (SSA), on 1/7/16, at 8:30 a.m., she stated there was an IDT meeting on 12/17/15 and she heard Resident 1's family member (FM) complain about a licensed nurse who was rude and yelled at the resident. During an interview with the administrator (ADM), on 1/7/16, at 9:10 a.m., he stated the FM made two complaints about a licensed nurse. The ADM stated the first complaint the FM made was about a licensed nurse being rude to the FM. The ADM stated the first complaint was investigated. The ADM then stated the FM made another complaint at the 12/17/15 IDT meeting regarding the same licensed nurse. The ADM stated the FM told the IDT she was on the telephone with the resident when she heard a licensed nurse yelling at the resident. The ADM stated the second complaint made by the FM during the 12/17/15 IDT meeting was not reported to the CDPH and was not investigated.During an interview with the director of nurses (DON), on 1/8/16, at 2:20 p.m., she stated the licensed nurse who was accused of yelling at Resident 1 was never suspended.Review of the facility's 2/6/13 policy, "Prevention of Abuse", indicated the ADM was ultimately responsible for the reporting of all incidents of alleged abuse or suspected abuse to the CDPH within 24 hours. Any employee suspected of alleged abuse would be suspended during the investigation and ultimately terminated if the investigation confirmed willful abuse. The facility failed to investigate, suspend an employee suspected of alleged abuse, and notify the CDPH within 24 hours about the incident of alleged abuse. These violations had a direct relationship to the health, safety, or security of the residents. |
| 070000097 |
WILLOW GLEN CENTER |
070012005 |
B |
02-Feb-16 |
R0U211 |
5192 |
F329 - 483.25(l) UNNECESSARY DRUGSEach resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used in excessive dose (including duplicate therapy); or for excessive duration; or without adequate monitoring; or without adequate indications for its use; or in the presence of adverse consequences which indicate the dose should be reduced or discontinued; or any combinations of the reasons above.Based on a comprehensive assessment of a resident, the facility must ensure that residents who have not used antipsychotic drugs are not given these drugs unless antipsychotic drug therapy is necessary to treat a specific condition as diagnosed and documented in the clinical record; and residents who use antipsychotic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs. The facility failed to manage and monitor Resident 1's use of the Fentanyl patch (pain medication applied to the skin) when a licensed nurse failed to remove an old Fentanyl patch prior to the application of a new patch and when the facility staff failed to monitor the respiratory rate of the resident as ordered by the attending physician. Resident 1's clinical record was reviewed and indicated she had diagnoses of chronic (long term) respiratory failure, neuropathy (disease of one or more peripheral nerves causing numbness or weakness), restless legs syndrome (overwhelming and unpleasant urge to move the legs while at rest), osteoarthritis (degeneration of the joints and bones which causes pain and stiffness), and chronic pain syndrome. The physician order, dated 5/6/15, indicated Resident 1 had an order to apply a 50 microgram per hour (mcg/hr, dose measurement per hour) Fentanyl patch to the skin every three days for chronic pain syndrome, to monitor and verify for placement, to hold for a respiratory rate of less than 14 breaths per minute, and to remove per the schedule.The nurses note, dated 11/30/15, indicated Resident 1 had difficulty waking up at 8 a.m. and then became lethargic (drowsy and lack of energy) with slurred speech (poor pronunciation of words or mumbling) at 10:30 a.m. She was sent to the hospital at 11:30 a.m.During an interview with registered nurse B (RN B), on 12/23/15, at 10:30 a.m., she stated on the day Resident 1 was sent to the hospital, she removed the old Fentanyl patch and applied a new one.The 11/2015 Medication Administration Record (MAR) indicated a Fentanyl patch was removed from and applied to Resident 1 on 11/30/15. The controlled drug record (document showing the dates when the Fentanyl patch was applied and removed) for Resident 1's Fentanyl patch, dated 11/24/15 through 11/30/15, indicated the 11/24/15 Fentanyl patch was not removed on 11/27/15 as scheduled.The emergency room hospital records for Resident 1 indicated two Fentanyl patches were found on Resident 1, one dated 11/24/15 and the other dated 11/30/15. The hospital notes also indicated Resident 1's lethargy was possibly from the double dosing of Fentanyl.During an interview with RN A, on 12/23/15, at 3:10 p.m., she stated Resident 1 was the person who removed the Fentanyl patch from her skin on 11/27/15 and handed it to the nurse. RN A stated she thought the patch was Fentanyl but it could have been something else.The MAR, dated 10/2015 to 11/2015, included a physician order to monitor the placement of the Fentanyl patch and to hold the patch if the resident breaths were less than 14 per minute. The MARs also indicated the facility documented the respiratory rate of Resident 1 every three days.During an interview with the pharmacist consultant (PC), on 1/8/16, at 9 a.m., he stated a Fentanyl patch is a very strong medication and accumulates in the body of an older person who does not move around. He stated it was better to monitor and document the respiratory rate of Resident 1 daily.During an interview with the director of nurses (DON), on 1/8/16, at 9:40 a.m., and on 1/12/16, at 10:27 a.m., she confirmed the respiratory rate of Resident 1 was not documented daily on the MAR during 10/2015 and 11/2015. She also stated the facility staff was not monitoring Residents 1's respiratory rate as ordered by the attending physician. The DON stated the facility staff was monitoring the respiratory rate if it was less than 12 breaths per minute instead of following the physician order to monitor the respiratory rate if it was less than 14 breaths per minute. She stated the monitoring done by the staff for Resident 1's respiratory rate was not adequate. According to the 5/2014 medication guide for the Fentanyl transdermal patch approved by the U.S. Food and Drug Administration, a Fentanyl transdermal patch should be removed after wearing it for three days. The patient should not wear more than one Fentanyl transdermal system at a time and should be monitored closely for respiratory depression. The facility failed to monitor Resident 1's respiratory rate and to ensure she did not receive a double dose of her Fentanyl medication.These violations had a direct relationship to the health, safety, or security of the residents. |
| 070000042 |
WINDSOR THE RIDGE REHABILITATION CENTER |
070012119 |
B |
16-Mar-16 |
LC0M11 |
7341 |
F323 -- 483.25(h) FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. The facility failed to ensure Resident 2 was free from an avoidable accident. The resident had a fall from his bed on 12/28/15 resulting in a fractured right lower tibia/fibula, and subsequent above the knee amputation of the same leg. The facility failed to follow its established policy and procedure in lifting residents by use of a mechanical device and follow the recommendations of the mechanical device manufacturer. These failures resulted in Resident 2 falling from his bed resulting in a fractured leg with subsequent amputation.A review of Resident 2's clinical record indicated he was admitted to the facility with numerous diagnoses including hereditary hemorrhagic telangiectasia (HHT, abnormal blood vessel formation in the skin and the organs), unspecified dementia (group of thinking and social symptoms interfering with daily living), chronic obstructive lung disease (COPD, lung diseases blocking airflow and making it difficult to breathe), a mental disorder secondary to a physical condition, high blood pressure, and hypothyroidism (low performing gland causing fatigue and sluggishness). A review of Resident 2's fall risk assessment dated 12/30/15 indicated Resident 2 had a "moderate risk" fall level. Resident 2 had a non-injury fall earlier in the year on 2/22/15. A review of the facility's 12/2012 policy, "Falls Management", indicated "residents will be assessed for fall risk and interventions will be implemented to reduce the risk of falls." Resident 2's Minimum Data Set (MDS, an assessment tool), dated 9/2/15 and 12/2/15, indicated he was severely impaired, required extensive assistance with 2+ persons in bed mobility, transfer, dressing, bathing, and toileting. He was totally dependent on staff. A review of Resident 2's Fall Care Plan, dated 3/11/13, indicated he was a fall risk relative to his history of falls, use of heart medications, poor safety awareness, and decline in functional status. The interventions used by the facility included placing his bed in the lowest position, fall mat on floor, and sensor pads on his bed and wheelchair.Another care plan addressed Resident 2's self-care deficits in bathing, hygiene, dressing, toileting, and transfer (how the resident moves between surfaces including to or from, bed, chair, wheelchair or standing position). Additionally there was a care plan addressing Resident 2's cognitive loss/dementia causing impaired decision making. During an interview with the facility regional quality manager (RQM) on 2/4/16, at 11 a.m., she stated certified nurse assistant A (CNA A) was attending to Resident 2's ADLs, had gotten him changed, dressed, and was getting ready to put him in the wheelchair at his bedside. The lifting sling was underneath Resident 2 while he was flat on his back. The beds do not have side rails, but bars at the head of the bed. CNA A went out to get the lifting device located outside Resident 2's room. When CAN A returned to the room, Resident 2 was on the floor. Resident 2's bed was at medium height while the ADLs were being performed. CNA A alerted the charge nurse, licensed nurse B (LN B) who assessed Resident 2 and he was placed back in bed. During an interview with charge nurse, LN B on 2/4/16 at 2:15 p.m., she stated, CNA A came to her and told her Resident 2 fell out of bed. LN B went to the room, and saw Resident 2 was on his back on the floor. Resident 2 stated "I slide off from the bed". The resident had a mild abrasion on his left forehead. LN B further stated resident slid off the bed with the lift pad under him and he usually used side rails to hold on to as he does not want to fall. During an interview with CNA A on 2/4/16 at 2 p.m., she stated she was a regular caregiver for Resident 2 and was familiar with his level of care needs. She stated she left Resident 2 on the sling on his bed and went out to get the lifting device. When she returned, Resident 2 was on the floor. During an interview with LN C, the director of staff development on 2/5/16, at 1:55 p.m., she stated she trains the facility CNAS in skills training upon hire, annually, and as needed. "How I train them is when you get ready to use the Hoyer lift, there is the prepping stage, then the assist/lift stage. The prepping stage is the resident's clothes are on, the Hoyer pad is placed underneath them. One CNA is able to do this. The CNA then goes to get the machine. Lifting stage, two people need to be there for the transfer part itself, always. Was working on day [Resident 2 ] had fall. Passed by his room just second before fall, then immediately after and saw him on the floor, on his left side facing the door." Review of nurses note, dated 12/28/15 at 1022 late entry "Resident found on floor by CNA , resident was ready to get up to the W/C (wheelchair), CNA left him on top of the bed with the Hoyer pad under him, she said she went to bring the Hoyer lift back to transfer resident to the W/C, so when she come back resident was on the floor. Nurse practitioner was notified and she assess the resident like 1330." Per review of the Interdisciplinary (IDT) Progress Notes dated 12/31/15 at 1446, revealed present at the meeting were the Regional Quality Manager, director of nursing, and director of staff development. "The resident was in bed underneath his Hoyer lift pad. The CNA left to get the hoyer lift and another staff member for assistance. By the time they returned (about three minutes later) the resident was found on the floor with the hoyer pad still underneath him...explained to responsible party (RP) when the resident fell on 12/28/15 that nurse practitioner and nurse assessed patient he had no apparent injury. On 12/30/15 some deformities were noted. NP assessed resident and ordered x rays to rule out fx (fracture) to R (right) lower leg. RP stated that the nurse practitioner called him yesterday and left a message. Explained to him if the resident does have a fracture it is mostly r/t (related to) his fall from 12/28/15. Resident does not ambulate, is transferred via hoyer lift and needs mostly total assistance with bed mobility. The Nurse Practitioner Progress Note, dated 12/31/15 at 1730 indicated the X-ray revealed fractures in the bones of his right lower leg. He was sent to the hospital and the fracture was stabilized with a splint. Review of the facility's 11/2012 policy, "Lifting Residents by Use of Mechanical Device", indicated in underlining the staff were to follow the manufacturer's instructions for the use of each specific type of lifting machine. In addition, a minimum of two staff members should be used to reduce the risk of staff or resident injury. Review of the manufacturer's manual indicated the manufacturer recommended two assistants be used for all lifting preparation, transferring from, or transferring to procedures. The facility failed to follow their policy regarding the use of a mechanical lift and the safety recommendations of the mechanical device manufacturer. These violations had a direct or immediate relationship to the health, safety , and security of the residents. |
| 070000042 |
WINDSOR THE RIDGE REHABILITATION CENTER |
070012120 |
B |
16-Mar-16 |
10J811 |
8301 |
F323 - 483.25(h) Free of Accident Hazards/Supervision/Devices The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. The facility failed to ensure Resident 1 was free from an avoidable accident when the facility failed to conduct an accurate and complete wandering/elopement risk and follow the facility's policy in dealing with an eloped resident after two elopements from the facility with the last one resulting in a fall and a fractured finger when he was left alone by a staff member to wander in the night until he was found by law enforcement. Resident 1's clinical record was reviewed and indicated he was admitted to the facility for short term physical and occupational therapy rehabilitation following a five day hospitalization after being discovered unresponsive in his vehicle by a passerby in a shopping center. His treating physicians thought he had experienced seizures brought on by blood sugar extremes due to his diabetes (disease resulting in too much sugar in the blood) resulting in a significant cognitive functioning decline. He was admitted to the facility with numerous diagnoses including dementia (group of thinking and social symptoms interfering with daily functioning), encephalopathy (disease of the brain), diabetes, muscle weakness, instability of gait (way of walking or running), and hypothyroidism (deficient thyroid gland resulting in fatigue and sluggishness).Resident 1's Wandering Risk Assessment, dated 1/13/16, indicated he was a low risk for wandering although the form was not completely filled out or signed. His nurse's note, dated 1/14/16, indicated at "Approximately 1600 AD notified writer that resident walked out of the facility unattended....writer communicated with MD, new order for wanderguard. Wanderguard applied to left ankle." Resident 1's nurse's note, dated 1/15/16, indicated "At 0230, resident became confused and aggressive. He was wandering the corridors. His family member was able to come in to the facility to calm resident down....MD notified....order for anti-anxiety medication was recommended. Will continue to monitor." Resident 1's interdisciplinary team (IDT, department heads meet and plan to decide the course of a resident's care) care conference, dated 1/19/16, indicated a family member (FM) attended the conference. The nursing summary indicated the FM was informed Resident 1 had left the facility (walked outside) and at times was very difficult to redirect back to the facility. The FM and social services (SS) indicated Resident 1's cognition was impaired and the FM was told he needed a secure facility due to his wandering/eloping behavior. The activity director (AD) indicated Resident 1 walked all day long and he left the activities he was attending.Resident 1's Minimum Data Set (MDS, an assessment tool), dated 1/20/16, indicated he was moderately impaired, wandered, required one person physical assistance when walking in his room, the hallway, or off the medical unit, and was totally dependent on staff for his bathing needs. Resident 1's nurse's note, dated 1/23/16, indicated "around 2200 resident was not to be found in room...resident was in room at 2130 when CNAs [certified nurse assistants] offered to help change resident into pajamas. Resident's sliding door found open, belongings still in his closet. Searched facility and local area, resident gone. Resident found by local law enforcement at 23:10. Returned to facility at 23:15 by law enforcement. Suggested visual check to oncoming shift." Resident 1's nurse's note, dated 1/24/16, indicated in a late entry "resident came back around 23:15 with police. He was assisted by NOC [night] CNAs back to his room. One CNA stayed just outside the resident's room to monitor his behavior. Pt [patient] was in his room during the night from approx 23:30 to 0400 resting. He woke up approx 0400 and needs were attended to by staff. At approx 0530 resident walked around the hallway. Staff offered food and drinks, resident refused, continued to redirect resident. At approx 0545 wanderguard alarm went off. Staff checked outside, resident seen in street. CNA continued to redirect resident back to the facility and followed him. Writer called police. Resident retrieved by police and taken to local hospital." Resident 1's Discharge Summary from the acute hospital's emergency room, dated 1/24/16, indicated he had a nondisplaced fracture of the proximal phalanx (part of the bone in the finger) of the left little finger, an unspecified fall, a contusion (a region of injured tissue) of the other part of the head, and Alzheimer's disease (progressive disease destroying memory and other important mental functions), unspecified. A brief history and physical indicated he was brought in by the police following a fall occurring on the sidewalk next to a park. He was unable to describe the exact location. He stated he stumbled while walking, was not able to regain his balance, fell to the ground, and could not get up right away. Multiple police officers came to his aid shortly thereafter. He reported remembering the entire event and does not recall hitting his head during the fall. Resident 1's Incident Note, dated 1/24/16, indicated "pt eloped during noc shift. Received call from local hospital ER [emergency room] @ approx 0800 notifying us that resident had been brought to their facility via ambulance...subsequently received call from hospital ER nurse stating that the patient's family member was not going to transport him back to this facility." A review of CNA A's facility's Interview Record concerning Resident 1, dated 1/25/16, indicated "Around 0540 resident went outside the front door, wanderguard alarm went off. I went outside with resident trying to get him back inside, resident refused. NOC LN [licensed nurse] knew I went outside, NOC LN was outside trying to get resident back inside the building. NOC LN verbalized she was going to call the police. Resident was wearing jacket and shoes. Resident verbalized he wanted to go outside and walk around. I followed the resident all the way to Lupin St. Resident cont. [continued] to refuse to go back to the facility. Resident verbalized, 'Why are you stopping me?' I replied, 'It's dark & not safe.' Resident cont. to walk. Around 0605 I walked back to the facility. Resident cont. to walk towards Main St. When I got to the facility, I notified the LN, whom was talking on the phone with the police. I grabbed my jacket and cell ph. [phone] and went back outside to catch up with the resident, but could not find him. I walked back to the facility at approx. 0630, notified LN." During a telephone interview on 3/1/16, at 11:31 a.m., with the night shift charge nurse on 1/23/16, she stated she was the charge nurse the morning Resident 1 eloped from the facility out the front door. CNA A was the only CNA to go outside after the resident. There were three other CNAs assigned, but they were helping other residents. The night shift charge nurse did not go after the resident, but called the police. She asked CNA A to go after the resident but CNA A got cold and returned to the facility for his coat, then went back out to find the resident. CNA A did not find the resident, and she did not see Resident 1 again. A review of the facility's 11/2012 policy, "Elopement Prevention", indicated a wandering resident was recognized as one who was actively/purposely looking to leave the facility as well as one who may inadvertently attempt to leave the facility due to a cognitive impairment. If the resident resists, the staff member should alert others for assistance, without leaving the resident, and continuously redirect and assist the resident to return to the building. The facility failed to conduct an accurate and complete wandering elopement risk assessment for Resident 1 and failed to follow its policy in dealing with an eloped resident when the resident was left to wander outside the facility. These failures resulted in Resident 1 falling on the sidewalk, injuring his head, and fracturing his finger.These violations had a direct or immediate relationship to the health, safety, or security of the residents. |
| 070000097 |
WILLOW GLEN CENTER |
070012121 |
B |
15-Mar-16 |
56PH11 |
2375 |
F221 -- 483.13(a) RIGHT TO BE FREE FROM PHYSICAL RESTRAINTS The resident has the right to be free from any physical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms. The facility failed to ensure one of three sampled Resident 1 was free from physical restraints when bed sheets were tied on the side rails and bedrails to prevent Resident 1 from falling. This failure prevented the resident from attaining her highest practicable level of physical and psychosocial well-being. Resident 1 was admitted to the facility with diagnoses of severe intellectual disabilities, cognitive communication deficit, and generalized muscle weakness. The Minimum Data Set (MDS, an assessment tool), dated 2/22/16, indicated Resident 1 had severely impaired decision making skills. During an interview with housekeeping A (HK A) on 3/10/16, at 2:40 p.m., she stated she heard Resident 1 crying in her room. When HK A opened the curtain in Resident 1's room, she saw Resident 1 lying on her bed with the bed sheets tied across her abdomen, legs and ankle areas.During an interview with registered nurse B (RN B) on 3/11/16, at 7:45 a.m., he stated HK A informed him regarding her observations of Resident 1. He went to Resident 1's room and saw the bed sheets tied to the side rails and the bedrails. RN B stated he called the certified nurse assistant to untie the bed sheets from the side rails and the bedrails. During a telephone interview with certified nurse assistant D (CNA D) on 3/11/16, at 3:40 p.m., she stated she helped CNA C tie the bed sheets across the side rails and the bedrails to prevent Resident 1 from falling. During a telephone interview with CNA C on 3/11/16, at 4 p.m., she confirmed she tied the bed sheets to the bedrails across Resident 1's abdomen, legs, and ankle areas. Review of the facility's policy, "General Policy Guidelines on Restraints," revised 3/24/2011, indicated the facility will honor the resident's right to be free from any physical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms. The facility was a restraint free facility. The violation of this regulation had caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety, or other emotional trauma to residents. |
| 070000088 |
WINDSOR SKYLINE CARE CENTER |
070012255 |
B |
16-May-16 |
S6EC11 |
5476 |
F323--483.25(h) FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. The facility failed to ensure Resident 1 had adequate supervision to prevent an accident and injuries when the resident fell out of his wheelchair after he was struck by the facility's van and sustained an abrasion (a wound caused by superficial damage to the skin) on his left wrist and a hematoma (swelling of clotted blood within the tissues) on his forehead.Resident 1's clinical record was reviewed and indicated he had diagnoses including dementia (a group of thinking and social symptoms interfering with daily functioning). His Minimum Data Set (MDS, an assessment tool), dated 2/5/16, indicated his cognition was moderately impaired. His activity care plan, dated 2/1/16, indicated he preferred to sit outside. Resident 1's nurses notes, dated 4/26/16, at 9:15 a.m., indicated he was sitting in his wheelchair out in the parking lot next to the facility's van. The van driver (VD) told Resident 1 not move but he moved and was hit by the van while the van was backing up. He fell to the ground on his left side.Resident 1's Change in Condition form, dated 4/26/16, indicated he had a 2 centimeter (cm, a unit of measurement) x 1.6 cm abrasion on his left wrist, a 3.5 cm x 3.5 cm hematoma on the left side of his head, and he complained of pain in his left upper leg. There was no swelling or redness of his left upper leg. Resident 1's nurses notes, dated 4/26/16, at 3:45 p.m., indicated his responsible party (individual making medical decisions) and his physician were notified and he was transferred to the emergency room at an acute care hospital. The Acute Care Summary from the acute care hospital, dated 4/27/16, indicated Resident 1 hit his head, left hand, and left hip after he fell out of his wheelchair. He was evaluated and diagnosed with an old fracture with no new concerns. He was discharged the next day and returned to the facility. During an interview on 4/27/16, at 12:38 p.m., with the VD, he stated he has been a van driver for the facility for sixteen years and he knew Resident 1 who liked to sit outside in his wheelchair in the sun, and pick flowers to put them in his hat. On 4/26/16, at 9:15 a.m., the VD was scheduled to pick up another resident from an appointment. He stated he saw Resident 1 sitting approximately six feet from the side of the van. He stated he spoke to Resident 1 in his native language and advised him not to move while the van was backing up. The VD got into the van, checked his mirrors, and backed up the van. He stated while he was backing up the van, he felt like he hit something so he stopped. He stated he got out of the van, saw Resident 1 on his left side on the ground, and summoned assistance.During an interview on 4/27/16, at 1:45 p.m., registered nurse A (RN A) stated she heard a page requesting assistance in the front patio. RN B stated she went outside and saw Resident 1 on the ground on his left side. RN A stated she noted he had a hematoma on his forehead and a small abrasion on his left wrist.He also complained of pain in his left hip. She stated she wanted to transport Resident 1 to the acute care hospital but he refused. RN A stated she helped transport him to his room with the assistance of a mechanical lift.During an interview on 4/27/16, at 1:55 p.m., RN B stated one of the restorative nurse assistants (RNA) told her she was needed in the parking lot. She stated she saw Resident 1 on the ground on his left side. RN B stated there was no blood visible and his wheelchair was tipped over but it was not broken. She noted a small abrasion of Resident 1's left wrist and assisted other staff member to transport him back to his room via a mechanical lift. During an interview on 4/27/16, at 2 p.m., licensed vocational nurse C (LVN C) stated she heard a page for a mechanical lift to the parking lot. She stated she saw Resident 1 on his left side on the ground. LVN C stated she assisted other staff members to transport him back to his room via a mechanical lift. She stated she assessed Resident 1 after the fall and noted a hematoma on his forehead and an abrasion on his left wrist. LVN C stated he complained of pain in his left hip but there was no redness or swelling. She stated Resident 1's RP and physician were notified. LVN C stated his physician ordered a transfer to the acute hospital but Resident 1 initially refused to go and it took several hours to convince him to accept a transfer. She also stated he refused to take any medication.A review of the facility's 11/2012 policies, "Nursing Department Philosophy and Goals" and "Safety, Resident", indicated the nursing staff will follow regulations and standards to maintain resident safety and the staff will use safe practice guidelines while delivering care to the residents. The facility failed to ensure Resident 1 received adequate supervision to prevent an accident and injuries when the resident fell out of his wheelchair after he was struck by the facility's van and sustained an abrasion (a wound caused by superficial damage to the skin) on his left wrist and a hematoma (swelling of clotted blood within the tissues) on his forehead.The violation had a direct or immediate relationship to the health, safety, or security of the resident. |
| 070000097 |
WILLOW GLEN CENTER |
070012470 |
A |
22-Sep-16 |
FY1H11 |
8289 |
F323 - 483.25(h) Free of Accident Hazards/Supervision/Devices The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. The facility failed to provide adequate supervision to prevent Resident 1 from falling consistent with the resident's assessed needs and plan of care. This failure resulted in Resident 1 sustaining an acute subdural hematoma. (An acute subdural hematoma is usually the result of a serious head injury. The bleeding fills the spaces around the brain very rapidly, compressing brain tissue. This often results in brain injury and may lead to death.) Resident 1 died the next day. Resident 1's clinical record was reviewed. Resident 1 was a 69 year old female, who was readmitted to the facility on 8/30/12. She had been in the facility since 8/29/2008. She had diagnoses that included hypertension, stroke with right sided hemiplegia (paralysis of one side of the body) and expressive aphasia (difficulty in conveying thoughts through speech or writing). Review of Resident 1's Minimum Data Set (MDS, an assessment tool) dated 6/27/16, indicated the resident required extensive assistance (resident involved in activity, staff provide weight-bearing support) with one-person physical assistance for toileting. It indicated the resident was unsteady and only able to stabilize with staff assistance when she moved on and off the toilet. Review of Resident 1's MDS, dated 6/27/16, also indicated functional limitation in range of motion due to impairment on one side. This meant that limitation interfered with daily functions or placed the resident at risk of injury. Review of Resident 1's Fall Notes (FN), dated 7/4/16, indicated the resident was heard yelling for help and found face down on the bathroom floor on 7/4/16 at 11:00 a.m. The FN also indicated this was an unwitnessed fall as Resident 1 attempted to transfer herself to her wheelchair and fell. Review of another FN, dated 7/4/16, indicated on the same day at 12:20 p.m., Resident 1 had a second fall in her room right next to her bed and was face down. It also indicated this was an unwitnessed fall and Resident 1 attempted to get her items from her drawer and fell. Resident 1 was transferred to an acute care hospital after this second fall incident. During an interview with licensed vocational nurse A (LVN A), on 7/19/16, at 1:49 p.m., she stated on 7/4/16 at 11 a.m. Resident 1 yelled and LVN A found her on the bathroom floor face down. LVN A stated that certified nursing assistant B (CNA B) was not in Resident 1's room to assist Resident 1 during transfer. LVN A further stated that CNA B should have stayed with Resident 1, and should never have left her unattended and alone on the toilet. During a telephone interview with CNA B, on 7/19/16 at 3:51 p.m., she stated she left Resident 1 in the bathroom because she stepped out to assist another resident. CNA B stated after Resident 1's first fall, she was not given instructions to supervise Resident 1 more closely. During an interview with CNA C, on 7/19/16 at 1:21 p.m., she stated Resident 1 needed extensive assistance with toileting because of her weakness. CNA C stated she would never leave Resident 1 unattended during toileting. During an interview and record review with registered nurse G (RN G), on 7/22/16 at 9:38 a.m., she stated Resident 1 was assessed and was identified as a fall risk. Review of the falls care plan, dated 3/11/13, indicated an intervention to assess and anticipate the resident's needs in toileting. The falls care plan was revised on 9/11/13, and indicated to assist the resident to the bathroom promptly. There was no intervention for the CNA to stay with the resident in the bathroom until after the first fall on 7/4/16. Review of Resident 1's fall resolved care plans dated 2008, 2009, 2010, 2011, and 2012, as well as her current clinical record, did not indicate Resident 1 refused assistance in the bathroom nor were there any interventions for the CNA to stay with the resident in the bathroom until the first fall on 7/4/16. Review of Resident 1's fall care plan dated 5/22/09 after Resident 1's fall incident indicated interventions included providing privacy during the resident's use of the bathroom, and waiting outside the bathroom door, instructing the resident to ask for help, and wait for the CNA to clean her after using the bathroom. Review of "Fall Notes" dated 8/25/13 indicated Resident 1 had an unwitnessed fall in the bathroom. The note indicated, "Describe any new intervention to prevent re-occurrence [sic] CHECK RESIDENT MORE FREQUENTLY WHEN SEATED IN [sic] THE TOILET..." During an interview with CNA D, who was acting as the team leader and trainer for CNA B, on 7/22/16 at 1:30 p.m., she stated CNAs were all trained to remain with the resident during toileting. CNA D stated CNA B should never have left Resident 1 unattended in the bathroom. During an interview with CNA F, on 7/22/16 at 10:44 a.m., she stated she would stay in Resident 1's room until she finished toileting. CNA F further stated they were all trained not to leave residents alone on the toilet who required transfer assistance. During an interview on 7/22/16 at 1:51 p.m., CNA E acknowledged she was the team leader of the station where Resident 1 resided. CNA E stated CNAs should stay with Resident 1 during toileting and should wait outside the bathroom door until Resident 1 indicated that she was finished. CNA E also stated that if another resident needed assistance, she would call for help and would never leave Resident 1 unattended while on the toilet. During an interview with the director of staff development (DSD), on 7/22/16 at 1:36 p.m., he stated all CNAs were given in-service training in assisting residents with their activities of daily living. The DSD also stated floor orientation was given by team leaders who were experienced and highly competent CNAs. The DSD stated there was no written evidence or any documentation for this training. During an interview with the administrator on 9/10/16 at 10:09 a.m., he stated there was no documentation in Resident 1's clinical records indicating Resident 1 refused assistance or the presence of staff while Resident 1 used the bathroom. A review of Resident 1's Critical Care History and Physical (H&P) from the acute care hospital, dated 7/4/16, indicated she was admitted on 7/4/16 with altered mental status following two mechanical falls. A Computed Tomography (CT, diagnostic procedure in which the computer constructs cross-sectional images from several X-rays to detect a variety of diseases and conditions) scan of the head, dated 7/4/16, revealed a large right hematoma up to 2.2 cm (centimeters, unit of measurement) with midline shift. Further review of Resident 1's Inpatient Medicine Discharge Summary, dated 7/5/16, indicated Resident 1 had a right subdural hematoma with midline shift likely secondary to her two falls at the skilled nursing facility and subsequently passed away on 7/5/16 at 5:25 p.m. A review of the Certificate of Death, signed by a deputy coroner on 7/12/16, indicated that the immediate cause of death was complications of subdural hematoma from a fall in the nursing home. During an interview on 8/16/16, at 1:28 p.m., the deputy coroner confirmed that Resident 1's immediate cause of death was from complications of subdural hematoma from a fall. A review of the facility's 1/3/10 Fall Prevention Program policy indicated "All residents shall remain as free of accident hazard as is possible and all residents will receive adequate supervision and assistive devices to prevent accidents." It further indicated that any residents identified as at risk for falls should have an individual plan of care that includes interventions to prevent falls from occurring. The care plan should be reviewed and updated as needed and appropriate interventions were properly implemented. Therefore, the facility failed to ensure Resident 1 had adequate supervision to prevent accidents and injuries. 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. |
| 070000084 |
WINDSOR GARDENS REHABILITATION CENTER OF SALINAS |
070012641 |
B |
14-Oct-16 |
54CZ11 |
7285 |
F323 - 483.25(h) Free of Accident Hazards/Supervision/Devices The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. The facility failed to provide adequate supervision to prevent Resident 9 from falling consistent with the resident's assessed needs and plan of care. These failures resulted in Resident 9 sustaining a fracture of her right hand, a head injury, and laceration of the scalp on 11/20/15 after a fall incident. Resident 9's medical record was reviewed and indicated she was admitted with diagnoses including history of falls, abnormality of gait or mobility, extrapyramidal and movement disorder and dementia (memory problem). Her minimum data set (MDS, an assessment tool) dated 11/13/15, indicated she had severely impaired decision making skills and required assistance from the nursing staff with activities of daily living (ADLs; bed mobility, transfer, ambulation, dressing, toileting, personal hygiene, and bathing). During an interview and record review with the registered physical therapist on 10/4/16 at 4:15 p.m., she stated Resident 9 had physical therapy on 6/3/15 and Resident 9 was discharged on 6/18/15 to ambulate with supervision on an even surface, and distant supervision with all functional transfers. Review of Resident 9's progress notes, dated 10/3/15 at 2 a.m., indicated Resident 9 had an unwitnessed fall in the hallway, was transferred to an acute hospital and returned to the facility with diagnosis of a fracture of the left shoulder and fractured ribs. Resident 9's fall care plan and intervention, dated 10/3/15, indicated continue at risk plan intervention e.g., to provide safe environment with floors free from spills or clutter and encourage resident to participate in activities, and bed alarm to alert staff if the resident tried to get out of bed without assistance. Review of Resident 9's fall risk assessment, dated 10/3/15, indicated she had a score of 21 (represents a high risk for falls). It also indicated under gait analysis, Resident 9 exhibited loss of balance while standing, used short discontinuous steps or shuffling steps, changed gait pattern when walking through doorways, exhibited jerking or instability when making turns, and decrease in muscle coordination. Review of Resident 9's progress notes indicated another unwitnessed fall in her room on 11/20/15 at 3 p.m. She was transferred to the acute hospital and returned to the facility with a diagnosis of fracture of the right hand, minor head injury, and laceration on the scalp. Resident 9's fall care plan and intervention, dated 11/20/15, indicated a landing floor pad was not indicated due to an increased risk of the resident tripping on it, one-on-one with the resident, and assist with all ADLs. Review of Resident 9's fall risk assessment, dated 11/13/15, indicated she had a score of 22 (represents a high risk for falls). It also indicated under gait analysis, Resident 9 exhibited loss of balance while standing, used short discontinuous steps or shuffling steps, the resident required hands-on assistance to move from place to place, changed gait pattern when walking through doorways, exhibited jerking or instability when making turns, and decrease in muscle coordination. During an interview and record review with the registered physical therapist on 10/4/15 at 4:20 p.m., she stated Resident 9 had a decline related to fall. She started physical therapy on 10/19/15 and was discharged on 11/13/15 with supervision or standby assistance for safe ambulation and transfer. She also stated due to her shuffling gait and impaired cognition, Resident 9 was risk for falling which required assistance from the facility staff with her ADLs. Review of Resident 9's fall scene investigation report on 12/28/15 at 11:20 a.m. Resident 9 had another witnessed fall in the activity room when she transferred herself from her wheelchair and slid onto the floor. Resident 9's fall care plan and intervention, dated 12/28/15, indicated continue with one-on-one supervision with the resident, and ambulation with facility staff in the hallway. Review of Resident 9's fall scene investigation report on 2/17/16 at 1:15 p.m., documented Resident 9 had a witnessed fall at the facility's front lobby when Resident 9 transferred herself from the wheelchair to the chair and slid to the floor. Resident 9's fall care plan and intervention, dated 2/17/16, indicated to assist the resident to ambulate on her own, and offer a chair when the resident appears to be tired or have an unsteady gait. Review of Resident 9's fall scene investigation report on 7/30/16 at 12:41 p.m., documented Resident 9 had a witnessed fall when Resident 9 ambulated in the dining area, stepped backward and lost her balance. Resident 9's fall care plan or intervention, dated 7/30/16, indicated staff will ambulate Resident 9 with standby supervision and provide resident with a seat to rest. Review of Resident 9 on 9/23/16 at 9:45 a.m. in the dining area, Resident 9 had a witnessed fall when she got up from her chair, slipped on wet floor and fell. Resident 9's care plan or intervention, dated 9/23/16, indicated staff will ambulate the resident with standby supervision, and if noted to be tired provide her with a seat to rest. During an observation on 10/3/16 at 5:15 p.m. Resident 9 was laying on her bed by herself with a landing floor pad on the floor by the left side of her bed. On 10/4/16 at 4:45 p.m., during activities observation in the dining area Resident 9 walked around while the activity assistant (AA) did some activities with other residents and was not paying attention to Resident 9. There was no other staff in the activity room to supervise Resident 9. During an observation and interview with the clinical consultant (CC) at 10/4/16 at 10:30 a.m., Resident 9 sat alone, inside the office of the director of nursing. The CC confirmed Resident 9 was alone and with no supervision by the facility staff. She also verified Resident 9 had a landing floor pad on the left side of her bed which was a tripping hazard for Resident 9. The CC stated Resident 9 should have interdisciplinary team (IDT, team members from different departments involved in a resident's care) notes regarding her landing floor pad at her bedside. During an interview with registered nurse B (RN B) on 10/5/16 at 2:55 p.m., she stated she was the assigned charge nurse for Resident 9 and Resident 9 required assistance with her ADLs. Resident 9 was not steady with her gait and Resident 9 was observed ambulating by herself without staff assistance. She confirmed Resident 9 was a fall risk due to her cognition and unsteady gait. Review of the facility's 11/2012, "Falls Management", indicated it was the policy of this facility that the physical environment remains as free of accident hazards as possible. Residents will be assessed for fall risks, and interventions will be implemented to reduce the risk of falls. Residents scoring as a high risk will have interventions implemented to reduce the potential for falls to outline in their plan of care. This failure had a direct relationship to the health, safety, or security of residents. |
| 070000097 |
WILLOW GLEN CENTER |
070012668 |
B |
31-Oct-16 |
8E0411 |
3432 |
F223 483.13(b), 483.13(c)(1)(i) FREE FROM ABUSE/INVOLUNTARY SECLUSION The resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. The facility must not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion. The facility failed to ensure Resident 1 was free from verbal abuse when on 10/7/16, certified nurse assistant A (CNA A) said inappropriate words to Resident 1. This failure had the potential to cause mental anguish as well as a decrease in self-esteem for Resident 1. Review of Resident 1's Minimum Data Set (MDS, an assessment tool) dated 10/10/16, indicated a Brief Interview for Mental Status (BIMS) score of 15 (scores of 13-15 indicate intact memory and cognition). Review of Progress Notes which were written by the social services assistant (SSA), dated 10/7/16 at 4:47 p.m., indicated Resident 1 reported CNA A yelled, screamed, and cussed at him during the morning. Review of the facility's 10/10/16 investigation summary and conclusion indicated CNA A admitted he was angry because of the way Resident 1 was treating him and might have said a bad word in the situation because Resident 1 kept on swearing at him and talking very derogatorily to him. During an interview with CNA A on 10/17/16 at 2:30 p.m., he acknowledged an argument with Resident 1 on 10/7/16 around 10:20 a.m. while he was caring for Resident 1. CNA A stated Resident 1 did not have the right to talk to him the way he did that morning. During an interview with the SSA on 10/18/16 at 9 a.m., she stated Resident 1 told her he had been verbally abused by CNA A on 10/7/16. The SSA stated she then interviewed Resident 1's roommate who confirmed he heard CNA A use swear words including the "F" word directed toward Resident 1 on 10/7/16. During an interview with Resident 1 on 10/18/16 at 1:30 p.m., he stated CNA A said the "F" word when he was caring for him on 10/7/16. During an interview with Resident 1's roommate (Resident 7) on 10/18/16 at 1:35 p.m., he stated he heard CNA A use the "F" word when caring for Resident 1 on 10/7/16. During an interview with the director of nursing (DON) on 10/18/16 at 2:45 p.m. she stated during their investigation, Resident 1 said CNA A had cursed at him. The DON stated if CNA A was upset by what Resident 1 was saying to him, he should have left the room and had someone else help Resident 1. The DON stated it was inappropriate if CNA A said something back to Resident 1. During an interview with the administrator (ADM) on 10/18/16 at 3:10 p.m. he stated he believed CNA A did say a bad word while caring for Resident 1 on 10/7/16. Review of the facility's 2013 policy "Abuse, Prevention" indicated residents had the right to be free from verbal abuse from the staff. It indicated the definition of verbal abuse was the use of oral, written, or gestured language that willfully included disparaging and derogatory terms to the residents regardless of their age, ability to comprehend or disability. The failure occurred under circumstances likely to cause significant humiliation, indignity, anxiety, or other emotional trauma to residents. Therefore, the facility failed to ensure the resident was free from verbal abuse. The above violation caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety, or other emotional trauma to residents. |
| 070000906 |
WREN HOUSE |
070012691 |
B |
4-Nov-16 |
Z5KK11 |
4690 |
Welfare & Institutions Code 4502(b)(4) (b) It is the intent of the Legislature that persons with developmental disabilities shall have rights including, but not limited to, the following: (4) A right to prompt medical care and treatment. The facility failed to ensure Client 1's right to prompt medical care and treatment. The physician was not immediately notified when Client 1 complained of pain, with swelling and a bruise on her right foot. The bruise was not assessed and investigated as per the facility's policy and procedure. This resulted in an acute fracture of Client 1's right ankle. Review of Client 1's clinical record on 9/13/16 indicated Client 1 was admitted to the facility with diagnoses including severe mental retardation, mixed bipolar disorder, dependent edema, with a history of seizure. She was alert and able to express her needs. Client 1 was ambulatory but she required staff supervision and/or assistance to walk. She used a wheelchair to go to the day program and community outings. The facility communication record dated 8/21/16 stated "[name] has swollen feet with bruise" and the registered nurse consultant (RNC) was informed the same date of the incident. During an interview on 9/13/16 at 7:45 a.m., the facility manager (FM) stated on 8/21/16 a Sunday morning, she and direct care staff A (DCS A) noticed Client 1's foot was slightly swollen. She stated she reported it to the RNC and the RNC arrived the same date in the afternoon. She also stated staff did not know how Client 1 got the right foot fracture. In a concurrent interview at 8:15 a.m., the qualified intellectual disability professional (QIDP) stated on 8/21/16 the facility staff, noticed the client's foot "a bit swollen". The QIDP stated the following day on 8/22/16 he took the client to the clinic for a check-up and an X-ray was taken with result of an acute fracture of the right ankle. During an observation on 9/13/16 at 8:45 a.m., Client 1 was sitting in a wheelchair by the living room. She was wearing soft boots on her feet. She talked constantly changing from one topic to another. She was not able to say what happened to her foot but she stated "no more pain". During record review on 9/13/16, of the nurse's notes dated 8/21/16, was written "client in bed with discoloration to R [right] foot, minimal swelling, if foot is touched, client demonstrates pain". A pain medication was administered and the client's feet were elevated, but there was no evidence the physician was notified until 8/22/16, which was the following day when Client 1 was taken to the clinic for a check-up and an X-ray was taken with result of acute fracture of the right ankle. The record had no documentation the bruise was assessed and investigated. In a concurrent interview at 10:45 a.m., the RNC stated she was informed on 8/21/16 by the facility staff regarding the client's swollen foot with a bruise. The RNC stated she went to the facility that same day, during the afternoon, and saw the client. When asked about the bruise the RNC stated, "It was also my concern of what had happened". The physician's progress record dated 8/22/16 indicated Client 1 was seen at the clinic due to right foot swelling with a bruise. It documented a right ankle effusion and pain with tenderness. The acute care hospital's diagnostic imaging report dated 8/22/16, had findings that included acute fracture of the medial malleolus (a break in the bony process situated at the inner aspect of the ankle). During an interview on 10/20/16 at 9:00 a.m., DCS A caring for Client 1 stated the morning of 8/21/16, the client took a shower and complained that her right foot was painful. DCS A stated she saw the client's foot was swollen and had a bruise about the size of a lemon on the outer right ankle. DCS A stated she called the house manager (HM), and she and the HM checked the client. She stated the HM reported the incident to the RNC. The facility's "Special Incident Report" dated 8/26/16 had no indication the client had a bruise on the right foot. The facility's undated "Special Incident reports" policy and procedure included that special incidents were to be investigated and the physician was to be notified immediately of any health related incidents and when necessary was to examine the client. The facility failed to immediately notify the physician when the client complained of pain on her right foot with swelling and a bruise. The bruise was not assessed and investigated. The facility's procedure for special incidents was not followed. The client sustained an acute fracture of the right ankle. This violation had a direct relationship to the health, safety and security of clients. |
| 070000094 |
Watsonville Post Acute Center |
070012741 |
A |
28-Nov-16 |
4MSP11 |
8289 |
F323 - 483.25(h) Free of Accident Hazards/Supervision/Devices The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. The facility failed to provide adequate supervision to prevent an accident and injury for Resident 1 when Resident 1 eloped (to leave a long term care facility without permission) and was found lying down on a sidewalk by bystanders (people present at the incident). This failure resulted in Resident 1 sustaining a mandibular (jaw) fracture with significant displacement. Resident 1 was recommended to be on a soft diet for three to four weeks and had pain and difficulty eating after her hospital discharge. Resident 1's clinical record was reviewed. The resident was admitted to the facility on 3/16/12 with a diagnosis of dementia (brain disease causing a long-term and often gradual decrease in the ability to think, remember, and affecting a person's daily functioning) with behavioral disturbance and had the behavior of trying to leave the facility if unattended. Review of Resident 1's Minimum Data Set (MDS, an assessment tool) dated 8/21/16, indicated her cognition was severely impaired. Resident 1 required supervision (staff must have oversight of the resident) when the resident moved to and returned from various areas within the facility such as the lobby, dining, and activity areas. Review of Resident 1's Elopement Risk Assessment (ERA) dated 8/29/16, indicated the total score for ERA was "10" which meant the resident was at risk for elopement (the total score of "5" or above represents at risk for elopement). The ERA indicated how to address the elopement precaution on the care plan including a plan to implement routine monitoring of the resident's whereabouts. There was no documented evidence on the care plan, however, that routine monitoring of the resident's whereabouts was initiated. Review of Resident 1's Elopement Care Plan dated 4/2/15, indicated the resident had a WanderGuard (small device placed on the ankle or wrist of the resident, alarms to notify the staff if the resident tries to leave the facility) due to wandering and attempts to leave the facility unattended. It also indicated to notify the responsible party (RP) and the medical doctor (MD) if the resident has increased episodes of wandering even with redirection. Review of Resident 1's Medication Administration Record (MAR) dated 10/1 to 10/31/16, indicated to monitor Resident 1's episodes of trying to leave the facility every shift. Review of Resident 1's MAR for October 2016 for the 3 to 11 p.m. shift indicated Resident 1 tried to leave the facility on 10/3, 10/4, 10/5 (twice), 10/6, 10/9, and 10/15/16 (twice). On 10/15/16, for the 7 to 3 p.m. shift, Resident 1 attempted to leave the facility five times. There was no documented evidence the RP and MD were notified of the resident's increased episodes of elopement. Review of Resident 1's SBAR (situation, background, assessment, and recommendation, a communication and assessment tool used by nurses for a resident's change of condition) dated 10/15/16, indicated on 10/15/16 at 8:20 p.m., the resident was missing and the staff performed a facility search but could not locate the resident. Review of Resident 1's History and Physical from an acute care hospital dated 10/15/16, indicated the resident was brought in by the paramedics after she was found lying on a sidewalk by bystanders. Review of Resident 1's Discharge Summary from an acute care hospital dated 10/17/16, indicated she sustained "bilateral sub condylar (jaw) fractures with significant displacement", and "was recommended to be on a soft diet for 3-4 weeks." Review of Resident 1's Health Status Note dated 10/18/16 at 10:29 p.m. indicated, "Resident c/o [complains of] tenderness to neck, jaw, and right arm and received routine pain medications. Resident ate 10% of dinner." Review of Resident 1's Health Status Note dated 10/19/16 at 10 p.m. indicated, "Resident does feel a lot of pain to jaw, area surrounding is very sensitive to touch and hurts. Difficult for her to swallow and chew medications and eat food." Review of Resident 1's Health Status Note dated 10/20/16 at 2 p.m. indicated, "She ate 10% of breakfast and lunch." Review of Resident 1's Health Status Note dated 10/20/16 at 9:45 p.m. indicated, "Resident 1 continues to feel a lot of pain to body and jaw. Still has difficulty taking meds and refuses to eat dinner." During an interview with the minimum data set coordinator (MDS C) on 10/21/16 at 2:05 p.m., she stated Resident 1 required supervision from the staff when moving from one location to another. During an interview with certified nursing assistant A (CNA A) on 10/21/16 at 1:10 p.m., she stated Resident 1 was ambulatory, walks around the facility, and she checked on her from time to time but there was no routine monitoring of the resident's whereabouts. During an interview with the admission coordinator (AC) on 10/21/16 at 1:20 p.m., she stated on 10/15/16 at 11:30 a.m., she saw Resident 1 leave the facility. She immediately followed the resident. The resident walked to the store located next to the facility and staff was able to convince the resident to return to the facility. During an interview with receptionist B (RB) on 10/21/16 at 1:35 p.m., she stated on 10/15/16 during the morning, Resident 1 tried to elope multiple times. During an interview with licensed vocational nurse B (LVN B) on 10/26/16, at 10:50 a.m., she stated the RP and MD were not notified regarding Resident 1's increased elopement episodes. She said she did not document Resident 1's 10/15/16 elopement episode on the morning shift, in the resident's progress notes, or in the 24 hour endorsement log. During an interview with licensed vocational nurse C (LVN C) on 10/26/16, at 11:45 a.m., he stated on 10/15/16 at 8:20 p.m., when they discovered Resident 1 was missing, they initiated a facility search but could not locate the resident. At approximately 8:40 p.m., he received a call from an acute care hospital confirming Resident 1 was a facility resident, and would be admitted to the hospital. During a concurrent interview with LVN C, he stated LVN B did a verbal endorsement regarding Resident 1's elopement episode on 10/15/16, during the morning shift. During a concurrent interview with LVN B, she stated there was no routine monitoring of Resident 1's whereabouts, and she never used the transmitter tester to test the WanderGuard. She said on her shift, she only checked the placement of the WanderGuard. During an interview with licensed vocational nurse E (LVN E) on 10/26/16, at 11:15 a.m., she stated she did not use the transmitter tester on the graveyard (2300-0730) shift to check if the WandeGuard was functional. She said she would ask Resident 1 to get close to the exit doors and if the alarm went off, it meant it was working. During an interview with the director of nursing (DON) on 11/1/16 at 11:20 a.m., she stated the graveyard shift was responsible to check the WanderGuard's functionality using the transmitter tester. She also acknowledged there was no routine monitoring of Resident 1's whereabouts. Review of the WanderGuard user guide manual, indicated transmitters in use must be tested at least weekly using the transmitter tester. The manual stated, "Never take a resident to a door to test their transmitter". Review of the facility's policy "Safety and Supervision of Residents" dated 12/2007 indicated resident supervision is a core component of the system approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment. The facility failed to provide adequate supervision to prevent an accident and injury for Resident 1. Resident 1 sustained a mandibular (jaw) fracture with significant displacement and needed to be on a soft diet for three to four weeks after her hospital discharge and had pain and difficulty eating as a result of this injury. 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. |
| 070000062 |
Westland House |
070012805 |
B |
13-Dec-16 |
96M511 |
8436 |
F281--483.21(b)(3)(i) SERVICES PROVIDED MEET PROFESSIONAL STANDARDS (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. The facility failed to provide professional standards of quality of care for Resident 1 when occupational therapy (OT) staff failed to use a gait belt (device used to transfer or ambulate people who have problems with balance) and a wheelchair (WC) to safely ambulate the resident. This failure resulted in a fall for the resident with injuries and ongoing pain. Resident 1's clinical record was reviewed on 12/5/16. His minimum daily set (MDS, an assessment tool) dated 11/13/16 indicated he required one person physical assistance to walk. A physician's order dated 11/7/16 indicated Resident 1 was to receive an OT treatment up to one time daily, six days a week, for three weeks, for activities of daily living (ADL), safe functional mobility, training with balance, home skills with weight bearing (the amount of weight put on the legs) as tolerated, and other therapeutic exercises. Review of an Occupational Therapy Evaluation dated 11/7/16 indicated Resident 1 was a fall risk due to weakness. His plan of care included safety training, ADL retraining, and home management skills. A physician's order dated 11/7/16 indicated Resident 1 was to receive physical therapy (PT) twice a day, six to seven days a week for balance training, gait training (ability to walk), weight bearing as tolerated, stair training, therapeutic exercises, transferring and assistive device training. Review of a narrative PT progress note dated 11/10/16, during the p.m., authored by the doctor of physical therapy (DPT), indicated Resident 1 consented to PT, but when the resident sat on the edge of the bed, he complained of some dizziness. DPT notified nursing staff who confirmed the resident had a low blood pressure (LBP) of 87/46 millimeters of mercury (mm/Hg, a unit of measure). The note indicated when the resident stood and took a few steps he began to lose his balance. The resident sat down and reported he still felt dizzy. He was helped back to bed, his legs were elevated, and his nurse was notified. During an interview on 12/5/16 at 11 a.m. with the DPT, she stated Resident 1 was good about telling her how he felt. She stated on 11/10/16 at the beginning of his PT treatment, he stated he felt dizzy. She stated the RN checked his BP that indicated he had a (LBP) of 87/46 mm/Hg. She stated she had planned to walk the resident, but as his BP was so low, she did not. She stated the resident was assisted to a wheelchair (WC) to rest. During a continued interview on the above date and time, the DPT stated ninety-five percent of the time staff were required to use gait belts to walk residents. She stated rehabilitation staff, including the OTs, should have been using a gait belt with Resident 1 at all times, especially since he had been dizzy. The DPT stated the OT should have been aware of Resident 1's LBP on 11/10/16 by reading DPT's PT notes dated 11/10/16. Review of a narrative progress note dated 11/11/16 authored by occupational therapist A (OT A) indicated Resident 1 consented to OT treatment and wanted to walk outside of his room. The note indicated the resident agreed to use his front wheeled walker (FWW, a tool for people who need additional support walking) as he had had an episode of LBP on 11/10/16 during PT. OT A stated the resident walked out of his room and complained of feeling woozy (dizzy). It indicated OT A asked staff for a WC after the resident was stabilized against the wall, however the resident fell on his left side. The note indicated nursing staff arrived and the resident stated he was able to get up. The resident stood up and was transferred to the wheelchair with moderate assistance of two registered nurses (RNs) and OT. During an interview on 12/5/16 at 9:50 a.m. with OT A, she stated she walked the resident out of his room using his FWW. Resident 1 complained of feeling woozy and asked for a WC. OT A stated she stabilized the resident against the wall outside his room and was trying to hold him by his waist. He fell to the floor on his left side. There was a WC in the hallway for him in case he got dizzy, but it was not in a reachable area near the resident. Staff arrived to assist, and OT A assisted the resident to the WC. She stated when the resident was walking with her she was guiding him with her hand on his waist at his side. During a continued interview on the above date and time with OT A, she stated the WC should have been within reaching distance of Resident 1, but it was not. She was aware the resident had hypotension (LBP) and during the resident's OT treatment on 11/10/16, OT A had been holding on to the WC while walking with the resident. During a continued interview on the above date and time with OT A, she stated she did not use a gait belt with Resident 1 when walking with him. She stated she only used one if the resident was a two-person transfer or when the resident had a balance deficit. She stated Resident 1's LBP was a balance deficit and she probably should have used a gait belt. During an interview on 12/5/16 at 11:17 a.m. with OT A, she stated she had read the previous day's PT note authored by DPT, indicating Resident 1 had LBP. She stated maybe she should have withheld his treatment on 11/11/16, or given him treatment while he remained in bed. During an interview on 12/5/16 at 11:30 a.m. with Resident 1, he stated he had a fall on 11/11/16 while walking with OT. He stated he continued to be in "a lot of pain," and he has had severe back pain ever since his fall. Review of a physician's progress noted dated 11/18/16 indicated Resident 1 had a fall with OT after feeling lightheaded and having labile (unstable) BPs. The back pain was new and an MRI of the spine was ordered. A physician's order dated 11/18/16 indicated Resident 1 was to receive an MRI for the lumbar spine (lower back). Review on 12/5/16 of Resident 1's MRI dated 11/25/16 indicated he had an acute compression fracture (force downward on a vertebra [backbone]) of the superior L1 (lumbar) endplate (top of vertebrae) of L2 with minimal loss of vertebral body height. (Height loss is an indicator for the presence of vertebral fractures). Review of a physician's order dated 11/11/16 indicated Resident 1 was to receive Norco (a narcotic analgesic pain medication) 5/325 milligrams (mg) every four hours as needed for pain. Review of a Psychotropic Drug Record dated 11/11/16 through 12/4/16 indicated Resident 1 had received Norco for back pain two to four times daily since his fall for moderately strong to severe pain levels (pain levels documented were mostly between "6" and "9" on the pain scale). A pain scale is a rating of pain on a scale of 1 to 10 with "0" being no pain and "10" being the worst pain one can imagine. Review of the Post Fall Assessment dated 11/11/16 at 5:24 p.m. indicated Resident 1's BP taken after the fall was 90/57 mm/Hg. A BP lower than 90/60 mm/Hg. indicated a LBP. The pain assessment indicated the resident had moderate aching back pain with a pain scale of "6" after the fall. Review of the Standards of Practice for Occupational Therapy (http://AOTA.org terms) indicated an occupational therapist is responsible for all aspects of occupational therapy service delivery, and is accountable for the safety and effectiveness of the occupational therapy service delivery process. Review of the facility's 11/10/2009 policy, "OCCUPATIONAL THERAPY SCOPE OF SERVICES" indicated Clinical interventions by OT services include, "Evaluation and re-evaluation of the patient's level of function." Review of the facility's 11/17/2009 policy, "OT Progress Notes" indicated daily documentation, including a narrative note, will be reviewed from any previous treatment. The facility failed to provide occupational therapy (OT) services for Resident 1 to maintain his highest level of functioning and psychosocial well-being when OT staff failed to use a gait belt (device used to transfer or ambulate people who have problems with balance) and a wheelchair (WC) to safely ambulate the resident. This failure resulted in a fall for the resident with injuries and ongoing pain. This failure had a direct or immediate relationship to the health, safety, or security of residents. |
| 070000094 |
Watsonville Post Acute Center |
070012840 |
B |
22-Dec-16 |
C7VK11 |
5757 |
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 unsafe wandering and implement a different intervention in response to repeated attempts at elopement (resident leaves the facility without permission) for Resident 2. On 11/27/16 and 11/28/16, Resident 2 attempted to leave the facility. The interdisciplinary team (IDT, a group of health care professionals from diverse fields who work toward a common goal for residents) did not discuss and implement new interventions to prevent another incident. On 11/30/16, Resident 2 was found alone outside the building and had an unwitnessed fall. This failure resulted in Resident 2's attempts at elopement and a fall outside the building sustaining a discoloration on her left cheek and a skin tear on her left hand. Review of Resident 2's clinical record indicated she had diagnoses including Alzheimer's disease (a progressive disease that destroys memory and mental functions). Resident 2 had a history of attempting to leave the facility unattended and exited the building on 11/27/16, 11/28/16, and 11/30/16. Resident 2's Minimum Data Set (MDS, an assessment tool), dated 10/20/16, indicated she was cognitively impaired and required supervision when walking. Review of Resident 2's Fall Risk Assessment, dated 10/20/16, indicated she was at a moderate risk for falls. Review of Resident 2's Elopement Risk Assessment, dated 11/17/16, indicated she was at a high risk for elopement. Review of Resident 2's care plan for risk of elopement, initiated on 1/12/16, indicated she had interventions to prevent elopement including redirect resident as needed, a WanderGuard (a small device placed on the ankle or wrist of resident, alarms to notify the staff if resident tries to leave the facility) at all times, and monitor the WanderGuard placement, expiration, and function. The care plan was last updated on 11/17/16 with new interventions including an individualized safety monitoring plan and engage resident in activity of interest. The care plan was not updated after Resident 2's attempts to leave the facility on 11/27/16 and 11/28/16. Review of Resident 2's progress notes, dated 11/19/16, 11/20/16, and 11/26/16 indicated she was difficult to redirect. Review of Resident 2's progress notes, dated 11/25/16, indicated she was showing increased agitation when being redirected to activities. Review of Resident 2's progress notes, dated 11/27/16, indicated she went outside and was escorted back to the building. Review of Resident 2's progress notes, dated 11/28/16, indicated she "walked out of building again" and at times she was not able to be redirected. Review of Resident 2's Change in Condition note, dated 11/30/16 at 8 a.m. indicated the resident was in the parking lot outside of the building and was observed sitting on the ground. The note further indicated Resident 2 had a discoloration on her left cheek and a skin tear on her left hand. During an interview on 12/14/16 at 10:30 a.m., medical records staff A (MRS A) stated she received a call from an employee from a neighboring building to inform her that Resident 2 was outside the building. MRS A stated when she went outside Resident 2 already had a discoloration on her face and skin tear. During a telephone interview on 12/14/16 at 11:05 a.m., MRS B stated she was in the parking lot and saw Resident 2 outside the building by herself. MRS B stated she called the facility to inform them and saw Resident 2 on the ground, but did not witness her fall. During a telephone interview on 12/15/16 at 11 a.m., the director of nursing (DON) stated there was no IDT meeting regarding Resident 2's attempts at elopement on 11/27/16 and 11/28/16. During a telephone interview, at 12/15/16 at 11:40 a.m., the DON stated 11/17/16 was the last time Resident 2's care plan for elopement risk was updated. The DON stated Resident 2's monitoring frequency was changed, but no new interventions were added to the previous interventions of redirection and monitoring. During an interview on 12/16/16 at 8:05 a.m., the social services director (SSD) confirmed there were no new interventions implemented after Resident 2's attempts at elopement on 11/27/16 and 11/28/16 to prevent Resident 2's attempt at elopement and fall on 11/30/16. The SSD stated interventions should be discussed with the IDT when the interventions were not working to prevent another attempt at elopement. Review of the facility's 12/2007 revised policy, "Safety and Supervision of Residents," indicated monitoring the effectiveness of interventions to reduce accident risks and hazards includes evaluating the effectiveness of interventions. Therefore, the facility failed to prevent unsafe wandering and implement a different intervention to prevent repeated attempts at elopement. The above violation had a direct or immediate relationship to the health, safety, or security of residents. |
| 070000097 |
WILLOW GLEN CENTER |
070012866 |
B |
6-Jan-17 |
CHZI11 |
8571 |
F323-483.25(d)(1)(2)(n)(1)-(3) Free of Accident Hazards/Supervision/Devices d) Accidents. The facility must ensure that - (1) The resident environment remains as free from accident hazards as is possible; and (2) Each resident receives adequate supervision and assistance devices to prevent accidents. (n) - Bed Rails. The facility must attempt to use appropriate alternatives prior to installing a side or bed rail. If a bed or side rail is used, the facility must ensure correct installation, use, and maintenance of bed rails, including but not limited to the following elements. (1) Assess the resident for risk of entrapment from bed rails prior to installation. (2) Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation. (3) Ensure that the bed's dimensions are appropriate for the resident's size and weight. The facility failed to ensure the resident's environment remained as free from accident hazards and received adequate supervision and assistance devices to prevent a fall for Resident 1. On 11/17/16, Resident 1 used a walker to go to the bathroom. It was uncertain who provided the walker to the resident. Without assistance, using the walker, Resident 1 walked to the bathroom, had an unwitnessed fall, and sustained an L1 (the first lumbar vertebra (lower back)) fracture (a complete or partial break in a bone). This failure resulted in Resident 1 sustaining a fall and injury. Review of Resident 1's clinical record indicated he was admitted to the facility on XXXXXXX with diagnoses of dyspnea (difficult or labored breathing), pain in unspecified joint, difficulty in walking, generalized muscle weakness, and back pain. Review of Resident 1's Functional Abilities and Goals Assessment dated 11/14/16 through 11/16/16, indicated the resident required partial or moderate assistance with toilet transfer. Review of Resident 1's nurses notes dated 11/15/16, indicated the resident was alert, oriented, and able to make his own decisions. Review of Resident 1's physical therapy (PT) care plan dated 11/15/16 indicated the resident had functional deficits which included a decrease in bed mobility, transfers, gait, sitting balance, standing balance, and lower extremity strength and endurance. Review of Resident 1's occupational therapy (OT) care plan dated 11/15/16 indicated the resident required assistance with activities of daily living (ADLs) and mobility. Review of Resident 1's PT evaluation and plan of treatment dated 11/15/16, indicated the resident was referred to PT for the new onset of the decrease in functional mobility and pain. Resident 1 presented with an impairment of left lower extremity weakness due to pain and spinal stenosis (narrowing of the spinal canal). This impairment limited bed mobility, transfers, gait, and activity tolerance. Review of Resident 1's ADLs Documentation Survey Report dated 11/15/16 through 11/17/16, indicated the resident required limited to total assistance with the support of one person for toilet use. Review of Resident 1's nurse notes dated 11/17/16 at 7:23 a.m., indicated the resident had an unwitnessed fall on 11/17/16 at 2:40 a.m. after using the bathroom. Resident 1 stated when he fell he had a crack on his back. Resident 1 was then transferred to an acute care hospital. Review of Resident 1's computerized tomography (CT, an imaging test of the inside of the body) spine lumbar (lower part of the spine) report dated 11/17/16 at 3:54 a.m., indicated the resident sustained an L1 fracture. Review of Resident 1's Post Fall Assessment dated 11/17/16, indicated the resident had an unsteady gait and used assistive devices (a device which helps people overcome a handicap such as mobility) such as a walker and a cane. He was also compliant with instructions to call for help when necessary. Review of Resident 1's interdisciplinary team (IDT) review dated 11/17/16 indicated the resident stated he went to the bathroom using his forward wheel walker (FWW). After using the toilet, Resident 1 stated he lost his balance and fell when he tried to back out of the bathroom. Resident 1 sustained an L1 fracture as a result of the fall. Review of Resident 1's PT daily treatment note dated 11/17/16, indicated the resident had a fall risk and was ambulating to the bathroom at the time of the fall using his personal walker. It indicated Resident 1 was not cleared for ambulation in the room. During an interview with Resident 1 on 12/1/16 at 11:45 a.m., he stated he went to the bathroom using his walker and when he started to leave, he fell on his back and heard a crack. Resident 1 stated he usually went to the bathroom by himself. He stated the facility did not tell him to ask for assistance when he went to the bathroom. During an interview with occupational therapist B (OT B) on 12/1/16 at 12:11 p.m., he stated Resident 1 complained of sciatic nerve pain. OT B stated Resident 1's balance was poor and based on the therapy department's evaluation he could not go to the bathroom by himself. During an interview with physical therapist A (PT A) on 12/13/16 at 9:28 a.m., he stated during the initial evaluation, Resident 1 was in a lot of pain. PT A stated he did not want Resident 1 to walk. During an interview with PT A on 12/13/16 at 1:33 p.m., he stated Resident 1 did not have clearance from the therapy department whether he was able to walk in the room at the time of the fall. PT A stated nursing staff did not ask him whether it was safe for Resident 1 to walk in the room using his walker. During an interview with OT B on 12/13/16 at 1:37 p.m., he stated Resident 1 was at a fall risk. He stated the therapy department provided Resident 1 a wheelchair, but not the walker. OT B stated at the time of the fall Resident 1 was not fit to use a walker, and he was unaware who provided Resident 1 the walker. OT B also stated the nursing staff did not ask him whether Resident 1 was cleared to walk in his room using a walker. During an interview with licensed vocational nurse D (LVN D) on 12/13/16 at 2:23 p.m., she stated at the time of the fall Resident 1 had a walker and a cane in the room. LVN D stated she was unaware where the cane and walker came from. During an interview with LVN C on 12/13/16 at 2:28 p.m., he stated he did not remember if Resident 1 brought a cane or a walker when he was admitted to the facility. During an interview with certified nursing assistant E (CNA E) on 12/14/16 at 8:51 a.m., he stated Resident 1 had a walker in the room. CNA E stated he always made sure the walker was at Resident 1's bedside. During an interview with CNA F on 12/14/16 at 9:20 a.m., she stated Resident 1 had a walker in his room before the fall incident. CNA F stated she had helped Resident 1 to go to the bathroom using a walker. During an interview with PT A on 12/14/16 at 12:58 p.m., he stated on 11/16/16 which was a day before the fall, Resident 1 had pre-gait training which was training to sit and stand to prepare for walking. PT A stated Resident 1's actual gait training occurred after the 11/17/16 fall and the resident started walking on 11/18/16. He stated the therapy department did not provide the walker which Resident 1 used at the time of the fall on 11/17/16. During an interview with CNA E on 12/16/16 at 11:10 a.m., he stated he was not informed Resident 1 was not allowed to use a walker in his room prior to the fall. During an interview with CNA H on 12/16/16 at 11:30 a.m., she stated no one informed her Resident 1 was not supposed to use a walker in his room. During a telephone interview with Resident 1 on 12/16/16 at 11:50 a.m., he stated no one in the facility informed him it was unsafe to use his walker in the room. He also stated he used the walker when he needed to go to the bathroom. Resident 1 stated he would not have used his walker if a staff member told him it was unsafe to do so. Review of the facility's 10/13/06 policy "SUPERVISION OF RESIDENT CARE" indicated to assure that the resident's safety and well-being are maintained, the environment of the resident should be reviewed and checked for safety. All residents shall receive adequate supervision. The licensed nurse shall assure that care is implemented per the resident's individualized care plan. The facility failed to monitor Resident 1's environment to ensure he did not use a walker in his room and receive adequate supervision and assistive devices to prevent a fall. This violation had a direct relationship to the health, safety, or security of the residents. |
| 070000002 |
WOODLANDS HEALTHCARE CENTER |
070013026 |
B |
9-Mar-17 |
3CXQ11 |
5352 |
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 an elopement (to leave a long term care facility without permission) and accident for Resident 1 when Resident 1 was assessed as high risk for elopement, the facility did not intervene to reduce the risk of elopement. This failure resulted in Resident 1's elopement, falling backwards, and sustaining a six centimeter (cm, unit of measurement) hematoma (collection of blood outside the blood vessels, caused by trauma or injury) to the back of her head when she hit her head on the ground.
Resident 1's clinical record was reviewed. The resident was admitted to the facility on XXXXXXX17 with a diagnosis of dementia (brain disease causing a long-term and often gradual decrease in the ability to think, remember, and affecting a person's daily functioning) and history of falls.
Review of Resident 1's Minimum Data Set (MDS, an assessment tool) dated 2/12/17, indicated her cognition was severely impaired.
Review of Resident 1's Physical Therapy Assessment dated 2/6/17, indicated the resident could walk on an even surface using a walker with minimum assistance.
Review of Resident 1's Elopement Screening (ES) dated 2/5/17, indicated the total score for ES was "9" which meant the resident was at risk for elopement (the total score of "9" or above represents at risk for elopement).
During review of Resident 1's clinical notes on 2/17/17, there was no documented evidence the elopement risk was addressed.
During an interview with certified nursing assistant A (CNA A), on 2/17/17, at 12:25 p.m., she stated on 2/13/17 she took Resident 1 to the resident's room and sat the resident in the wheelchair. CNA A stated she could not remember if she attached the tab alarm to the resident (Tab alarm clips to the back of the resident's clothing, and if the resident moves too far, the pull cord releases the magnet and the alarm sounds to alert the caregiver the resident attempted to ambulate. This is used for fall management and wandering prevention).
Review of Resident 1's Nurses Notes dated 2/13/17, indicated at 5:45 p.m., the resident was missing and the staff performed a facility search but could not locate the resident.
Review of Resident 1's Progress Notes dated 2/14/17 at 12:11 p.m. indicated the facility called the nearest acute hospital at 6:45 p.m. on 2/13/17 to inquire about their missing resident. The acute hospital informed them Resident 1 was brought in by the paramedics to their hospital emergency room. She was crossing the street, was witnessed falling backwards, and hitting her head.
Review of Resident 1's History and Physical from the acute care hospital dated 2/13/17, indicated the resident was crossing the street and was witnessed falling backwards hitting her head on the ground. The resident sustained a six cm hematoma to the back of her head.
During an interview with the minimum data set coordinator (MDS C), on 2/17/17, at 1:00 p.m., she acknowledged Resident 1 was assessed during admission as high risk for elopement. She stated the facility did not initiate elopement risk interventions, (i.e., WanderGuard) because the resident had a hip fracture and she never thought the resident could walk.
During an interview with the director of nursing (DON), on 2/17/17, at 2:30 p.m., she stated she did not initiate the elopement risks interventions, (i.e, WanderGuard) because Resident 1 was not ambulatory due to a hip fracture.
During an interview with physical therapist B (PT B), on 2/24/17, at 10:30 a.m., she stated during the assessment on 2/6/17 using a walker, Resident 1 could walk 100 feet with minimum assistance.
Review of the facility's policy "Elopement Risk Assessment" dated 03/2010, indicated the facility was to provide a safe environment for all the residents. Residents who are at risk for elopement will have an appropriate plan of care developed to address the risk.
Review of the facility's policy "Wander Monitoring System" dated 03/2010, indicated residents identified to be at risk for elopement will have a wander monitoring bracelet to reduce the risk for elopement.
Therefore, the facility failed to prevent an elopement (to leave a long term care facility without permission) and accident for Resident 1, when Resident 1 was assessed as high risk for elopement, and the facility did not intervene to reduce the risk of elopement.
This failure had a direct relationship to the health, safety, or security of residents. |
| 070000097 |
WILLOW GLEN CENTER |
070013116 |
B |
13-Apr-17 |
Z8O811 |
4147 |
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 follow their abuse policy when the alleged abuse of Resident 1 was not reported to the immediate supervisor and administrative designee and appropriate agencies in a timely manner. This failure had the potential for continued abuse and harm to residents.
Review of Resident 1's clinical record indicated she had diagnoses including dementia (decline in mental capacity affecting daily function). Resident 1's minimum data set (MDS, an assessment tool) dated 3/20/17 indicated her cognition was moderately impaired.
Review of Resident 1's progress notes, dated 3/21/17, indicated Resident 1 claimed a certified nursing assistant (CNA) hit her on her right hip yesterday during the PM shift.
During a telephone interview on 4/3/17 at 12:20 p.m., certified nursing assistant A (CNA A) stated on the evening shift of 3/20/17 she was assigned to Resident 1. CNA A indicated she cleaned up Resident 1 and put her back to bed. After answering a call light in another room, CNA A went back to answer a call light in Resident 1's room. CNA A indicated Resident 1 stated she was hit by CNA A and that she would report her. CNA A stated after Resident 1 indicated she was hit, she did not report the allegation to anyone.
During an interview on 4/4/17 at 11:15 a.m., the administrator (ADM) stated in the afternoon of 3/21/17, Resident 1's family member reported to him that Resident 1 stated someone hit her on the hip while she was in the bathroom. The ADM also stated if a resident told a CNA that he or she was hit, the CNA should report the abuse allegation to the supervisor, and report up until it got to the ADM.
During a telephone interview on 4/4/17 at 1:30 p.m., CNA A stated as a mandated reporter, she should report abuse. CNA A stated Resident 1 made an allegation of abuse and any allegation of abuse should be reported.
On 3/22/17 at 1:04 p.m., the California Department of Public Health (CDPH) received a faxed report containing form SOC 341, "Report of Suspected Dependent Adult/Elder Abuse." The report indicated on 3/21/17, Resident 1 told a family member that a PM shift CNA hit her on the hip during transfer to the toilet on 3/20/17.
Review of the facility's revised 2/6/13 policy, "Prevention of Abuse," indicated all health practitioners and all employees in a long-term healthcare facility are mandated reporters and all mandated reporters are required by law to report incidents of known or suspected abuse. The policy also indicated the staff member informed of an incident of alleged abuse will be responsible for informing his/her immediate supervisor and initiating an incident report and the report should be routed to the administrative designee. The policy further indicated a written report should be sent to the local law enforcement, CDPH, and local ombudsman within 24 hours.
Therefore, the facility failed to follow their abuse policy when an allegation of abuse was not reported to the immediate supervisor and administrative designee, and the appropriate agencies in a timely manner.
The above violation had direct or immediate relationship to the health, safety, or security of residents. |
| 070000088 |
WINDSOR SKYLINE CARE CENTER |
070013289 |
B |
14-Jun-17 |
ETMB11 |
5820 |
F314 -- 483.25(b)(1) TREATMENT/SVCS 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 one of 16 sampled residents (Resident 8) to prevent pressure ulcer (skin injury caused by unrelieved pressure that results in damage to the underlying tissues) on her left heel. Resident 8's left heel had no treatment and no pressure relieving device (used to reduce pressure points caused by the resident's body weight) for the left heel.These failures resulted in Resident 8's sustaining a left heel 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) and unable to determine (UTD, is a measurement of depth) the stage of the pressure sore.
Review of Resident 8's clinical record indicated she was admitted on XXXXXXX13 with the following diagnoses: dementia (memory problem), muscle weakness, hemiplegia (paralysis on one side of the body) and aphasia (loss of ability to understand or express speech). Her Minimum Data Set (MDS, an assessment tool) dated 5/2/17, indicated she was at risk for developing pressure ulcer, severely impaired in decision making, and required assistance for bed mobility, transfer, bathing, dressing, and hygiene.
Review of Resident 8's Admission Assessment, dated 1/25/13, indicated she had bruises on the left arm and the lower extremities. There was no evidence of pressure ulcer on the left heel.
Review of Resident 8's care plan for high risk pressure ulcer, dated 9/2/15, indicated she was at risk for pressure ulcer related to impaired mobility, incontinence, and the resident rubs her heels against the mattress. The intervention includes heel slope mattress to prevent pressure ulcer. There was no evidence of heel slope mattress was in placed.
Review of Resident 8's wound weekly monitoring assessment, dated 2/28/17, indicated she had DTI and a fluid blister (a small pocket of body fluid) on the left heel. The intervention included to float the left heel (positioned in such a way as to remove all contact between the heel and the bed) at all times.
Review of Resident 8's Braden scale (assessment tool to evaluate a resident's risk of developing a pressure ulcer), dated 4/30/17, indicated she had a score of 15 (a score of 15-16 represents a mild risk for developing pressure ulcer).
Review of Resident 8's Treatment Administration Record (TAR), dated 5/2017 indicated, the left heel treatment was discontinued on 5/19/17.
During an observation on 5/30/17 at 9:15 a.m., 5/31/17 at 10:10 a.m., and 5/31/17 at 1:40 p.m., Resident 8 was lying on her back, sock on her foot, and her left heel was not floated on her bed.
During an observation and interview with Licensed Vocational Nurse B (LVN B) on 5/31/17 at 1:50 p.m., she confirmed Resident 8 had a DTI and UTD on her left heel. LVN B stated Resident 8 had a scab (a dry, rough protective crust that forms over a wound during healing) on the left heel and she was not sure if the scab was completely healed. She stated the treatment for Resident 8's left heel should not have been discontinued on 5/19/17 but instead she should have informed the physician to continue the treatment on the left heel. She acknowledged Resident 8 left heel was rested on the bed and it should have been floated off the bed to prevent pressure ulcer.
During an interview with Certified Nursing Assistant C (CNA C) on 5/31/17 at 2:10 p.m., she acknowledged she was the assigned staff and providing care for Resident 8. She confirmed Resident 8's left heel was not floating on 5/30/17 and 5/31/17 during her shift.
During an interview with the Wound Physician (WP) on 6/1/17 at 2:20 p.m., she stated Resident 8 was a high risk for pressure ulcer and the resident left heel should have off load (heel of the bed) when she was lying in bed to prevent pressure ulcer. She also stated the licensed nurse should have assessed the heel and made a decision to continue the treatment.
During an interview and record review with the Director of Nursing (DON) on 6/2/17 at 7:50 a.m., she confirmed Resident 8's left heel DTI was developed in the facility on 7/21/15 and healed on 3/14/16. Resident 8's left heel started as a blister on 2/28/17, the blister opened, and continued with the treatment until 5/19/17. The DON acknowledged there was no interdisciplinary (team members from different department involved in a resident's care) notes regarding the left heel on 2/28/17. She also stated there was no heel slope mattress in placed and there was no treatment documentation after 5/19/17. She stated the licensed nurse should have assessed and monitored the left heel until completely healed. The DON also stated Resident 8's left heel should have been floating in bed to prevent pressure ulcer.
Review of the facility's policy 11/2012, "Pressure Ulcer Risk Assessment", indicated the at-risk resident needs to be identified and have interventions implemented promptly and to attempt to prevent pressure ulcers. Review the resident's care plan to assess for any special needs of the resident.
This failure had a direct relationship to the health, safety, or security of residents. |
| 070000093 |
Watsonville Nursing Center |
070013355 |
B |
19-Jul-17 |
189611 |
3384 |
F226, 483.12(b)(1)-(3), 483.95(c)(1)-(3) DEVELOP/IMPLEMENT ABUSE/NEGLECT, ETC POLICIES
483.12
(b) The facility must develop and implement written policies and procedures that:
(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property,
(2) Establish policies and procedures to investigate any such allegations, and
(3) Include training as required at paragraph ?483.95,
483.95
(c) Abuse, neglect, and exploitation. In addition to the freedom from abuse, neglect, and exploitation requirements in ? 483.12, facilities must also provide training to their staff that at a minimum educates staff on-
(c)(1) Activities that constitute abuse, neglect, exploitation, and misappropriation of resident property as set forth at ? 483.12.
(c)(2) Procedures for reporting incidents of abuse, neglect, exploitation, or the misappropriation of resident property
(c)(3) Dementia management and resident abuse prevention.
The facility failed to implement their abuse policy for Resident 1 when the alleged abuse incident was not reported to the department within 24 hours and the alleged abuser was not immediately removed from duty. This failure had the potential for continued abuse and harm to the resident by the suspected abuser.
Resident 1 was admitted to the facility on XXXXXXX14 with diagnoses including epilepsy (seizure disorder), cerebrovascular disease (damage to the brain from interruption of its blood supply) and depression (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life).
Review of Resident 1's minimum data set (MDS, a resident assessment tool) dated 4/20/17 indicated Resident 1 was cognitively intact and required extensive assistance with two-person physical assist during bed mobility.
During an interview with licensed vocational nurse A (LVN A), on 6/21/17 at 3:30 p.m., LVN A stated that during medication administration, Resident 1 verbalized that she was yelled upon and hit by certified nursing assistant B (CNA B). LVN A did not report the incident. LVN A stated she should have reported the incident but she went home soon.
Review of Resident 1's nursing progress notes dated 6/16/17 indicated there was no documentation that LVN A was told Resident 1 was yelled at and hit by CNA B.
During an interview with the director of staff development (DSD) on 6/21/17 at 3:45 p.m., the DSD stated LVN A should have reported the allegation of abuse within 24 hours. The DSD also stated that failure to report timely is considered neglect.
Review of the facility's form SOC 341 (form used to report an incident of suspected abuse or neglect), indicated the incident took place on 6/16/17, and the form was completed on 6/19/17.
The Department received the SOC 341 via fax on 6/19/17.
The facility policy and procedure titled "Reporting Abuse to State Agencies and Other Entities/Individuals", revised date 12/09, indicated "...2. Verbal/written notices to agencies will be made within twenty-four (24 hours) of the occurrence of such incident and such notice may be submitted via special carrier, fax, e-mail, or by telephone.
Notices will include, as appropriate..."
The above violation has a direct or immediate relationship to the health, safety, or security of the resident. |
| 220001063 |
Webster House |
070013428 |
B |
18-Aug-17 |
D2IK11 |
4584 |
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 follow their abuse policy when an injury of unknown origin for Resident 1 was not reported to the immediate supervisor, to the administrator, and to the appropriate agencies in a timely manner. This failure had the potential to affect the resident's safety and protection from harm.
Review of Resident 1's record was initiated on 8/9/17. Resident 1 had diagnoses of cerebral infarction (stroke) and muscle weakness.
Review of Resident 1's Minimum Data Set (MDS, an assessment tool) dated 5/30/17 indicated a Brief Interview for Mental Status (BIMS) score of 9 (scores of 9 to 12 indicate the person has moderate impairment of cognition and memory).
Review of Resident 1's "Non-Pressure Skin Condition Report", dated 8/8/17, indicated a three centimeter (cm., a unit of measure) by three cm. yellowish and purple skin discoloration was located on Resident 1's front right jawline close to the chin.
Review of Resident 1's nurses notes dated 8/7/17 indicated Resident 1 reported the yellowish discoloration on her right jaw to her physician on 8/7/17. The nurses' notes indicated Resident 1 reported another resident had caused the discoloration on her right jaw.
During an observation and interview of Resident 1 on 8/9/17 at 11:30 a.m., a yellow-green with purple center round bruise was located on the right jaw area close to the chin. Resident 1 stated a man who she did not recognize held her face with a cupped hand and caused the bruise located on her right jawline. Resident 1 stated the man did not grab her chin in violence but it was "like a joke". Resident 1 stated she did not have a good memory of the incident.
During an interview with Licensed Nurse A (LN A) on 8/9/17 at 11:55 a.m., she stated the physician reported Resident 1's bruise to her on 8/7/17 at around 2 p.m. LN A stated the police and administrator were notified immediately.
During an interview with Certified Nursing Assistant B (CNA B) on 8/9/17 at 12:15 p.m., she stated she noticed the bruise on Resident 1's right jaw area on the morning of 8/5/17 and did not, but should have, report this to her supervisor.
During an interview with CNA C on 8/10/17 at 2:25 p.m. he stated he first saw the bruise on Resident 1's right jaw area on 8/6/17 during the evening shift. CNA C stated he did not, but should have, report the bruise to his supervisor.
During an interview with the director of nursing (DON) on 8/10/17 at 3:25 p.m., she stated CNA B and CNA C should have reported the bruise to their supervisors immediately upon discovery of Resident 1's bruise.
On 8/8/17 at 3:46 p.m., the California Department of Public Health (CDPH) received a faxed report containing form SOC 341, "Report of Suspected Dependent Adult/Elder Abuse." The report indicated on 8/7/17 Resident 1 was observed to have a bruise on the right jaw line, discovered on 8/7/17.
Review of the facility's undated policy, "Elder Abuse Prevention", indicated incidents including injuries of unknown source must be reported no later than 24 hours to the administrator of the community and to other officials, including the State Survey Agency, in accordance with State law.
Therefore, the facility failed to follow their abuse policy when an injury of unknown origin for Resident 1 was not reported to the immediate supervisor, to the administrator, and to the appropriate agencies in a timely manner. This failure had the potential to affect the resident's safety and protection from harm.
The above violation had a direct relationship to the health, safety, or security of residents. |
| 090000042 |
Windsor Gardens Convalescent Center of San Diego |
090010170 |
B |
01-Oct-13 |
433K11 |
9043 |
F314 483.25(c) Pressure Sores Based on the comprehensive assessment of a resident, the facility must ensure that: (1) A resident who enters the facility without pressure sores does not develop pressure sores unless the individual's clinical condition demostrates that they were unavoidable; and (2) a resident having pressure sores receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing.The facility failed to ensure that Resident A who was admitted to the facility for short term rehabilitation did not develop pressure ulcers. Instead, three months later, it was documented that Resident A had developed 4 unstageable (full thickness tissue loss in which the actual depth of the wound bed cannot be determined) purplish discolored pressure ulcers. In addition, upon transfer to the general acute care hospital (GACH) two additional unstageable purplish discolored pressure ulcers were discovered upon admission.Measurements at the skilled nursing facility on 11/18/12: 1. The right great (big) toe unstageable purplish discoloration measured 1.0 centimeter (cm) x 1.0 cm. 2. The left great toe unstageable purplish discoloration measured 1.5 cm x 2.0 cm. 3. The right heel unstageable purplish discoloration measured 1.0 cm x 1.0 cm. 4. The left heel unstageable purplish discoloration measured 4.5 cm x 3.5 cm. There was no indication that Resident A had any discoloration on the right thigh or the coccyx area prior to being transferred to the general acute care hospital on 11/25/12. Measurements at the general acute care hospital (GACH) on 11/25/12: 1. The right great toe purplish discoloration measured 1.0 cm x 1.0 cm. 2. The left great toe purplish discoloration measured 2.0 cm x 1.5 cm. 3. The right heel purple discoloration measured 2.0 cm x 2.0 cm.4. The left heel purple discoloration measured 4.0 cm x 4.0 cm5. The right thigh purplish discoloration measured 14.0 cm x 0.5 cm. 6. The coccyx (tailbone)/sacrum (base of the spine) purplish discoloration measured 6.0 cm x 5.0 cm. Resident A was admitted to the facility on 8/24/12. She was admitted with diagnoses that included rehabilitation, cerebral vascular disease (stroke), abnormality of gait, and generalized muscle weakness, per the Admission Record.According to the Admission Skin Assessment completed on 8/24/12, Resident A had the following: a popped blister on the left inner thigh. There was a skin tear on the left lateral (side) knee. There were multiple purplish skin discolorations on the right forearm. The dorsal (back) area of the left hand was red. The left knee was swollen. She had an old surgery scar on her abdomen. And there were multiple dry scabs on her right ear. There was no documented evidence that Resident A had pressure ulcers upon admission.The Pressure Ulcer Risk Assessment form totaled an "8" which indicated that Resident A was at high risk for the development of skin breakdown. The pressure ulcer risk assessment form is completed for every resident. A resident who scores a 15-16 is considered low risk, 13-14 moderate risk and a score of 12 or less is considered a high risk for the development of pressure ulcers. The facility developed a care plan on 8/24/12 identifying that Resident A had the potential for skin breakdown and pressure ulcers due to fragile skin and decreased mobility yet there were no preventative measures identified on the care plan.The facility completed the Minimum Data Set (MDS) Assessment on 9/4/12. According to the MDS Patient A had no skin issues. A care plan was developed for the potential for skin breakdown and pressure ulcers due to fragile skin, decreased mobility and incontinence of urine. However, there were no interventions indicated for preventative measures such as monitoring the skin for changes. The documented approach plan addressed toileting, fluids, and the use of the call light. On 10/31/12 and 11/7/12, according to the facility's Shower Sheet, Resident A?s skin was clear, and was signed by both a CNA (certified nursing assistant) and the LN (licensed nurse). The facility was unable to produce the requested Shower Sheets for 11/11/12 thru 11/17/12. On 11/18/12 at 2:40 P.M., according to the licensed nurse?s progress notes Resident A was noted to have purplish discoloration on the left great toe, left heel, and right heel. There was also a reddened area on the right great toe.On 12/6/12 at 3:40 P.M., an interview with CNA 2 was conducted. CNA 2 stated Resident A?s skin was intact from 8/24/12 thru 10/19/12, prior to transfer to the front station. CNA 2 stated when Resident A was transferred back to the original station, there was a change in condition. Resident A's face was thin from weight loss, had complaints of pain with movement, and would not eat only drank juice, had difficulty in EZ stand (machine used to help in sit to stand position) use, and had treatment on both feet. CNA 2 stated it was the facility policy to check all resident?s skin for any changes during showers. If there are any changes, then it should be reported to a LN and documented on the shower sheets per, CNA 2. On 12/6/12 at 4:15 P.M., an interview with the director of nursing (DON) was conducted. The DON stated the CNA who discovered and reported the discoloration on 11/18/12, was no longer employed at the facility. The DON further stated there were three different CNA's who had provided care to Resident A prior to the discovery of wounds. The DON stated; however, the discoloration had not been reported. The DON stated it was the facility policy for both CNA?s and LN?s to complete a skin check and document the skin condition on the shower sheets on each shower day. If there are any concerns it should be documented then reported to a LN who cosigns the form. The DON stated in Resident A's case, this had not happened.On 12/7/12 at 12:10 P.M., an observation of Resident A at the GACH (general acute care hospital) was conducted. Resident A was in the bed on an air mattress with both eyes closed. Resident A had a nasal gastrostomy (tube inserted in the stomach thru the nose for consumption of oral intake) tube; there were heel protectors on both feet and an antibiotic and blood pressure medication being administered via intravenous (IV) pump. In addition, Resident A received hemodialysis (method to remove waste from the body) at bedside due to her medical condition.On 12/7/12 at 12:20 P.M., an interview and joint review of the admission notes at the GACH with licensed nurse (LN) 3, was conducted.LN 3 stated when Resident A was admitted to the GACH there were multiple decubitus ulcers. Resident A had wounds on her coccyx, right inner thigh, both heels, and both great toes. Resident A was placed on a dolphin bed (air mattress). On 11/25/12, according to the admission note Resident A had suspected deep tissue injury (SDTI- Purple or maroon localized area of discolored intact) to the coccyx/sacrum, left and right heel, and right inner thigh, left and right great toe. Resident A was referred to the wound team.According to the National Pressure Ulcer Advisory Panel, ?Suspected Deep Tissue Injury: Purple or maroon localized area of discolored intact skin (or blood-filled blister see below) due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer, or cooler as compared to adjacent tissue.? On 12/7/12 at 1:00 P.M., an interview and joint review of Resident A?s progress notes with LN 4 was conducted. LN 4, a wound nurse, stated since Resident A could move around in bed the wounds on both heels and coccyx/sacrum areas were avoidable.Residents in skilled nursing facilities have medical conditions that put them at increased risk for developing pressure ulcers such as fragile skin, lack of mobility, incontinence and inadequate nutrition.The facility failed to: 1. Implement measures to prevent skin impairment. 2. Monitor Resident A?s skin condition on each shower day according to the facility?s policy and procedure. 3. Adequately assess Resident A?s skin condition to identify wounds in the early stage in order to provide appropriate measures for wound healing. 4. Identify additional pressure ulcers prior to discharge to the general acute care hospital. As a consequence, the skilled nursing facility staff?s failure to implement measures to prevent skin impairment contributed to development of Resident A?s pressure ulcers. The lack of supervision of the CNA?s during shower days lead to missed identification of Resident A?s skin impairment in the early stages of development. The failure to adequately assess Resident A?s skin during completion of the weekly summary also contributed to the delayed identification of the skin impairments. Resident A developed six SDTI (Suspected Deep Tissue Injury) pressure ulcers which could have been very painful to this resident.A violation of this regulation had a direct or immediate relationship to the health, safety or security of patients. |
| 110000013 |
Windsor Vallejo Nursing & Rehabilitation Center |
110009395 |
B |
13-Jul-12 |
CI4T11 |
11819 |
72311 (a)(1(C) Nursing Service - General (a) Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (C) Reviewing, evaluating and updating of the patient care plan as necessary by the nursing staff and other professional personnel involved in the care of the patient at least quarterly, and more often if there is a change in the patient's condition.72311(a)(3)(E) Nursing Service - General (a) Nursing service shall include, but not be limited to, the following: (3) Notifying the attending physician promptly of: (E) Any untoward response or reaction by a patient to a medication or treatment. 72315(f)(1) Nursing Service - Patient Care (f) Each patient shall be given care to prevent formation and progression of decubiti, contractures and deformities. Such care shall include: (1) Changing position of bedfast and chairfast patients with preventive skin care in accordance with the needs of the patient. 72315 (f)(4) Nursing Service - Patient Care (f) Each patient shall be given care to prevent formation and progression of decubiti, contractures and deformities. Such care shall include: (4) Using pressure-reducing devices where indicated. 72315(f)(7) Nursing Service - Patient Care (f) Each patient shall be given care to prevent formation and progression of decubiti, contractures and deformities. Such care shall include: (7) Carrying out of physician's orders for treatment of decubitus ulcers. The facility shall notify the physician, when a decubitus ulcer first occurs, as well as when treatment is not effective, and shall document such notification as required in Section 72311(b). 72523(a) Patient Care Policies & Procedures (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. Based on observations, interviews and record reviews the facility failed to 1.) Review, evaluate and update Resident 1's care plans as necessary for Resident 1 catheter care. 2.) Administer services, on a prompt and timely basis, as prescribed by physician. 3.) Follow Facility Pressure Ulcer Prevention Measures policy for a bedfast resident with pressure preventive skin care requirements.This contributed to Resident 1 developing an ulcer and deformity at the tip of his penis.Findings:Resident 1 was an 87 year old male resident who was admitted on 6/04/2011 with Advanced Dementia, pressure ulcers, Parkinson's disease, and severe contractures of multiple joints. He had a condom catheter at the time of admission and no indication of penile skin problems. During a confidential phone interview with Relative 1 on 1/3/2012 at 10:45 a.m. it was indicated that the family was very concerned with Resident 1's care and the "neglect "of their father. The family stated they had observed Resident 1's penis being excoriated and dripping pus out the end with a hole at the tip of penis from the Foley catheter.... The family supplied photos that they said were taken of Resident 1 on 12/26/2011. The photos showed a penis ulcer with swelling and redness. Relative 2 stated that he had asked the CNAs about the foley catheter and the infected looking tip of the penis on every visit, but staff "shined me on" and said well, that's just how they always look. Photographs showed a black male penis with ulceration of the underside of the distal head of the penis. There was yellow/orange drainage visible on the absorbent bed protection pad.1.) The facility failed to review, evaluate and update Resident 1's care plans evidenced by: Documentation review of a Skin Integrity Care Plan Prevention document initially dated 6/4/2011 included a hand written problem of an Indwelling Foley catheter. This entry was undated, there was no indication of the staff responsible for care, reevaluation date or signature/initial of the staff who wrote the entry on the care plan.The Bladder Evaluation assessment form, dated 6/4/2011, indicated Resident 1's functional status was totally dependent, on bedrest, had contractures and a condom condom catheter upon admission. Notes dated 6/7/2011 revealed a Foley (indwelling catheter) was inserted for wound healing. The remainder of the evaluation document was not completed. There was no assessment of the perineal skin status as called for under item 10.On 7/10/2011 a Short Term plan was developed for a problem of "Device related ulcer to tip of penis [secondary to] chronic indwelling catheter". Interventions were to monitor v/s (vital signs Temperature Pulse Respiration Blood Pressure and Pain) every shift and treatment as ordered and to notify the physician of any further complications. There was a reevaluation due date of 7/26/2012. There were no specific measurable interventions to prevent further erosion.A Resident Care Conference Review document dated, 10/7/2011, included notes regarding Foley catheter and recommendations for Fole Catheter care every shift and as needed, Moisture barrier to affected area every incontinent episode and as needed and site care; cleanse with normal saline every day and as needed. However there was no evidence these recommendations were brought forward to the care plan.Record review on 1/3/2012 revealed that the bladder incontinence evaluation assessment indicated a new Foley catheter was inserted on 8/4/2011, to refer to skin flow sheet dated 8/4/2011. The Skin flow sheet and documentation of a new Foley catheter being inserted on this date was not found during record review. All documents regarding the foley catheter were requested from facility medical records staff. No skin sheet relative to the catheter or penis was provided. Except for one entry on 7/10/11, the nurse's notes throughout the record indicated a Foley catheter was "in place and draining yellow urine", however there was no documentation of any assessment of the meatus or the condition of the foreskin. On 7/10/11 the physician ordered treatment with xeroform for 14 days and then reevaluate. The treatment record for July 2011 showed staff followed the physician orders for nine days. IDT notes from 7/13/2011, 7/22/11 and 7/26/2012 show no reevaluation of the device induced injury to the penis.The Nurses notes from 8/10/2011 to 12/27/2011 showed no documentation of the Foley catheter ever being changed. Acute Care discharge planner notes dated 12/28/11 state..."has a ..../chronic Foley cath (pt was examined by Urologist - pt has mild penile erosion from foley not being changed regularly)... Documentation dated 6/8/2011, 8/10/2011, 9/16/2011 and 12/12/2011 indicated the presence of a catheter, but did not include any specific quantifiable, measurable objectives for catheter/tubing bag care or assessment of the meatus (tip of penis) or foreskin.The Catheter Care, Urinary policy, dated July 2008, stated frequency of catheter changes would be per physician's order. The policy did not give any guidance for ongoing assessment of the patient with the device after insertion.2.) The facility failed to administer services, on a prompt and timely basis, as prescribed by the physician as evidenced by:During an interview with Licensed Staff 3 at 12:20pm on 5/10/2012 Staff 3 indicated that the CNA's check the resident's catheter, and then reports any problems to the charge nurse. Licensed Staff 3 stated that if she had a chance she looked at the catheter site and assessed how it looked......"Resident 1 had a split on his penis; the foreskin was split on the bottom".The doctors' notes written by Physician Staff F dated on 9/16/2011 indicated that if patient had a Foley indwelling catheter, it was to be irrigated as needed for occlusion per Skilled Nursing Facility (SNF) protocol and changed every 30 days and as needed per written physician orders and facility protocol of Catheter Care, Urinary. Record review indicated physician orders on 6/7/2012 and 8/10/2012 to change the catheter as needed for blockage or displacement and catheter care every shift and prn. Physician orders dated 9/16/2011 stated "...change catheter every 30 days and as needed..." Physician Staff E wrote orders on 12/21/2011 for Urinary/bladder care.....indwelling catheter irrigate as needed for occlusion per facility protocol. Change the catheter every 30 days and as needed. There was no evidence in the record that the facility changed the catheter.Hospital documentation during acute care stay from 12/27/2011 to 1/11/2012 revealed a consult by Physician Staff D who visited Resident 1 on 12/27/2011 to evaluate the Foley catheter complications. Physician Staff D documented "Foley catheter had not been changed in a long time". Evaluation of penile edema. erythema and penile ulcer has revealed "Uncircumcised, foreskin retracted with edema, slight paraphimosis (an uncommon condition in which the foreskin, once pulled back behind the glans penis, cannot be brought down to its original position, can lead to necrosis and partial amputation of the distal penis), thus causing an emergent state. Foley intact, meatus with minor ulceration from erosion and compression. 3.) The facility has failed to follow Pressure Ulcer Prevention Measurements policy as evidenced by:A record review occurred on 1/03/2012 including admission assessments and care plans dated 6/4/2011. .... The Pressure Ulcer Risk Evaluation dated 6/20/2011 revealed a high score of 15 (any score above 8 is consider high risk) for pressure ulcers.The Admission Skin Assessment dated 6/4/2011 revealed condom catheter to gravity clear yellow urine. The Wound/Skin Healing Record dated 6/4/2011 indicated wounds at the Sacrum and the left heel. There were no indications of any sores on the penis on the date 6/4/2012 of admission.The short term goals dated 9/25/11, nurse's notes dated 9/28/2011 and 10/02/2011 documented a "Blister like hard tissue with swelling on top of penis and redness as well". A Care plan reevaluation on 9/28/2011 goal was "blister will resolve without complications". No documentation of penis ulcer on 10/05/11 noted on Infection control IDT progress notes or record of penis ulcer on 10/7/2011 on Resident 1 Care Conference review. Facility Pressure Ulcer Measures policy required staff to use supportive surfaces, development of individualized programs for skin care, demonstration of positioning to decrease risk of tissue breakdown, and accurate documentation of pertinent data.The physician was not notified on 9/28/2011 of an ulcer at tip of penis and no order for wound care was obtained. During an interview on 5/10/2012 at 12:05 p.m. with Unlicensed Staff 7 when asked if the facility had a turning and positioning program? He said, "No we don't have that here". when asked how often do you turn Resident 1; He stated ....We try to turn the Resident every hour and change the position of the catheter if we have time, it doesn't always get done.At 2:30 p.m. Unlicensed Staff 4 was interviewed concerning Resident 1 about Foley catheter care and turning and positioning the resident. It was stated that we try to get help to position, but sometimes we have to do it alone. Did you see a sore on Resident 1's penis during his care? Yes, I told the charge nurse about that, he can't move or change positions by himself. At 2:40 p.m. during an interview with Licensed Staff 2 who was asked, do you have a turning policy.....No. At 3:00 p.m. with Unlicensed Staff 5 and 6 it was revealed that Administrator B tells them on a daily basis what to look for with the foley catheter residents. When asked. had they had been taught about a turning and positioning program....... Staff 5 and 6 stated "Everyone just kind of does their own thing".Therefore, the above violations had direct relationship to the failure of the health, safety and security of Resident 1. |
| 110000013 |
Windsor Vallejo Nursing & Rehabilitation Center |
110009677 |
B |
19-Dec-12 |
69W011 |
3915 |
1418.21(a)(1)(B) Health & Safety Code 1418 (a) A skilled nursing facility that has been certified for purposes of Medicare or Medicaid shall post the overall facility rating information determined by the federal Centers for Medicare and Medicaid Services (CMS) in accordance with the following requirements: (1) The information shall be posted in at least the following locations, in the facility: (B) An area used for employee breaks. 1418.21(a)(1)(C) Health & Safety Code 1418 (a) A skilled nursing facility that has been certified for purposes of Medicare or Medicaid shall post the overall facility rating information determined by the federal Centers for Medicare and Medicaid Services (CMS) in accordance with the following requirements: (1) The information shall be posted in at least the following locations, in the facility: (C) An area used by residents for communal functions, such as dining, resident council meetings, or activities. 1418.21(a)(2)(C) Health & Safety Code 1418 (a) A skilled nursing facility that has been certified for purposes of Medicare or Medicaid shall post the overall facility rating information determined by the federal Centers for Medicare and Medicaid Services (CMS) in accordance with the following requirements: (2) The information shall be posted on white or light-colored paper that includes all of the following, in the following order: (C) The most recent overall star rating given by CMS to that facility, except that a facility shall have seven business days from the date when it receives a different rating from the CMS to include the updated rating in the posting. The star rating shall be aligned in the center of the page. The star rating shall be expressed as the number that reflects the number of stars given to the facility by the CMS. The number shall be in a clear and easily readable font of at least two inches print. 1418.21(b) (b) Violation of this section shall constitute a class B violation, as defined in subdivision (e) of Section 1424 and, notwithstanding Section 1290, shall not constitute a crime. Fines from a violation of this section shall be deposited into the State Health Facilities Citation Penalties Account, created pursuant to Section 1417.2. Based on observation and interview, the Five Star Rating was not posted in all the required areas and the posting did not have the required numeral. This resulted in the information not being easily available to staff, residents/legal representatives, and the public. Findings: During an observation on 11/26/12 at 7:30 a.m., there were two postings of the Five Star Rating in the lobby area. One posting was on the wall next to the administrator's office. The other posting was next to the survey binder on a table in the lobby at the entrance to the building. Neither posting had the required numeral. During an observation on 11/26/12 at 11:55 a.m., there was no Five Star Rating posted in the Kelly Room which is the assisted dining room. During an observation on 11/26/12 at 1:15 p.m., there was no Five Star Rating posted in the Employee Break Room. During an observation on 11/27/12 at 9:05 a.m., there was no Five Star Rating posted in The Rose dining room which is the social dining room and activity room. During an observation on 11/27/12 at 9:15 a.m., there was a Five Star Rating posted in the Admissions Office. The posting did not have the required numeral. During an interview on 11/29/12 at 11:30 a.m., when Administrative Staff A was asked if there was a Five Star Rating posted in the dining rooms or the employee break room, Administrative Staff A stated "I think they are not there." When Administrative Staff A was shown the Five Star Rating posting that was located in the Admissions Office, next to the administrators' office, and next to the survey binder on the table in the front lobby, Administrative Staff A acknowledged that there was no numeral on the posting. |
| 110000013 |
Windsor Vallejo Nursing & Rehabilitation Center |
110010849 |
A |
06-Aug-14 |
2DKG11 |
13051 |
F323 ?483.25(h) Free of Accident Hazards/Supervision /Devices The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. The facility failed to implement its smoking policies and allowed a non-ambulatory resident with a mental disorder and limited judgment to possess cigarettes and lighters and to frequently smoke in bed unsupervised by staff for more than one year. These circumstances represented a fire hazard and endangered all 151 residents in the facility. On 7/2/14 at 3:46 p.m., a Department Representative met with the facility Administrator, the Director of Nurses, and the Assistant Director of Nurses and declared Immediate Jeopardy. At 4:10 p.m., the facility Administrator presented an acceptable written plan of correction. After observations revealed implementation of the plan of correction, the Department representative met with the Administrator and abated the Immediate Jeopardy on 7/2/14 at 4:13 p.m. Findings include: Observations on 7/02/14 at 11 a.m. revealed a sign at the entrance of the facility indicated, "THIS IS A TOBACCO-FREE & SMOKE FREE FACILITY." On 6/17/14 at 11:30 a.m., the initial review of Resident 1's clinical record reflected a care plan dated 6/27/13 indicated, "... SNF (skilled nursing facility) placement at young age, w/c (wheelchair) bound with contractures, evidence of confabulation ... presents with Borderline Personality traits, low intellectual functioning, and history suggests limited judgment and minimal insight into present situation and future." Plans dated 5/29/13 reflected a psychology assessment on that date indicated Resident 1, "... is not capable of making decisions for her healthcare at this time. Judgment is so impaired that she poses a safety and professional risk to the staff, as well as to herself." Observations on 6/17/14 at 12:50 p.m. revealed Resident 1 was in bed. Both lower extremities were severely contractured. The room was cluttered with clothing, pillows, linens, and personal items stacked on all furniture surfaces. There was a strong odor of tobacco in the room. During concurrent interview, Resident 1 said, "Yes I do smoke." Resident 1 stated the tobacco smell was from cigarette butts she kept in her purse. Observations revealed Resident 1 displayed a cigarette with the end broken off. When asked how she would light the cigarette butt, Resident 1 reached into her purse and obtained a lighter which she then ignited to display the flame. Review of medication administration records indicated Resident 1 received regular daily dosages of pain medications including Oxycodone, Methadone, Neurontin and Norco. Potential adverse drug interactions of these central nervous system depressants include increased sedation and drowsiness. (http://reference.medscape.com/drug-interactionchecker). A review of a care plan dated 3/5/13 indicated, "(Resident 1) at risk for incidents R/T (related to) narcotic use ... (resident) is non complian (sic) (compliant) with POC (plans of care) ie: if it is raining she stillwants (sic) to smoke depite includes (sic) to wait ...". Plans dated 6/27/13 indicated, "... Non-compliant with smoking policy and procedures ... Has habit of keeping trash (empty cigarette boxes & used cigarette [sic]". Plans dated 6/28/13 indicated, "Risk for smoking ... injury secondary to smoking in her room and bed. Resident has smoked in her room and putting it out in brief or flashing (flushing) (sic) it in the bathroom. (Resident 1) denies this but staff has been smelling smoke inside her room multiple times ... Evidence was presented (briefs with cigarette butts) ... Smoking P&P non-compliant, refuses to turn in cigarette and lighter. Wheels her self out to smoke after hours ...". Plans dated 11/20/13 documented a pattern of increase in behaviors when (Resident 1) doesn't have cigarette supplies On 6/19/14, a review of a facility document entitled, "Smoking Policy" dated 5/28/13 indicated, [Smoking is allowed only in the designated area and only during scheduled times ... Residents are not permitted to keep smoking materials, lighters, matches or any other related items in their possession ... Residents requesting to smoke will be required to wear a "smoking apron" designated to retard combustion ...]. On 6/20/14, a review of physician's orders reflected an order dated 5/5/13 indicated, "Pt is safety risk for herself, staff and other residents ...". An order dated 3/15/14, "Explain to pt. the danger of smoking in bed including her burning in bed ...". Orders dated 3/15/14 indicated, "Continue to monitor smoking in the room. Monitor for cigarette smell coming from room every shift."On 7/2/14 at 1 p.m., during a second review of the clinical record, progress notes dated 1/9/14 documented, "She continues to be reported smoking in her room and this (writer) saw a lot of ashes on her bed ... her room smells like a cigarete." Notes of 2/16/14, 2/20/14, 2/26/14, 3/1/14, 3/7/14, 3/14/14, 3/15/14, 3/18/14, 3/19/14, 3/20/14, 3/21/14, 3/22/14, 3/23/14, 3/26/14, 3/31/14, 4/1/14, 4/3/14, 4/5/14, 4/12/14, 4/15/14, 4/19/14, 4/20/14, 4/22/14, 4/24/14, and 4/28/14 documented the smell of cigarette smoke coming from Resident 1's room. A review of progress notes of 3/12/14 indicated Resident 1 admitted to smoking in bed and stated, "I only took 2 hits that's all and I stop." Notes of 3/13/14 documented staff explained to Resident 1, "... that she is at highest risk to burn in her bed if she does not stop smoking in the bed." Notes of 3/15/14 at 11:56 p.m. indicated Resident 1 also had incense burning in her room. Notes of 3/19/14 indicated staff saw smoke in her room. Notes of 3/20/14 indicated, "... (Resident) is smoking in room, concerned (with) fire danger to self and facility." Notes of 3/21/14 indicated, ".. usual habit of smoking in her room ... refusing to let staff check all her bags where she keeps a lot of her belongings ...". Notes of 3/31/14 indicated, "Smelled smoke coming from her room ... re emphasized the danger of smoking inside the room, like putting herself on fire considering that she has bedsheets, linens all over her and her room full of clothes and not to mention fire which would jeopardize people (sic) life." Notes of 4/5/14 indicated, "Smell of cigarette smoke coming from room and ashes are on the blankets." and "Resident was found with smoke coming out of mouth/nose .. her cna (certified nursing assistant) saw her smoking in the (room) this afternoon with a lighted cigarette in her mouth and the cna was having difficulty breathing when she enter (room)." Notes of 4/11/14 indicated, "... reported numerous time and caught smoking in her room this week ... wouldn't give up her lighter ... This is putting the whole building at risk for possible fire and specially with her, of burning herself by secretly trying to smoke on her bed ...". Notes of 5/4/14 documented, "Discussed ... the dangers of smoking inside the room for her and other residents ...".Notes of 5/9/14 documented ashes in the bed. Notes of 5/20/14 indicated, "... continues to be reported as smoking in the room but very good at hiding it ... was ... bragging about how she can do anything she wants in that room."Review of a progress note of 5/31/14 at 4:28 p.m. indicated, "... smelled a very strong smell of smoke and noticed (Resident 1) was playing with a towel as if she was putting out the fire ... there was a small burnt mark on the towel with ashes everywhere ... when searching her room we were not able to find (her lighter)." Notes of 6/2/14 indicated, "... she has been continually been secretly smoking inside her room and she has been wrapping it inside a wet towel so she won't be caught by nursing staff every time they come to check her ... how big risk it is that she is putting the facility and the rest of the patients in this building because of her non-compliance." Notes of 6/19/14 indicated, "... on-going cigarette problem ... and risk of fire with all her clothes just laying beside her and not willing to lock it up nor hang it in the proper place ..." and, "... resident smoking in the front. I asked her to please smoke in the smoking patio and reminded her not to smoke in her room due to the hazard of possibly starting a fire in her room. I also asked her if she had a lighter and she stated that she did not have one and that she uses other residents." A review of care plan revisions dated 1/9/14 indicated, "... Now she is refusing to submit her cigarettes again once she gets her new supplies. Continues reported strong smell of cigarettes in her room and (staff member) seeing lots of ashes on her bed but adamantly denies it still ...". Written interventions included, "... Install 2 smoking alarms in her room; continues monitoring and if staff sees smoke or smells smoke in her room to immediately get inside the room and correct patients behavior." Revisions dated 3/14/14 indicated, "refused more and more to get out of bed and despite all education continues to smoke in the bed ..." Revisions dated 3/15/14 indicated, "... resident admitted she smokes in bed ... Two requests made to niece not to hand resident cigarettes and lighters and explained risk of pt catching fire". A review of the medication administration record for the month of May 2014 indicated Resident 1 was smoking in her room on at least 75 occasions. There were 19 occasions during day shift, 44 occasions during evening shift, and 12 occasions during night shift.The records for June of 2014 indicated Resident 1 had been smoking in her room on 15 occasions between 6/1/14 and 6/16/14. During interview on 6/16/14 at 2 p.m., the facility administrator stated, "She (Resident 1) will smoke in her room. You smell it. She refuses to wear a smoking apron." During interview on 6/16/14 at 2:25 p.m., when inquiry was made as to smoking in bed, Resident 1 stated, "you see how long it takes them to get me up. If they don't do it (get me up), I'm gonna do it (smoke in bed)." During interview on 7/2/14 at 11:10 a.m., the facility administrator stated there was no evidence Resident 1 continued to smoke in her room after the Department visit on 6/17/14. However, review of the medication administration records for June of 2014 indicated staff smelled smoke coming from Resident 1's room on three occasions on 6/29/14. A review of care plans reflected no further care interventions had been designed. Observations on 7/2/14 at 11:20 a.m. revealed Resident 1 was reclined in her wheelchair and smoking a lighted cigarette in the parking area in front of the building. Resident 1 was holding a lighter. Resident 1 was not wearing a smoking apron. A sign posted in the area indicated, "SMOKING PROHIBITED IN THIS AREA."About a minute later, a direct care staff member arrived with a smoking apron and moved Resident 1's wheelchair to another area of the parking lot.During concurrent interview, Resident 1 stated she keeps her own cigarettes in her bag.Resident 1 stated she usually smokes outside unsupervised.During interview on 7/2/14 at 12 noon, the Administrator stated Resident 1 still keeps her own cigarettes. The Administrator stated staff cannot search Resident 1's bags for cigarettes and lighters. Observations on the smoking patio on 7/2/14 at 3:05 p.m. revealed random residents holding personal bags containing packs of cigarettes and lighters.When Resident 1 needed to light her cigarette, she borrowed a lighter from another resident.During interview, a random resident stated he got the cigarette he was holding from, "a friend" and he thought the smoking rules were, "stupid." During an interview on 7/2/14 at 3:10 p.m., Licensed Staff Member A stated she smelled cigarette smoke coming from Resident 1's room the evening before at about 11 p.m.On 7/2/14 at 3:46 p.m., a Department Representative met with the facility Administrator, the Director of Nurses, and the Assistant Director of Nurses and declared Immediate Jeopardy. At 4:10 p.m., the facility Administrator presented an acceptable written plan of correction. After observations revealed implementation of the plan of correction, the Department representative met with the Administrator and the Immediate Jeopardy was abated on 7/2/14 at 4:13 p.m.Therefore, the facility failed to ensure the environment remained free of accident hazards when staff did not implement the established smoking policies designed to protect the health and safety of all residents. For over one year, staff reported the smell of tobacco smoke, observed ashes on the linens, and reported ignition of a towel yet Resident 1 continued to possess smoking materials and to frequently smoke in bed in her room at all hours without supervision. This practice endangered Resident 1 and all 151 residents in the facility. These facility failures presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result. |
| 010000005 |
Windsor Care Center of Petaluma |
110011896 |
B |
23-Mar-16 |
CL8711 |
14272 |
T22 DIV5 CH3 ART5-72527(a)(10) Patients' Rights (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (10) To be free from mental and physical abuse. The facility violated the above regulation when it failed to ensure residents' rights to be free from mental and physical abuse. When Resident 1 exhibited increased confusion and escalating behaviors of aggression toward others. Resident 1 verbally threatened, physically threatened, physically assaulted, and psychologically upset Residents 2, 3, 4, 5, 6, and one unidentified resident causing fear and anxiety among the resident population over a period of four months as follows: Observations on 10/6/14 at 11 a.m. revealed Resident 1 ambulating in the hallway and dining room with and without a walker. During an attempted interview, on 10/6/14 at 3 p.m., Resident 1 did not respond to inquiries with complete sentences or relevant words. A Minimum Data Set (MDS) assessment dated 7/28/14 indicated Resident 1 was 6 feet tall and weighed 164 pounds. Resident 1 was admitted on 4/21/14 with diagnoses including Dementia and severe memory problems. The assessment indicated Resident 1 had behavior problems including verbal symptoms directed at others and wandering. Resident 1's care plan interventions, dated 5/12/14, documented identification of the problem of confusion and anger manifesting as threatening behavior toward staff and other residents. Interdisciplinary Team (IDT) Progress notes dated 6/9/14 indicated Resident 1 got very distracted while walking and was just wandering around. Notes dated 6/13/14 indicated Resident 1 was holding his cane in a position to strike another resident. When redirected by staff, Resident 1 stated, "I let my cane do the talking."Resident 1's nursing care plans indicated identification of the problem of using the cane in inappropriate ways such as using the hook to grab another, poking people with the cane and raising the cane in a striking position. Interventions dated 6/13/14 indicated, "Resident 1 will no longer possess a cane ..." Interventions did not include an increase in supervision for Resident 1.IDT notes, dated 7/2/14, indicated Resident 1 ambulated using a walker and was exhibiting sun-downing behavior (Confusion and agitation worsen in the late afternoon and evening, or as the sun goes down.) An IDT note, dated 7/10/14, indicated an episode of extreme agitation and verbal abuse. An IDT note, dated 7/16/14, documented an episode of verbal and physical aggression toward another. Resident 1's nursing care plan indicated identification, on 8/5/14, of the problem of impaired behavior possibly due to a diagnosis of depression manifested by angry outbursts towards others. Interventions included medication and documentation of behaviors.Interventions did not include an increase in supervision.Resident 1's nursing care plan documented identification, on 8/29/14, of the problem of going into other residents rooms and starting to undress. A problem, identified on 9/4/14, indicated Resident 1 was intruding on the privacy of other residents by entering their rooms, starting to undress, and becoming agitated to the point that he scared the other residents. Interventions for the identified problems did not include an increase in supervision. RESIDENT 2: Resident 2's nursing care plan, dated 10/6/14, documented diagnoses including Epilepsy, Depressive Disorder, and Anxiety Disorder.Resident 1's record reflected IDT notes, dated 9/11/15 and 9/12/15, that documented an altercation between Residents 1 and 2 who shared a room at the time.Notes indicated a certified staff observed Resident 1 taking clothes out of Resident 2's closet. Resident 2 had his hands on Resident 1's arm and caused a skin tear to Resident 1. Resident 2's IDT notes, dated 9/11/14, documented the altercation and indicated Resident 2 became agitated after the incident and left the facility AMA (Against Medical Advice).During an interview, on 10/6/14 at 4:30 p.m., with the assistance of a Spanish speaking certified staff member as interpreter, Resident 2 stated he was living in the same room with Resident 1 during September 2014. Resident 2 stated Resident 1 was not very nice to him. Resident 2 stated Resident 1 went to his closet and took his clothes. When Resident 2 tried to take his clothing back, Resident 1 raised both fists and tried to hit him. Resident 2 stated he was scared when Resident 1 made fists and he remained scared of Resident 1. Resident 1's record reflected IDT notes dated 9/12/15 indicated Resident 1 became physically aggressive towards another and was extremely agitated and hard to redirect. Staff obtained an order from the physician for a sedative. IDT notes dated 9/17/15, indicated a verbal altercation with another resident in the lobby. Resident 1 stated, "I'll get you" and lifted his walker. Notes indicated the care plan was updated to include monitoring Resident 1 for aggression for two weeks.Interventions did not include increased supervision of Resident 1. RESIDENTS 3 & 4: Observation on 10/6/14 at 3 p.m. revealed Residents 3 and 4 were sisters who lived together in a room at the facility. An MDS assessment, dated 8/1/14, indicated Resident 3 was 94-years-old and had diagnoses including Depression, Acute Myocardial Infarction (heart attack), and Heart Failure.An MDS assessment, dated 8/2/14, indicated Resident 4 was 98-years-old and had diagnoses including Depression, Atrial Fibrillation (irregular heart beat), and Cardiomyopathy (heart muscle problems). Progress notes, dated 10/1/14, for both Residents 3 and 4 reflected entries by a Social Services Director indicating, "Resident filed a complaint regarding being afraid of (Resident 1) because he wanders, gets lost and enters her room. Resident who wanders care plan was updated for improved redirection and room orientation ..." Resident 1's care plan interventions dated 10/1/14 documented identification of the problem of his condition getting more acute as seen by confusion, physical aggression such as raising his walker, slamming down on tables and counters, pointing at people saying, "I'll get him." Interventions included redirection, offering reading materials and activity boards, and inviting Resident 1 for a stroll three times a week. There were no plans for increased supervision.IDT notes of 10/2/14 indicated, "the resident is getting more aggressive in the last month he is having a hard time coping with everything during the day." Resident 3's progress notes dated 10/2/14 indicated, "(Resident 1) enter room ... throwing water on one resident and pushing the other down the hallway."A facility form titled, "Potential Resident Abuse Report Form" dated 10/2/14 included an attached note authored by a staff member, dated 10/2/14. The note indicated, "I ... heard a scream. I went into room ... and (Resident 1) ... was in the room insulting (Resident 3) and the patient told me (Resident 1) threw a cup of water at her. I tried to get him out of the room, but he got aggressive. I had to call a co-worker to help me get him out."Resident 4's progress notes dated 10/2/14 indicated, "Resident was in her room when another (Resident 1) went into her room scaring her and pushing her down the hallway ..."A, "Potential Resident Abuse Report Form," dated 10/2/14, indicated Resident 1 took the handgrips of Resident 4's wheelchair, pulled her out of the room and pushed her down the hallway. The report indicated Resident 4 was scared that Resident 1 came into their room.During an interview, on 10/6/14 at 3:15 p.m., Resident 3 stated there had been a problem with Resident 1 since his admission. Resident 3 stated, "We had a terrible problem with that man." Resident 3 stated, practically every day, Resident 1 would enter their room after lunch or dinner. They would both tell him it was not his room and eventually he would leave. Resident 3 stated Resident 1 had been carrying a cane but lately he was using a walker. Resident 3 stated they would ring the bell for staff, but they, "...couldn't sit around and wait ..." for staff. Resident 3 said, "I would be looking for something heavy to hit him with. He usually had a big cane." Resident 3 stated Resident 1 came farther into the room on 10/2/14. When Resident 3 asked him to leave, Resident 1 picked up a water glass and threw cold water on her. Resident 3 stated if felt, "horrible." Resident 3 stated, "It frightened the life out of me. Just by being around him you are helpless." Resident 3 stated, "I have never had an experience like that in my whole life. It was frightening."During the interview on 10/6/14 at 3:15 p.m., Resident 4 stated she saw Resident 1 throw water on her sister. Resident 4 stated, "Lucky it wasn't hot. Rather chill than burn." Resident 4 said Resident 1 grabbed her by the shoulder after throwing water on Resident 3. During the interview on 10/6/14, Residents 3 and 4 stated that Resident 1 came back into their room about three days ago. Resident 1's care plan interventions dated 10/2/14 documented identification of the altercation with Residents 3 and 4. Interventions included redirection from the hallway where Residents 3 and 4 lived and monitoring for 72 hours for behaviors of moving others and throwing water on others. Interventions did not include increased supervision. Resident 3's progress notes of 10/5/14 indicated, "(Resident 1) was caught going down (the) hallway (where Residents 3 and 5 lived). Resident 3's progress notes dated 10/6/14 indicated, "... I don't like that man." RESIDENTS 5 & 6: An MDS, dated 8/10/14, indicated Resident 5 was 65 years old and had diagnoses including Paraplegia, Anxiety Disorder, lung problems, and heart problems.During an interview, on 10/6/14 at 3:30 p.m., Resident 5 stated he was yelling for the nurse on 10/4/14, when a strange man (later identified as Resident 1) pulled his curtain back, moved his bedside table out of the way, grabbed his left wrist, and proceeded to punch him in the right cheek once and on the forehead twice. When Resident 5 screamed for help, the man said, "Shut Up" then grabbed him by the throat and began to choke him. Resident 5 stated a resident from across the hall arrived (later identified as Resident 6) and tried to assist but could not get the hand off his throat. Resident 5 stated the three of them struggled until a nurse arrived to help. Resident 5 stated he was 95% disabled and nervous because Resident 1 was still around. Resident 5 stated he was having trouble sleeping because he was frightened every time he heard a noise. Resident 6's MDS assessment dated 7/17/14 indicated diagnoses included Coronary Artery Disease, Heart Failure, Anxiety Disorder, and Respiratory Failure. During an interview, on 10/6/14 at 4 p.m., Resident 6 stated Resident 1 was a, "Big tall guy across the hall." Resident 6 stated Resident 1, "... tried to pick a fight with me." Resident 6 stated he was with Resident 1 the day Resident 5, "... started hollering louder and louder, getting on (Resident 1's) nerves." Resident 6 stated, "all of a sudden (Resident 1) took off." Resident 6 stated he heard Resident 5 begin screaming louder. Resident 6 stated he went into the room and saw Resident 1 doing something to Resident 5. Resident 6 stated he grabbed Resident 1 and Resident 1 let go of Resident 5. During an interview, on 10/6/14 at 11 a.m., Staff A stated she was in charge during the incident, on 10/4/14, when Resident 1 grabbed Resident 5. Staff A stated she heard loud screaming and found Resident 1 standing at Resident 5's bedside holding Resident 5's knees. Staff A stated she separated the two and spoke to Resident 5 who told her Resident 1 had grabbed him by the throat and swung at him. Staff A stated Resident 5 reported he was not hurt, but was scared. During the interview, Staff A stated Resident 1 was on general supervision. Staff A stated the facility policy was to check on each resident every two hours. Resident 1's nursing care plan interventions, dated 10/4/15, identified the problem of entering other resident's rooms and becoming physically aggressive. Interventions included identification of behaviors that require reevaluation and monitoring behaviors. Interventions did not include increased supervision. During an interview on 10/6/14 at 3 p.m. the Administrator stated his plans to increase supervision of Resident 1 during the dinner hour starting at 5 p.m. that day. Observations, on 10/6/14 at 4:35 p.m., revealed Resident 1 wandering the hall using a wheeled bedside table for support instead of a walker. Resident 1 pushed the bedside table past a nurse who was passing mediations. Observations revealed a certified staff walked past Resident 1. Observations revealed Resident 7 retrieved Resident 1's walker from her room and exchanged it for the bedside table which belonged to her.During concurrent interview, Resident 7 stated it was the first time Resident 1 had entered her room. During an interview on 10/6/14 at 4:45 p.m., the Administrator stated his intention to place Resident 1 on one-to-one supervision continuously starting immediately. Observations at 5 p.m. revealed Resident 1 was receiving continuous supervision by a dedicated certified staff member.Therefore, the facility failed to ensure the residents' rights to be free from mental and physical abuse when Resident 1 wandered the facility, exhibiting verbal threats, physical threats, and physical aggression of increasing frequency and intensity, upon vulnerable residents over a period of at least four months. This resulted in mental and physical abuse of multiple medically fragile residents, including Residents 2, 3, 4, 5, 6, and at least one other unidentified resident who was threatened with an upraised cane. The above violation caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety, or other emotional trauma to patients.. |
| 110000013 |
Windsor Vallejo Nursing & Rehabilitation Center |
110012000 |
B |
24-May-16 |
JU1411 |
10846 |
F333 ?483.25(m)(2) Residents Free of Significant Med Errors The facility must ensure that residents are free of any significant medication errors. The facility must ensure that residents are free of any significant medication errors. The facility violated the regulation by failing to ensure Resident 1 was free from significant medication error when licensed staff administered 10 wrong medications to Resident 1. This failure caused Resident 1 to experience bradycardia (slow heartbeat with a pulse rate below 60 beats per minute), weakness, and shortness of breath (SOB) that required admission to an acute care hospital ICU (intensive care unit). The Department's Intake Information form indicated the facility reported a medication error incident occurred on 6/8/15 involving Resident 1. Resident 1's admission record indicated that Resident 1 was admitted to the facility on 6/2/15, with diagnoses including unspecified diastolic heart failure, essential hypertension (high blood pressure), and anemia. During a concurrent interview with Assistant Director of Nursing (ADON) and Licensed Staff A on 6/17/15, at 9:30 a.m., the ADON stated that on 6/8/15 at around 11 a.m., Licensed Staff C prepared medications and handed the medications to Licensed Staff D. The ADON stated Licensed Staff D administered the medications to Resident 1. During the same interview, Licensed Staff A stated after Licensed Staff D administered the medications to Resident 1, both Licensed Staff C and D discovered that the medications were administered to a wrong resident. Licensed Staff A stated that Licensed Staff C said she told Licensed Staff D to give the medications to Random Resident 26 (by room number and bed letter), but Licensed Staff D said Licensed Staff C told her to give the medications to Resident 1 (by room number and bed letter). Licensed Staff A stated Resident 1's heart rate decreased to 38 beats per minute and was sent to a hospital emergency room at 6:45 p.m. due to the wrong medications. Licensed Staff A further stated that the nurse should not give the resident medications prepared by another nurse. The SBAR (Situation, Background, Assessment/Appearance, and Request) Communication Form - Change of Condition Progress Note, dated 6/8/15, at 12:33 p.m., indicated Resident 1 was rendered improper medications. The communication form indicated "Suggest or Request...monitor for b/p (blood pressure), bleeding, HR (heart rate), mental alertness, and respiratory suppression Q4hrs x 72 hrs (every four hours for 72 hours)." The communication form revealed the facility notified the physician on 6/8/15 at 12:30 p.m. and notified the family at 12:45 p.m. During a concurrent observation and interview on 6/17/15, at 12:20 p.m., Resident 1 was in her bed and awake. Resident 1 stated she went to the hospital because she had difficulty of breathing and felt something was wrong with her heart. Resident 1 stated nobody told her about the wrong medications. She stated she received some medications in the hospital and she felt better.During a concurrent record review and interview on 6/17/15, at 2:55 p.m., Licensed Staff A reviewed Random Resident 26's MAR (medication administration record). She stated that Random Resident 26's 10 morning medications were incorrectly administered to Resident 1. The medications included: 1) Aspirin 81 mg (milligram) (a medication for pain, fever, inflammation and prevention of stroke), 2) Atenolol 100 mg (a medication for lowering blood pressure and heart rate), 3) B-Complex 1 tablet (vitamin supplement), 4) Cetirizine 10 mg (a medication for allergies), 5) Cozaar 50 mg (a medication for lowering blood pressure), 6) Diltiazem extended release 24 hour 240 mg (a medication for lowering blood pressure), 7) Docusate 250 mg (a stool softener), 8) Fluticasone Propionate Suspension (nasal spray for allergies), 9) Heparin Sodium (a blood thinner) 5000 unit/ml (milliliter) inject one vial subcutaneously, and 10) Calcium 600+D Plus Mineral (calcium and mineral supplement) 1 tablet. Resident 1's MAR, dated 6/8/15, indicated Resident 1 also received her own morning medications including Lanoxin (also known as digoxin, a medication for slowing the heart rate) 125 mcg (microgram), Lasix 20 mg (a medication to decrease blood pressure), diltiazem 60 mg, Famotidine 20 mg (a medication for acid reflux), Iron-Vitamins one tablet (supplement), Allopurinol 100 mg (a medication for gout, a form of acute inflammation of a joint), Docusate 100 mg, Lactobacillus (a bacteria supplement for treating and preventing diarrhea), and Sennosides 8.6 mg (a medication for constipation).During an interview on 8/12/15, at 1:50 p.m., the ADON stated that she reviewed Resident 1's MAR and clinical chart. The ADON stated that according to the MAR, Resident 1 received her own morning medications on 6/8/15. She stated Resident 1 also received the 10 wrong medications on 6/8/15. During an interview on 6/17/15, at 12:30 p.m., the Administrator stated the two nurses made three mistakes during this medication error incident. He stated, 1) Licensed Staff C should not prepare the medications and give to another nurse to administer to the resident; 2) Licensed Staff D should not accept the medications prepared by another nurse; and 3) if Licensed Staff D accepted the medications, she should have checked the five rights (facility's Medication Pass Observation Review form, dated 10/31/10, indicated five rights: right resident, medication, dose, time, and route). The Administrator stated the two nurses did not follow the five rights and the medication pass process. He stated the medication error caused Resident 1 to be admitted to an acute care hospital for two to three days. He further stated that the two nurses were terminated from their positions. During an interview on 6/25/15, at 4 p.m., Licensed Staff D stated that on 6/8/15 at approximately 11 a.m., Licensed Staff C asked her to help to catch up medication pass. Licensed Staff D stated Licensed Staff C prepared the medications and asked her to give the medications to Random Resident 26 (by room number and bed letter), but she thought the medications were for Resident 1 (by room number and bed letter). Licensed Staff D stated she gave about 10 medications including supplement and heparin to Resident 1. She stated she did not know all the medications because she did not prepare the medications. Licensed Staff D stated after she administered the medications to Resident 1 and asked Licensed Staff C if they needed to give medications to Random Resident 26, they found out that Licensed Staff D gave the medications to a wrong resident. She stated they notified the nurse supervisor and the doctor and started monitoring Resident 1 for adverse effects. Licensed Staff D stated they (Licensed Staff C and D) breached the facility policy and procedure, which should recheck the five rights and do not give the medications prepared by another person.Resident 1's "NURSE'S NOTE" dated 6/8/15, indicated "...at 6:30 pm, CNA (certified nursing assistant) reported that she can't get the blood pressure and resident complaint of SOB. Rechecked v/s (vital sign), unable to appreciate BP (blood pressure), O2 Sat (oxygen saturation, normal range 95-100%) was 94% on Oxygen @ 2LPM (litter per minute). Shortly after I administered her oxygen but her PR (pulse rate) was 37 and still complaint of SOB. Head of bed elevated. Called MD (medical doctor) and notified him that I have to send the resident to ER (emergency room) for that reason ..." The acute care hospital discharge summary, dated 6/11/15, indicated Resident 1 was admitted to the hospital on 6/8/15 for treatment of Bradycardia due to extra dose of Cardizem (diltiazem). Resident 1 was monitored in ICU. The cardiology consultant note dated 6/9/15, indicated Resident 1 "was brought to the Emergency Room from a local skilled nursing facility for evaluation for complaint of generalized weakness ...she was found to be bradycardic with her heart rate dropping into the 30s at times ...has been feeling dizzy ...The caregivers at the facility at which she resides ...said that she may have gotten an extra dose of her calcium channel blocker earlier today..." The cardiology consultant note under "IMPRESSION AND PLAN," indicated "A Fib (abnormal heart rhythm) with Bradycardia related to medications, discontinue Digoxin and hold Cardizem for now, if difficult to control rate, pacemaker may be considered ..."During an interview on 8/11/15, at 3:45 p.m., Physician E stated the facility staff notified him of the medication error occurred on 6/8/15. Physician E stated that the Atenolol and Diltiazem decreased the blood pressure and heart rate and caused Resident 1 to be sent to the acute care hospital and monitored in ICU. Physician E stated that Resident 1 was on Digoxin, which increased the risk for lowering the heart rate. Physician E also stated that the heparin injection, which Resident 1 received by mistake, could cause Resident 1 to bleed to death. Physician E further stated that Resident 1 was also on anticoagulant (blood thinner) which was held after the medication error. He stated Resident 1 did not exhibit the side effect (bleeding) of the heparin, but the risks were there. During an interview on 8/12/15, at 11:22 a.m., Resident 1's daughter stated that the facility staff notified her on 6/8/15 after they discovered they gave the wrong medications to Resident 1. She stated her mother was admitted to an acute care hospital ICU because of the wrong medications. She stated she felt "so bad" because her mother originally transferred to the facility from an acute care hospital ICU and she was back to ICU due to medication error. The facility policy and procedure titled "MEDICATION ADMINISTRATION-GENERAL GUIDELINES," dated April 2008, indicated "...Prior to administration, the medication and dosage schedule on the resident's medication administration record (MAR) is compared with the medication label ...Medications are administered in accordance with written orders of the attending physician ...The person who prepares the dose for administration is the person who administers the dose ...Residents are identified before medication is administered ...The individual who administers the medication dose records the administration on the resident's MAR directly after the medication is given..." Therefore, The facility violated the regulation by failing to ensure Resident 1 was free from significant medication error when licensed staff administered 10 wrong medications to Resident 1. This failure caused Resident 1 to experience bradycardia, weakness, and shortness of breath that required admission to an acute care hospital ICU. The violation of the regulation had presented a direct or immediate relationship to resident health and safety. |
| 110000013 |
Windsor Vallejo Nursing & Rehabilitation Center |
110012568 |
A |
28-Dec-16 |
I45V11 |
6824 |
T22 DIV5 CH3 ART3-72311(a)(3)(B) (a) Nursing service shall include, but not be limited to, the following: (3) Notifying the attending physician promptly of: (B) Any sudden and/or marked adverse change in signs, symptoms or behavior exhibited by a patient. The facility failed to notify one resident's (Resident 1) physician of abnormal laboratory values. Resident 1's serum sodium level (sodium level in the blood) was low on 4/3/13 and 4/4/13. The facility failed to notify Resident 1's physician of these abnormal lab values and did not obtain a repeat sodium level on 4/5/13. On 4/6/13, Resident 1 was found on the floor and transferred to an acute care hospital. Her sodium level in the hospital emergency room was 112, a severely low level. This failure caused Resident 1 to require critical care and emergent interventions to prevent sudden deterioration. Resident 1 was an 85 year old woman who was admitted to the facility on xxxxxxx with diagnoses including traumatic fracture of the hip and rehabilitation following right hip surgery. Review of Resident 1's medical record revealed a physician's history and physical note that indicated Resident 1 had hyponatremia (reduction in the sodium level in the blood). Resident 1's medical record also indicated her serum sodium level was 128 on 4/2/13, the day after she was admitted to the facility. Normal serum sodium levels range from 135-145 meq/liter. Low sodium can lead to a state of volume depletion (loss of blood volume in the body). Review of Resident 1's medical record revealed the facility performed blood tests (including sodium level) on three consecutive days (4/2/13, 4/3/13, and 4/4/13) and the results indicated Resident 1's sodium level was steadily dropping. On 4/2/13, Resident 1's sodium level was 128. On 4/3/13, lab tests revealed Resident 1's sodium had dropped to 122. On 4/4/13, Resident 1's sodium had dropped further to 121. The medical record indicated the facility did not recheck Resident 1's sodium on 4/5/13. Review of Resident 1's medical record revealed her sodium was tested on 4/3/14 and the facility received the results at 10:40 p.m. The lab results indicated her sodium had dropped to 122. Nursing notes dated 4/4/13 at 3:52 a.m., 4/4/13 at 1:41 p.m., and 4/4/13 at 2:48 p.m. did not contain documentation that the licensed nurse had notified Resident 1's physician of her low sodium. Review of Resident 1's medical record, nursing note, (dated 4/4/13 at 4:52 p.m.) revealed Nurse Consultant B notified Resident 1's physician about her elevated ammonia level and low potassium level and discussed both with him. The nursing note did not contain documentation that Nurse Consultant B notified Resident 1's physician of her low sodium level. Review of Resident 1's medical record indicated her sodium was again tested on 4/4/13 but the facility did not receive the results until 4/5/13 at 2:59 p.m. The test results indicated Resident 1's sodium dropped further to 121. Nursing notes dated 4/5/13 at 10:16 p.m. did not contain documentation that the licensed nurse had notified Resident 1's physician of her low sodium. During a telephone interview on 8/14/14 at 2:55 p.m., the Director of Nursing stated sodium levels of 122 and 121 were critical values (critical lab results indicate a high risk of morbidity or mortality in the absence of rapid intervention). In a telephone interview on 8/18/14 at 10:45 a.m., the Director of Nursing stated licensed nurses should telephone the physician immediately to report critical lab results. The Director of Nursing stated she did not see any documentation in the nurses notes that indicated the licensed nurses had notified Physician E (Resident 1's physician) of her low sodium levels. Review of facility document titled, "Lab work, ordering & reporting (revised November, 2012) indicated upon becoming aware of a critically abnormal lab results, the licensed nurse will phone the results immediately to the physician. During a telephone interview on 8/18/14 at 11:35 a.m., Physician E stated if he had been aware that Resident 1's serum sodium was 121, he would have ordered the facility to repeat her sodium blood test. He also stated he would have considered transferring her to a hospital for hypertonic intravenous hydration. Hypertonic intravenous hydration are solutions used to replenish fluid and electrolytes (sodium). Review of Resident 1's medical record revealed that although her sodium level was low at 121 on 4/4/13, the facility did not recheck her sodium level on 4/5/13. During a telephone interview on 8/14/14 at 2:55 p.m., the Director of Nursing verbally confirmed that Resident 1's medical record indicated the facility had not rechecked Resident 1's blood sodium level on 4/5/13. During an interview on 6/21/13 at 9:12 a.m., Licensed Staff F stated she found Resident 1 on the floor by her bed on 4/6/13 when she was making rounds at approximately 3:30 a.m. Review of Resident 1's medical record nursing note (dated 4/6/13 at 4:03 a.m.) indicated Resident 1 was confused when staff found her and she was transferred to the hospital for evaluation at 3:35 a.m. Review of Resident 1's hospital physician clinical report (dated 4/6/13) indicated Resident 1 was brought to the emergency department and seen by Physician D 4:00 a.m. Resident 1's hospital medical record indicated that at 5:13 a.m., her sodium level was 112. The physician progress note indicated Physician D diagnosed her with, "severe hyponatremia." Physician D documented that the patient required critical care due to acute impairment of vital organ systems and a high probability of life threatening deterioration. He further documented emergent interventions were implemented to prevent sudden deterioration. According to the American Journal of Medicine (June, 1985), blood sodium levels that are less than 120 are defined as, "severe" hyponatremia and are often a life-threatening emergency that can result in permanent neurological damage or death (Am J Med. 1985 Jun;78(6 Pt 1):897-902). Therefore, the facility violated the regulation by failing to notify Resident 1's physician of her abnormally low sodium laboratory values. Resident 1's serum sodium level was low on 4/3/13 and 4/4/13. The facility did not notify Resident 1's physician of these low lab values and did not obtain a repeat sodium level on 4/5/13. On 4/6/13, Resident 1 was found on the floor and was transferred to an acute care hospital. Her sodium level in the hospital emergency room was severely low at 112. This failure caused Resident 1 to require critical care and emergent interventions to prevent sudden deterioration while in the hospital. 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. |
| 240000089 |
Western Healthcare Center |
120009041 |
B |
28-Feb-12 |
HVE611 |
6552 |
REGULATION VIOLATION: Title 2272311 Nursing Service - General and 72523 Patient Care Policies and Procedures. 72311 (a) Nursing service shall include, but not be limited to, the following: (3) Notify the attending physician promptly of: (B) Any sudden and/or marked adverse change in signs, symptoms or behavior exhibited by a patient. AND72523 (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved.The facility failed to promptly notify the physician on March 20, 2010 after facility staff observed Patient A with "greenish yellow bruising on the left outer leg" and after the patient complained of pain. The physician was notified four days later, on March 24, 2010. This resulted in a delay of treatment. Patient A was diagnosed with an, "acute fracture involving left proximal tibia with minimal displacement." The facility failed to implement their policy and procedure which stipulated injuries of unknown origin were to be promptly and thoroughly investigated. Review of the medical record was conducted on April 9, 2010 and September 13, 2011. Patient A was a 65 year old female, who was re-admitted to the facility on March 20, 2010 with diagnoses that included mental retardation, cerebral palsy, seizure disorder, and status post septic shock from a urinary source.Review of the History and Physical (H&P) report dated March 21, 2010 indicated that Patient A had some bruising to her left tibia. Review of the History and Physical (H&P) report dated March 26, 2010 indicated that Patient A was sent to an acute care hospital, where she was diagnosed with a fracture to her left leg. The documentation further showed, "Patient had a bruise over this area on admission on March 21, 2010 exam, and due to patient's complaint of pain, x-ray was ordered and [Patient A] found to have left tibia fracture, nondisplaced." Review of the written declaration of CNA 1, dated March 20, 2010, revealed the following.March 20, 2010 (11 PM - 7AM). "Noticed greenish yellow bruising on patient's left outer leg. Patient complained of pain." March 21, 2010 (11 PM - 7AM). "Bruising on patient's leg more yellow with a little bit of redness...patient complained of pain." March 22, 2010 (11 PM - 7AM). "Bruising on patient's leg mostly yellow, complained of pain." In an addendum letter, CNA 1 indicated that she did not report the bruising observed and the patient's complaints of pain on the above dates, "due to the fact that the bruising looked old," and "complaints of pain didn't seem any less normal than usual." Review of the written declaration of CNA 2 dated March 26, 2010, indicated on March 22, 2010 during her care with Patient A she noticed a bruise to patient's lower left leg, "fading yellowish color, like the bruise was going away." "I didn't report it to the charge nurse at the time because I thought it had already been reported." During an interview with CNA 2 on September 13, 2011 at 11:28 AM, CNA 2 confirmed and stated that she did not report the bruising since she thought it had been reported. Review of the written declaration of CNA 3 dated March 24, 2010, indicated that Patient A's left lower top extremity was "still swollen, hot, painful when moved and with bruising." The documentation also indicated that CNA 3 had reported her observation and showed the affected area to the Treatment Nurse/Charge Nurse.Review of the nurse's note dated March 24, 2010 at 2:20 PM, indicated that the physician was notified of the patient's complaint of pain, as well as edema to left knee and left lower leg. An x-ray of the left knee and lower leg was ordered. The following was identified via x-ray examination, "Acute fracture involving left proximal tibia with minimal displacement." Patient A was transferred to the acute care hospital on March 24, 2010 at approximately 8:55 PM. Patient A was admitted to the acute care hospital and was sent back to the skilled nursing facility on March 26, 2010. Review of the written declaration of CNA 4 dated March 20, 2010, revealed the following. "On this day (March 20, 2010) upon admission, she kept complaining of the drivers, she kept telling me she didn't want the driver in her room, she kept saying I hate him, don't let him come in my room. She said they dropped me." Review of the IDT note dated March 25, 2010 at 11:00 AM, indicated that the ambulance company office was contacted by the Director of Nurses (DON) to inquire about the incident. The DON documented, "I left a message to the field supervisor in his voice mail." The documentation also stipulated that there was no report of a fall received from the time of admission or any accidental hitting of the upper and lower extremities during transfer. There was no further documentation about follow-up of an investigation from the ambulance personnel.During an interview with Administrator A on April 9, 2010 at approximately 4:12 PM, Administrator A stated that the fracture might have occurred in the hospital or while enroute to the skilled nursing facility from the acute care hospital. Administrator A also stated that she did call and talk to the ambulance company's supervisor, who told her that they would do an investigation and get back with her with the findings. After that, a copy of the report with findings would be forwarded to the Department.During an interview with Administrator B on September 13, 2011 at 1:20 PM, Administrator B confirmed and stated, "There was no completed report regarding an investigation with the Emergency Medical Transport/American Medical Response personnel." Review of the facility's policy and procedure regarding "Abuse and/or Resident Neglect Investigation" stipulated that it was the facility's policy that "All reports of resident abuse, or neglect and injuries on unknown origin shall be promptly and thoroughly investigated." The investigation process included, "An interview with staff members (on all shifts), having contact with the resident during the period of the alleged incident and a review of all circumstances surrounding the incident."The facility failed to promptly notify the physician of Patient A's bruised and painful leg until March 24, 2010, four days after observing the change in condition. The facility failed to implement their policy and procedure regarding injuries of unknown origin. These facility failures had a direct or immediate relationship to the health, safety, or security of long-term health care facility patients or residents. |
| 120001431 |
Westgate Gardens Care Center |
120009134 |
B |
11-Jun-12 |
LQAF11 |
7730 |
72527 (a) (9) Patients' Rights. (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (9) To be free from mental and physical abuse. On July 20, 2011 at 8:45 AM an unannounced visit was made to the facility to investigate a report of alleged staff to resident abuse.Based on interview and record review, the facility failed to protect one patient (Patient 1) from verbal and mental abuse and neglect, which caused her anxiety, and emotional trauma. Patient 1 was an 85 year old female, admitted to the facility on July 6, 2001 with the diagnoses of post CVA with left sided weakness and anxiety. The admitting Nurses note indicated Patient 1 was able to make her needs known, was alert and oriented to person, place and time, and had left sided weakness with flaccid (not firm) arm and leg. The care plan for Patient 1 included Physical and Occupational Therapy for impaired mobility and decreased strength.During an interview with Patient 1, on July 20, 2011 at 10:55 AM, she described one of the Certified Nursing Assistants (CNA 1) was "belligerent" to her when she turned on her call light. Patient 1 described CNA 1 entered the room "jerked the call light out of my hand and threw it on the floor." Patient 1 stated she asked CNA 1 to adjust the bedding by pulling up the sheets. Patient 1 stated CNA 1 responded "if you can learn to run the light button you can learn to take care of yourself," and then left the room without helping. Patient 1 described another incident when an unidentified staff entered her room to answer the call light and stood over her bed and said "you need to quit using it (the call light) so much" and then took it away and hid it from her and left the room. Patient 1 was not able to see the name badge of this CNA. Patient 1 stated "I'm scared of those girls and don't want them in my room again. Patient 1 described another incident when she was placed at the Nurses' Station 2 for a long period of time and her back and bottom became very sore. Patient 1 stated she asked CNA 1 and another staff (unable to provide name) to take her back to her room because she was in pain but "they just looked at me and began laughing, and never put me back to bed." During an interview with CNA 2 on 7/20/11 AT 12:10 PM, she stated "I stopped at Nurses' Station 2 to ask CNA 1 and CNA 3 about going to lunch. Patient 1 was sitting in her wheelchair calling for help and I asked the CNAs who she was and was told she was a new patient." CNA 2 stated she left the Nurses' Station and did not see what occurred afterwards. During a review of investigation statements obtained from the DON on 7/20/11, CNA 2 wrote on "7/10/11 between 9 AM and 9:30 AM, I heard Patient 1 say she wanted to go to bed. I asked CNA 3 and CNA 1 who had her. They stated CNA 1 did. I told them she wanted to go to bed and went back to Nurse Station 1." During an interview with CNA 4 on 7/20/11 at 12:10 PM, she stated she heard Patient 1 yelling for help. CNA 4 described asking Patient 1 why she was yelling so loud, Patient 1 replied "I wouldn't have to yell if I had the call light, but it is on the floor, the other CNA's took it from me". CNA 4 stated Patient 1 began crying and told her she was scared and the night girls are so mean to her. Patient 1 did not know their names but did describe them to her. CNA 4 reported the incident to the Director of Nurses (DON). CNA 4 stated Patient 1 told her a CNA was standing over her bed and yelling at her for using the call light so much. CNA 4 stated Patient 1 told me the CNA said she had 30 patients to care for and Patient 1 needed to stay off the light (unable to identify CNAs by name). During a review of investigation statements obtained from the DON on 7/20/11, CNA 4 wrote, on 7/12/11 "she heard Patient 1 yelling for help and went to her room. When asked why she was yelling Patient 1began crying and replied she wouldn't be yelling but it's the only way she could get help because she didn't have her call bell, it's on the floor, the girl yelled at her. Patient 1didn't know her name but said she scared her. I asked her why and Patient 1 stated she stood over her bed and yelled at her because she was on the light all night and threw her bell on the floor. " CNA noted she assisted Patient 1 with her needs and reported incident to the DON.During a review of investigation statements obtained from the DON on 7/20/11, CNA 5 wrote, "on 7/10/11, Patient 1 was sitting by Nurses' Station 2 crying. Patient 1 was asking CNAs 1, 2, and 3 to please lay her down because her back was hurting and she couldn't be in the wheelchair any longer. Patient 1 asked many times. CNA 5 noted CNAs 1, 2, and 3 were staring right at the Patient and laughing. The Rehabilitative Nurse Assistant (RNA 1) assisted Patient 1 to her room after a few minutes." During a review of investigation statements obtained from the DON on 7/20/11, the Rehabilitation Nursing Assistant (RNA 1) wrote on 7/9/11 she noticed Patient 1's call light was unanswered and she went to her room. Patient 1began crying and told her the girls are not nice to her. Patient 1 told her a CNA here gets mad when she uses the call button. Patient 1 said the CNA tells me to not use it so much. Patient 1 identified the CNA as CNA 1. RNA 1 completed a second statement in which she wrote, Patient 1 was sitting by Nurses' Station 2. She was crying and when asked what was wrong, Patient 1 said she wanted to lay down because her back and bottom were hurting really bad. RNA1 described she assisted Patient 1 then went to dining room and CNA 1 was there. CNA 1 stated the reason she put Patient 1 in her wheelchair was so she (Patient 1) could leave them (CNAs) alone, and give them a break from the call light."During a review of investigation statements obtained from the DON on 7/20/11, Student 1 and 2 wrote "Patient 1 informed them a night shift nurse came into her room and yelled at her. The nurse told her to stop using her call light. The nurse told Patient 1 that she was a nuisance for using her call light and the nurse hid the call light from Patient 1. Patient 1 requested the nurse not come back into her room because she was afraid of her." During an interview with DON on 7/20/11 at 10:55 AM she stated she had discussed all allegations with Patient 1 and conducted an investigation. The DON stated they found Patient 1 was forced to be up at the nurses' station and staff were laughing at her and did not put Patient 1 back to bed as requested. During a phone conversation with DON, on 8/4/11 at 9:40AM, she stated during the investigation it was determined CNA 6 was the one who stood over Patient 1's bed and yelled at her and then took her call light.The clinical record for Patient 1 was reviewed on 7/20/11. The Care Plan for Anxiety, dated 7/7/11, related to real/perceived loss or stressful situation, unfamiliar environment and insufficient knowledge. The approach plan was to listen attentively, encourage resident to identify and express causes of anxiety, provide calm, quiet environment/approach, and provide assistance with tasks during period of anxiety.These violations resulted in Patient 1's needs not being met and experiencing emotional stress leading to increased anxiety. Caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety, or other emotional trauma to patients. |
| 120001431 |
Westgate Gardens Care Center |
120010455 |
A |
08-Apr-14 |
J10F11 |
7247 |
CFR 483.25 (h) (F323): The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents.The facility failed to protect one resident (A) from injury when she fell from a mechanical lift onto the floor while in the facility. This resulted in injuries to Resident A, including a small compression fracture of her spine, a contusion (bruise) and swelling to her head, bruises to her body, and increased pain throughout her body that persisted for several days. Findings: Resident A is a 63 year old female. She was alert and oriented, and able to make her needs known. She required extensive assistant from staff for her activities of daily living. Her admitting diagnoses included multiple sclerosis (a unpredictable, chronic, often disabling disease that affects the brain, spinal cord, and eyes, that can cause symptoms such as numbness in the arms and legs to more severe such as total inability to move arms and legs) paraplegia (inability to move or have sensation in the legs) and osteoarthrosis (pain & stiffness in the joints).Resident A's clinical record was reviewed on 12/27/12 at 10:40 AM. The Resident Admission indicated she had been a resident of the facility for over three years, and was 63 years of age. Her admission diagnoses included multiple sclerosis, and osteoarthrosis (pain & stiffness in the joints).The facility document titled "Minimum Data Set" (MDS, an assessment tool), dated 11/14/12, indicated Resident A was mentally intact, with no deficits, no problems with memory, and no behavior issues, always able to understand others, and make herself understood. The MDS also indicated she had impairments to both her legs and required a wheelchair to get around. The MDS indicated Resident A needed "extensive assistance, resident highly involved in activity, staff provide weight-bearing support" and required "two+ persons physical assist" when moving around in her bed. For transfers between her bed and other surface such as a wheelchair, Resident A was assessed to be "Not steady, only able to stabilize with staff assistance."The "Resident Progress Notes" dated 12/8/12 at 9:42 AM read she was "lying on floor with lift [a mechanical device used to 'lift' a resident safely] tipped over on resident... indentation on right side of head noted." At 1:25 PM, the "Progress Notes" read "complains of severe nausea, headache, pain..."The "Progress Notes" indicate Resident A left the facility via ambulance at 2:02 PM for evaluation and treatment at a local emergency department, and returned at 10:20 PM later that day.During a review of Resident A's clinical record for her 12/8/12 visit to the Emergency Department of a local General Acute Hospital (GACH E), the document titled "Physician Documentation" indicated she complained of ankle and back pain. The documentation also indicated she received an injection of narcotic medication morphine for her pain, which was repeated sixteen minutes later. The document titled "Discharge Instructions" read Resident A was diagnosed with "Low Back Pain with a minute vertebral compression fracture" (a small fracture of her spine), and she needed to "discuss the need to see a spine surgeon" with her primary physician.Over the next five (5) days after returning to the facility, the "Progress Notes" indicate Resident A complained of pain to her back, shoulders, in-between her shoulder blades, complained of nausea, refused to eat for "days", "hurts to take a deep breath", "lump to head", "severe headache", and "bad pain to whole body." The "Progress Notes" on 12/9/12 at 3:17 AM noted a "discolored area blue - purple area to back of right heel and dark pink to right upper arm."The "Progress Notes" dated 12/12/12 at 10 AM, contained the following entries: "IDT [Interdisciplinary Team] Root Cause Analysis - Fell while bumping head sustained while being mechanically lifted from bed to shower gurney [sic]... bumped head on bedside table... Recommendation: ... in-service all CNA's [Certified Nursing Assistants] on appropriate safety precautions and proper use of lifts."During an interview with Resident A on 12/27/12 at 12:55 PM, she stated she recalled the event where she fell to the floor during a lift transfer on 12/8/12. Resident A stated "As soon as I was away from the bed, the lift fell over, I was on the floor. I hit my head on the bedside table. Later, I had a headache and was sick to my stomach." Resident A also indicated she had been transferred many times in the past with the same lift without incident. Resident A stated "There had been no problems in the past, no falls. The only thing I knew of that was different about this transfer, was that [Licensed Nurse B] told me the lift's legs weren't apart like they were supposed to be. I was in a lot of pain, to my back, headaches, throwing up, I didn't eat, my heels were bruised from the fall."During an interview with Certified Nursing Assistant C (CNA C) on 12/27/12 at 1:20 PM at the facility, she stated she was one of two staff that was transferring Resident A on 12/8/12 when she fell to the floor. CNA C indicated the lift used was the "Vander-Lift II Model B-450", by pointing to it during the interview and stating "I'm pretty sure it was this one." CNA C indicated that during the transfer, "We had her [Resident A] up on the lift, she moved her arm a little, it tilted, the legs, they weren't open all the way, because they wouldn't fit under the bed." CNA C also stated Licensed Nurse B (LN B) came in the room after the fall.During an interview with LN B on 1/8/13 at 9:15 AM, he stated he recalled the event on 12/8/12. He stated when he entered the room; the legs of the lift were closed. LN B stated he asked the two CNA's about that, and they answered they hadn't opened the legs yet.During an interview with Certified Nursing Assistant D (CNA D) on 1/8/13 at 9:30 AM, she stated she recalled the event with Resident A on 12/8/12. CNA D indicated she and CNA C were the two staff assisting Resident A at the time of the fall. CNA D stated at the time of the fall, the legs of the lift "weren't completely open." CNA D stated she has since received training from the facility to make sure the legs of mechanical lifts were opened all the way before using them to lift residents.The document titled "Operating Manual" for the Vander-Lift II (Model B-450) was reviewed. It contained the following entries:"Make sure there is enough room in the patient's room to do the transfer. Move furniture or other things that may be in the way", and, "Move the Vander-Lift II into position... Open the base to its widest position... The base of the Vander-Lift II should be open to its widest position for all transfers."Therefore, the facility failed to protect Resident A from injury, and adequately supervise her with an assistive device when transferring her from her bed with a mechanical lift, allowing her to fall to the floor; causing a small fracture to her spine, a contusion and swelling to her head, bruises to her body, and increased pain throughout her body that persisted for several days. This violation warrants a Citation at the "A" level.1 |
| 230000029 |
Windsor Chico Creek Care and Rehabilitation Center |
230008886 |
B |
19-Apr-12 |
24ZF11 |
6055 |
T22 DIV5 CH3 ART3-72311(a)(2) Nursing Service - General (a) Nursing service shall include, but not be limited to, the following: (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. T22 DIV5 CH3 ART5-72523(a) Patient Care Policies and Procedures (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. The facility failed to implement the fall risk care plan for Patient 1, when the wrong transfer device was used to move her from a wheelchair to a shower chair. The facility failed to follow its transfer device and falls management policies and procedures when a staff member was alone and did not have help using a transfer device to move Patient 1. After Patient 1 fell, she was moved by a certified nurse assistant before she was assessed by a licensed nurse. The above actions resulted in Patient 1 falling and injuring herself, not receiving a prompt nursing assessment after the fall, and fracturing her left femur (thigh bone). Patient 1 was a 79 year old female re-admitted to the facility on 7/22/11. She had diagnoses that included altered consciousness, seizure disorder, and paralysis. She was described in a Minimum Data Set (MDS-a patient assessment tool), dated 6/12/11, as severely cognitively impaired, totally dependent on staff for transferring, and needing two staff members to help her move. The Admission Nursing Assessment, dated 7/22/11, indicated that she was non-weight bearing and needed total assist for transferring. During an interview on 1/3/12 at 2:15 pm, Certified Nurse Assistant (CNA) B stated that on 8/20/11, she was assigned to give Patient 1 a shower and needed to move her from her wheelchair to a shower chair using a transfer device. CNA B stated that at approximately 4:30 pm, she prepared Patient 1 on the Sit-to-Stand (a patient transfer device) and, in the process of moving Patient 1 from her wheelchair to the shower chair, Patient 1 fell to the floor. CNA B stated she, "was alone and had no help when she transferred Patient 1." CNA B described the fall and stated, "half way between the wheelchair and the shower chair, Patient 1 let go of the hand holds (on the transfer device) and fell to the floor, but I assisted her to the floor."A Sit-to-Stand is a mechanical device that is used to assist patients who can partially support their own weight during a transfer. The patients must have sufficient strength in their legs to partially stand and have the ability to maintain a grip on the hand holds for the duration of the transfer in order to be moved safely. According to Patient 1's MDS assessment, Patient 1 could not bear weight. Patient 1 would not be appropriate for using the Sit-to-stand device. Patient 1's record was reviewed on 1/3/12. A care plan for high fall risk, dated 7/22/11, indicated that a Hoyer Lift (a sling like transfer device that supports all of a patient's weight and used for a total body transfer of a patient who cannot bear weight) was to be used when moving Patient 1. A nurse's note, dated 8/20/11 and timed as a "late entry", indicated, "At 5 pm, CNA reported resident complained of leg pain. Assessed resident. Stated leg hurt and complained of pain on nursing touching left leg. Right leg without pain, medicated with Tylenol (a pain medication). Resident went to dinner." The same nurse's note further indicated that, at approximately 8 pm, after Patient 1 was assisted into her bed and reassessed, Patient 1 was unable to move her left leg because of, "pain with any slight movement ...." The nurse's note also read, "When CNA reported leg pain of resident, she did not mention lower to floor from Sit-to-Stand. Mentioned a few minutes later stating resident slipped out of Sit-to-Stand when she let go landing on buttocks controlled lower. Nursing was not notified that resident was on the floor and nursing was not notified until after two CNAs got resident off the floor ...." A physician's progress note, dated 8/20/11 at 8:05 pm, indicated, "Received call from RN related to possible fracture, as patient is in great pain after lower to floor from Sit-to-Stand. Transfer to (acute hospital)." A nurse's note, dated 8/20/11 at 10 pm, indicated that, "upon EMS (Emergency Medical Service) palpation (touching/feeling) of leg and attempt at ROM (range of motion - moving) left leg/knee - resident hollered in pain." An entry at 10:30 pm indicated Patient 1 was transferred to the acute hospital's emergency department. An X-ray consultation report from the acute hospital, dated 8/22/11 at 8:14 am, indicated that Patient 1 had a left distal femur fracture (a break in the thigh bone just above the knee). During an interview with Nurse Administrator C on 1/3/12 at 3:20 pm, she stated that CNA B violated facility policy because she transferred Patient 1 without the assistance of another staff member.The facility policy and procedure titled, "Lifting Machine by Mechanical Device," dated 7/08, indicated that when using a transfer device to move residents, "a minimum of two staff members should be used ...."The facility policy and procedure titled, "Falls Management," dated 7/08, indicated, "Resident is to be immediately evaluated by a nurse at the location of the fall without moving the resident until safe to do so." During an interview with Registered Nurse D on 3/8/12 at 1 pm, she stated that Patient 1 was not assessed at the time she slipped to the floor on 8/20/11, because CNA B did not report her fall to nursing at the time of occurrence, but waited until approximately 5 pm, after Patient 1 complained of leg pain.Therefore, the facility failed to implement Patient 1's fall risk care plan to use a Hoyer lift and follow its transfer devices and fall management policies and procedures. These failures resulted in Patient 1 falling and fracturing her left femur. These violations had a direct relationship to the health, safety or security of the patient. |
| 230000029 |
Windsor Chico Creek Care and Rehabilitation Center |
230009004 |
B |
24-May-12 |
VBCI11 |
4384 |
1418.91(a) Health & Safety Code 1418 (a) A long-term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the department immediately, or within 24 hours. Based on interview and record review, the facility failed to report to the Department the suspected abuse of Patient 2 by Patient 1 when Patient 1 was found in a public room with his mouth over Patient 2's mouth and his hand on her breast on top of her clothing. The actions of Patient 1 toward Patient 2 had the potential to be mentally harmful to Patient 2 by causing fearfulness with the initiation of the inappropriate activity, and was physically abusive.On 2/3/12, Patient 1's records were reviewed. Patient 1 was 84 years old and was admitted to the facility for short term rehabilitation on 12/4/11 with admitting diagnoses of bradycardia (slow heartbeat), falls, and dehydration. The face sheet (a demographic document) for Patient 1 indicated he was his own representative for all decisions. During an interview on 2/3/12 at 11 am, the administrator (ADM B) stated Patient 1 was his own responsible person and, "knew what he wanted and needed." ADM B described Patient 1 as fully ambulatory and self sufficient in caring for his needs. Records indicated that Patient 2, the victim, was 66 years old and had been admitted to the facility on 8/4/11 with diagnoses of dementia, Alzheimer's disease with psychosis, depression, and spastic involuntary movements. The face sheet identified that Patient 2 had, "No Capacity" for decision making. A quarterly minimum data set (MDS-a nursing assessment tool), dated 11/10/11, indicated Patient 2 had unclear speech and was rarely understood, rarely understood others, had short and long term memory problems, severely impaired cognitive skills (ability to think/reason), and required extensive assist and was totally dependent for all activities of daily living. The suspected abuse incident with Patient 2 being inappropriately touched by Patient 1 took place on 12/9/11 at approximately 10:15 am in a room across from the nurse's station where Patient 2 was placed in her wheelchair to watch the television. A nurse's note in Patient 2's medical record, dated 12/9/11 at 12:30 pm, indicated that licensed nurse A (LVN A) was informed by a visitor that the "possibility of inappropriate touching" was happening and when LVN A went to check on Patient 2, she witnessed that Patient 1 had "his mouth on hers and his hand on her breast."A statement verified by this surveyor and signed by LVN A on 2/3/12, read that LVN A told Patient 1 his actions were "not appropriate," moved Patient 2 away from Patient 1, and immediately reported the incident to the nursing supervisor.Patient 1 was spoken to by a team of staff members that included the Administrator, the Social Services Director, and the Director of Nursing and he promised not to do it again. Patient 1 was moved off the hallway where Patient 2's room was and he was discharged the next morning. During an interview on 2/3/12 at 2 pm, LVN A stated she found Patient 1 bending over Patient 2 with his mouth over hers and his hand on her clothes over her breast. LVN A stated the placement of Patient 1's hand was "not haphazard." LVN A added that Patient 2 would not be able to call out for help and would not be able to push Patient 1 away from her or tell him to stop what he was doing. She further stated that she filled out an incident report and gave it to the nursing supervisor.ADM B stated the facility investigated the incident on the day of 12/9/11, but found it was not reportable "related to the innocence of the gesture" by Patient 1. No documentation of a confidential investigative file for this incident was offered by Administration. A facility policy titled, "Reporting Abuse to Facility Management" (Abuse Prevention Policy and Procedure Manual, Revised 12/06) indicated, under Policy Interpretation and Implementation (page 1 - number five), that when an alleged or, "suspected case" of abuse is reported, the facility Administrator, or his/her designee, will immediately (within 24 hours of the alleged incident) notify "(a.) The State licensing/certification agency responsible for surveying/licensing the facility..."The violation of this regulation had a direct or immediate relationship to the health, safety, or security of patients. |
| 230000029 |
Windsor Chico Creek Care and Rehabilitation Center |
230009071 |
B |
24-May-12 |
VBCI11 |
9095 |
T22 DIV5 CH3 ART5-7523(a) Patient Care Policies and Procedures (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. T22 DIV5 CH3 ART5-72527(a)(9) Patients' Rights (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (9) To be free from mental and physical abuse. Based on interview and record review, the facility did not ensure that Patient 1 was free from physical abuse and also did not follow their policy and procedures to investigate, document, and report an alleged/suspected incident of abuse when Patient 2 was found in a public area with his mouth over Patient 1's mouth and his hand on her breast on top of her clothes. The actions of abuse by Patient 1 toward Patient 2 had the potential to be mentally harmful to Patient 2 by causing fearfulness with the initiation of the inappropriate activity, and was physically abusive. The failure to investigate the incident per policy and procedure had the potential to allow further abuse to Patient 2 and was a risk to other female patients of inappropriate actions by Patient 1.On 2/3/12, Patient 1's records were reviewed. Patient 1 was 84 years old and was admitted to the facility for short term rehabilitation on 12/4/11 with admitting diagnoses of bradycardia (slow heartbeat), falls, and dehydration. The face sheet (a demographic document) for Patient 1 indicated he was his own representative for all decisions. During an interview on 2/3/12 at 11 am, the administrator (ADM B) stated Patient 1 was his own responsible person and, "knew what he wanted and needed." ADM B described Patient 1 as fully ambulatory and self sufficient in caring for his needs. Records indicated that Patient 2, the victim, was 66 years old and had been admitted to the facility on 8/4/11 with diagnoses of dementia, Alzheimer's disease with psychosis, depression, and spastic involuntary movements. The face sheet identified that Patient 2 had, "No Capacity" for decision making. A quarterly minimum data set (MDS-a nursing assessment tool), dated 11/10/11, indicated Patient 2 had unclear speech and was rarely understood, rarely understood others, had short and long term memory problems, severely impaired cognitive skills (ability to think/reason), and required extensive assist and was totally dependent for all activities of daily living. The abuse incident with Patient 2 being inappropriately touched by Patient 1 took place on 12/9/11 at approximately 10:15 am in a room across from the nurse's station (the Tea Room) where Patient 2 was placed in her wheelchair to watch the television. A nurse's note in Patient 2's medical record dated 12/9/11 at 12:30 pm, indicated that licensed nurse A (LVN A) was informed by a visitor that the "possibility of inappropriate touching" was happening and when LVN A went to check on Patient 2, she witnessed that Patient 1 had "his mouth on hers and his hand on her breast."A statement verified by this surveyor and signed by LVN A on 2/3/12, read that LVN A told Patient 1 his actions were "not appropriate," moved Patient 2 away from Patient 1, and immediately reported the incident to the nursing supervisor.Patient 1 was spoken to by a team of staff members that included the Administrator, the Social Services Director, and the Director of Nursing and he promised not to do it again. Patient 1 was moved off the hallway where Patient 2's room was and he was discharged the next morning. During an interview on 2/3/12 at 2 pm, LVN A stated she found Patient 1 bending over Patient 2 with his mouth over hers and his hand on her clothes over her breast. LVN A stated the placement of Patient 1's hand was "not haphazard." LVN A added that Patient 2 would not be able to call out for help and would not be able to push Patient 1 away from her or tell him to stop what he was doing.During an interview on 2/3/12 at 1:30 pm, a certified nurse assistant (CNA C) stated Patient 2 had advanced dementia and would not be able to ask for a hug or kiss because she was not cognizant enough and did not speak well enough. CNA C stated that if anyone but her husband touched her without explanation she would jump and try to move away. CNA C also stated Patient 1 would not purposely allow anyone to hug and kiss her except her husband, and that was very limited.A facility policy titled, "Reporting Abuse to Facility Management," (Abuse Prevention Policy and Procedure Manual, Revised 12/06) under Policy Interpretation and Implementation, number 2 read: "All...visitors, etc., are encouraged to report incidents of resident abuse or suspected incidents of abuse." A visitor reported to LVN A the possibility of inappropriate touching happening in the Tea Room (the public room directly across from the nurse's station). In the policy, number ten read that the person performing an assessment examination after an incident of alleged or suspected abuse must complete a "Potential Resident Abuse Report Form" and obtain a written, signed, and dated statement from the person reporting the incident. A written statement from LVN A was obtained by the facility, on 2/3/11, the same date it was written, signed, and dated by LVN A, almost two months after the incident occurred. In the policy, number 11 read that a completed copy of the "Potential Resident Abuse Report Form" and the written statements from witnesses must then be given to the Administrator. An immediate investigation would be made and the copy of the findings of the investigation would be provided to the Administrator. ADM B stated he did not have a completed copy of the "Potential Resident Abuse Report Form" or a copy of the findings of the investigation.The policy under, "(L) Administrative Procedure and Investigation (483.13)(c)(3)" indicated the Administrator would initiate an investigation file labeled as, "confidential." All information from the investigation with summaries were to be presented to the Administrator including all interviews, reports, notes and other documents were to be maintained in this file. This should have included, "an Administrator's statement concerning the incident and his/her conclusion."Under, "Recordkeeping" the policy read that, "all documentation shall be maintained in a confidential file."ADM B stated he did not have a confidential investigative file regarding this incident. A nurse's note found in Patient 1's medical records, dated 12/9/11 at 11:30 am, indicated Patient 1 was found in the Tea Room "kissing and hugging" another patient. The note indicated that Patient 1 then met with the Administrator, the Social Services Director, and the Director of Nurses regarding not going into other patients' rooms and not hugging or kissing anyone, especially patients. It was documented that Patient 1, "agreed not to have any personal or physical contact with others until his discharge on 12/10/11."A Policy and Procedure titled: "Abuse Prevention, Investigation and Reporting," (SNF Management, Reviewed/Revised; 7/08), under (G.) Reporting number five, indicated the licensed nurse was responsible to notify the patient's physician of the incident and the result of the physical findings. No documentation was found that Patient 1 or Patient 2's physician had been notified of the incident.In this same policy, number six read that the licensed nurse was also responsible to notify the responsible party for the patient of the incident, that an investigation had been initiated, and that corrective action would be taken. No documentation was found in Patient 2's medical records that her responsible party was notified of the incident or the plan that was agreed to between the facility Administration and Patient 1. Patient 1 was his own responsible party. During an interview on 2/3/12 at 11 am, ADM B stated an investigation was conducted but the facility found that the incident was not reportable, "related to the innocence of the gesture" by Patient 1. ADM B stated there was no investigative file but notes were written in Patient 2's medical records by the interdisciplinary team. No interdisciplinary team notes describing the incident were found in Patient 1's medical records. The actions of abuse by Patient 1 toward Patient 2 had the potential to be mentally harmful to Patient 1 by causing fearfulness with the initiation of the inappropriate activity and was physically abusive. The failure to investigate the incident per policy and procedure had the potential to allow further abuse to Patient 2 and was a risk to other female patients of inappropriate actions by Patient 1.The violation of this regulation had a direct or immediate relationship to the health, safety, or security of patients. |
| 230000277 |
Wolf Creek Care Center |
230009110 |
B |
14-Mar-12 |
JI7G11 |
1862 |
A 064 1418.91(a) Health & Safety Code 1418 (a) A long-term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the department immediately, or within 24 hours. The facility failed to report an incident of verbal abuse when Certified Nursing Assistant (CNA) A told Resident 1, "If you touch me again, I'm going to hit you." This failure had the potential to expose the other residents in the facility to verbal abuse and possible physical abuse. During an interview on 11/28/11 at 1:10 pm, the Director of Staff Development (DSD) stated, on 11/19/11 at 8:30 am, Registered Nurse (RN) C told her that CNA A became angry with Resident 1 and told him, "If you touch me again, I'm going to hit you." The DSD stated that CNA A reported the incident to RN B, and Resident 1 reported the incident to RN C. The DSD stated that she reported the incident to the administrator. When asked why she had not reported the incident to the Department, the DSD replied, "The administrator felt it was not a reportable issue."During an interview on 11/30/11 at 11:30 am, RN B stated that she did not report the incident because the administrator told her, since Resident 1 did not feel threatened or fearful, it was not reportable. On 11/30/11 at 2 pm, RN C stated that she did not report the incident was because she "Thought it was up to the administrator." During an interview on 12/5/11 at 1:30 pm, the Administrator stated he discussed the incident with CNA A and Resident 1, and felt this was not an abusive situation, and did not feel it was reportable.Facility staff were aware of the abuse on 11/19/11 at 8:30 am, and should have reported the incident to the Department within 24 hours, 11/20/11 at 8:30 am. The facility did not report the incident, the Department received notification through a third party. |
| 230000277 |
Wolf Creek Care Center |
230009112 |
B |
14-Mar-12 |
JI7G11 |
1658 |
A 197 T22 DIV5 CH3 ART3-72315(b) Nursing Service--Patient Care (b) Each patient shall be treated as individual with dignity and respect and shall not be subjected to verbal or physical abuse of any kind. The facility failed to ensure Patient 1 was treated with dignity and respect and not subjected to verbal abuse by Certified Nursing Assistant (CNA) A, when CNA A stated, "If you touch me again, I'm going to hit you."Patient 1 was a 20 year old male admitted to the facility on 1/6/11 with diagnoses of abscess/cellulitis of his left arm, and long term intravenous drug use. A review of Patient 1's Minimum Data Set (MDS - an assessment tool) dated 11/9/11, showed he ambulated freely throughout the facility and could make his needs known.During an interview on 11/28/11 at 1:30 pm, CNA A stated that on 11/19/11 Patient 1 was following him around and provoking him while he was picking up the breakfast meal trays. CNA A explained that Patient 1 grabbed and jerked the stethoscope that was around his neck. CNA A stated that he told Patient 1 to stop. When CNA A turned, Patient 1 grabbed his bottom. CNA A stated that this made him angry and he told Patient 1 "If you touch me again, I'm going to hit you." CNA A stated that and went directly to his superior and self reported the incident, stating "I know I was wrong, I just snapped." Therefore, the facility failed to ensure Patient 1 was treated with dignity and respect and not subjected to verbal abuse by Certified Nursing Assistant (CNA) A, when CNA A stated, "If you touch me again, I'm going to hit you."This violation had a direct relationship to the health, safety, or security of patients. |
| 230000277 |
Wolf Creek Care Center |
230009305 |
B |
15-Oct-12 |
5E7011 |
9904 |
F309 483.25 Provide Care/ Services for Highest Well Being Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Based on interview and record review, the facility failed to ensure Licensed Nurse (LN) B examined Resident 1 after a fall on 3/9/12. Licensed nurses caring for Resident 1 on subsequent shifts, from 3/9/12 to 3/12/12, did not provided ongoing assessments and monitoring of Resident 1's physical condition for injuries or complications, in accordance with their clinical protocols for falls. As a result, Resident 1's fractured hip was not identified and treated for three days. Resident 1 was transferred to the hospital on 3/12/12 at 5:10 pm, three days after the fall incident occurred, a day after Resident 1 complained of left hip pain (3/11/12 at 6:45 - 7 pm), and nearly 10 hours after CNA G reported to a nurse that Resident 1 leg was limp and turned outward, and that the resident was crying and holding her left hip.Findings:On 3/12/12, the facility found that Resident 1 had redness, swelling and pain in her left hip area. An x-ray was obtained and showed that Resident 1 had a fractured left hip (proximal femur). The facility notified the Department of the incident, via fax, on 3/14/12. The facility's policy "Falls-Clinical Protocol," revised October 2010, identified four components used in their protocol to manage falls and fall risk. The first addressed physician and staff responsibilities in the assessment and recognition of residents at risk for fall and/or significant complications of falls. The protocol instructed staff to assess and identify risk factors, which included hypertension, cognitive impairment, and confusion. Physicians were to identify medical conditions such as the increased fracture risk in someone with osteoporosis; the thinning of bone tissue and loss of bone density over time. Staff were instructed to consider and treat circumstances, such as sliding out of a chair, as a fall. The second component instructed staff to attempt to define possible causes within 24 hours of falls. The third component instructed staff to identify pertinent interventions to address the risk for, and causes of falls. The last component, monitoring and follow-up, instructed staff to monitor for consequences and/or delayed complications such as late fractures and major bruising that could occur hours or several days after a fall. The facility policy, Assessing Falls and Their Causes, revised October 2010, further specified that "Nursing staff will observe for delayed complications of a fall for approximately forty-eight (48) hours after an observed or suspected fall, and will document findings in the medical record." In a written statement (no date), and interview on 3/22/12 at 3 pm, Certified Nurse Assistant (CNA) A described the event that occurred on 3/9/12 at approximately 7 pm. CNA A stated that she was getting Resident 1 ready for bed; the resident was in her nightgown sitting in her wheelchair next to the bed. CNA A was getting ready to put on her gait belt to transfer Resident 1 to bed when the resident scooted forward, her bottom was on the edge of the wheelchair seat and she was sliding out of her chair. CNA A stated that she was afraid Resident 1 was going to fall, so she helped the resident to the floor. CNA A statement read, "Resident 1 screamed out when I sat her down, but she screams out all the time, so it wasn't out of the ordinary." CNA A stated that she placed a pillow under Resident 1's head, and then left the room to tell Licensed Nurse (LN) B what happened. CNA A said that she asked LN B if she needed to take Resident 1's vital signs (recording body temperature, heart rate, blood pressure, and respiratory rate) and LN B told her "No." With the assistance of CNA C, CNA A transferred Resident 1 to bed. CNA A statement read, "Resident 1 screamed out again, but that wasn't out of the ordinary for her."... "Later that night, on last rounds, ...when we pulled her up (in bed) Resident 1 screamed out a little, but once we turned her, she was fine." During an interview on 3/22/12 at 3:45 pm, CNA C stated, during the evening of 3/9/12 she went into Resident 1 room and saw Resident 1 lying on the floor with a pillow under her head. CNA C stated, as she was assisting CNA A to transfer Resident 1 to bed the resident yelled out. CNA C stated, on 3/11/12 she noticed a palm size, blue and purple bruise on the back of Resident 1's left leg above the knee, and reported the finding to LN D. CNA C's written statement (no date) read, "On 3/11/12 CNA E and I noticed a bruise on Resident 1's leg. We reported it to the nurse before 5:30 pm. After dinner, around 7 pm, Resident 1 screamed in pain yelling, "It hurts!" "Anytime CNA E touched Resident 1's hip, she would scream in more pain."CNA E's written statement dated 3/12/12, read, on 3/11/12 Resident 1 was put to bed around 6:45 or 7 pm. "... She was screaming and whimpering. She usually vocalizes when we put her to bed but this was a little more intense. When I put my hand on her left hip/thigh area, Resident 1 said, "Oh, it hurts to touch." CNA E reported the incident to LN F. During her last rounds, around 9:45 pm, CNA E noted that "Resident 1 was asleep on her back ... she whimpered when I rolled her towards me. She seemed like she was in discomfort...it seemed like her pain was probably a two out of ten, if I had to guess." In LN F's written statement dated 3/12/12, LN F acknowledged that she was informed of Resident 1's leg pain. There was no documentation in Resident 1's record that LN F assessed Resident 1 verbalizations of pain after LN F was informed by CNA C and CNA E of a change in Resident 1's normal condition.During an interview on 3/22/12 at 3:55 pm, LN D confirmed that on 3/11/12, CNA C told her that Resident 1 had a bruise. LN D stated that she could not recall the size or location of the bruise on Resident 1's leg, and could not definitively say that she assessed the bruise. LN D stated that she did not document an assessment or monitoring of the bruise. LN D confirmed that the facility policy was to report, assess, document and monitor bruising. LN D also stated that she did not remember if she told the oncoming shift about the bruise.CNA G's written statement dated 3/12/12 read, "This morning I came in at 6:30 am, found Resident 1 up in wheel chair crying and holding her left hip. Her leg was turned outward and limp. Went straight to nurse (LN I) and reported it. Resident 1 cried in pain when touching the left hip and knee."On 3/22/12, Resident 1's record was reviewed. Resident 1 was admitted to the facility on 7/17/10 with diagnoses that included senile dementia. The Minimum Data Set (MDS), a resident assessment tool, dated 2/3/12, identified Resident 1 as confused, with both short and long term memory problems. She was unable to verbalize her needs, and was dependent on staff for eating, dressing and bathing. Resident 1 was unable to walk and had to be physically lifted in and out of bed by staff. Resident 1 was unable to maneuver her wheelchair and depended on staff to move her around the facility.There was no documentation entered into Resident 1's medical record on 3/9/12 regarding the resident being lowered to the floor or that she complained of left hip pain and that there was an increase in yelling out with care. There was no documentation of ongoing assessments, monitoring of the resident for injuries or complications following the incident on 3/9/12, and no documentation of a bruise being discovered behind her left knee on 3/11/12, in accordance with the facility's policies and nursing standard of care.An entry on Resident 1's 3/2012 medication flow sheet read, "Monitor for the presence of pain every shift using scale 0 -10. Zero equals no pain..." On the day, evening, and night shifts of 3/9, 3/10, and 3/11/12 Resident 1 was assessed as 0 (zero) no pain. Resident 1's PRN (as needed) Medication Flow sheet for 3/2012 showed that Resident 1 was able to receive two Tylenol tablets every four hours as needed (for pain). Despite Resident 1's yelling, screaming, crying, whimpering and complaints of pain in her left hip, there was no documentation that the cause of her discomfort was evaluated until 3/12/12 at 12:20 pm. The Resident Progress Note written at that time by LN H read, Resident complaining if increased pain with facial grimacing...left upper extremity red and swollen by hip, resident stated pain level 8 out of 10, two Tylenol tablets (650 milligrams) administered. LN H notified Resident 1's physician and obtained an order for an x-ray. The IDT (Interdisciplinary Team) noted dated 3/14/12 at 6:37 pm, contained the following information. On 3/12/12 at 4:50 am, CNAs got Resident 1 up and transferred her from her bed into her wheelchair. At approximately 7 am a CNA reported to a nurse that Resident 1's leg seemed to be hanging and crooked. The nurse examined the leg..., and moved the leg to the foot pedal. Resident was noted to be whimpering at that time. At approximately 12:00 pm, on the same day, the CNA brought the Resident to the nurses' station because she felt that something seemed wrong with the Resident. The nurse assessed the lower left proximal extremity by the hip and noticed that it was red, swollen and passive. Tylenol was administered, the physician was notified and an x-ray was ordered. The x-ray was obtained at 1 pm, and at 3:40 pm X-ray results showed left hip (proximal femur) fracture. At 3:50 pm, the MD responded with an order to transfer Resident 1 to hospital.During an interview on 6/21/12, the administrator stated that nursing staff did not provide post-fall care to Resident 1 in accordance with the facility's policies. |
| 230000044 |
Willows Center |
230009426 |
B |
11-Sep-12 |
Q26N11 |
2082 |
A 064 1418.91(a) Health & Safety Code 1418 (a) A long-term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the department immediately, or within 24 hours.The facility failed to report an incident of suspected verbal abuse that occurred on 7/7/12, between Visitor 2 and Resident 1, to the Department within 24 hours. This had the potential to negatively affect the physical or emotional well-being of Resident 1. On 7/9/12, the facility notified the California Department of Public Health (CDPH) of an incident of suspected abuse that occurred on 7/7/12. During an interview on 7/24/12 at 1:45 pm, the Director of Staff Development (DSD) stated that on 7/9/12, a nursing assistant student (NAS B) told her she overheard Visitor 2 tell Resident 1 to "quit being a f...ing bi...", on 7/7/12. DSD stated that it was her expectation that NAS B report this incident or if she needed help with reporting, NAS B should tell the charge nurse and get help from her. DSD stated that NAS B reported this to the charge nurse, Licensed Nurse (LN) A on 7/7/12. DSD confirmed with LN A that the incident had been reported to her on 7/7/12, but LN A did not notify CDPH. DSD confirmed that she reported the incident to CDPH on 7/9/12. During an interview on 7/24/12 at 3:25 pm, the Director of Nurses (DON) confirmed that LN A did not tell CDPH or administrative staff that the incident had been reported to her on 7/7/12. The DON confirmed that this incident should have been reported to CDPH within 24 hours.A facility policy titled "Abuse & Neglect Prohibition Program" dated 1/08, read as follows, "The center ensures that all alleged violation involving mistreatment, neglect, or abuse, . . . , is reported immediately to the administrator of the center and to other officials in accordance with state law through established procedures including to the state survey and certification agency." Therefore, the facility did not report an allegation of verbal abuse within 24 hours to the California Department of Public Health. |
| 230000044 |
Willows Center |
230009521 |
B |
23-Oct-12 |
4QUO11 |
5654 |
F223 483.13(b), 483.13(c)(1)(i) Free from abuse/involuntary seclusion The resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion.The facility must not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion.Based on interview and record review, the facility failed to ensure Resident 1 was not subjected to mental or emotional abuse when, on 6/6/12, Licensed Nurse (LN) B instructed the night shift Certified Nursing Assistants (CNAs) to awaken Resident 1 every 30 minutes even though she had requested to be allowed to sleep. This violated Resident 1's right to be free from abuse and harassment and had the potential to result in physical and psychological harm to Resident 1.A review of Resident 1's record disclosed that she was admitted to the facility with diagnoses that included generalized pain and paraplegia (inability to move the lower extremities).The Minimum Data Set, a resident assessment tool, assessed Resident 1 as having no memory impairment and no behavioral symptoms.During an interview on 7/17/12 at 11:40 am, Resident 1 stated that on 6/6/12 she had returned to the facility from a local emergency department where she had received treatment for a migraine headache. That night the CNAs came in her room every 30 minutes to awaken her. The CNAs told her that they had been ordered to do so by LN B, and that they would be sent home if they did not comply.During an interview on 7/17/12 at 10:15 am, Administrative Nursing Staff (Admin) A confirmed that LN B had been terminated for gross misconduct following the investigation of this incident. Admin A stated that LN B had given Resident 1 a sleeping pill around 9 pm, then told the CNAs to wake up Resident 1. During an interview on 7/17/12 at 2:50 pm, CNA C confirmed she had worked on the night shift of 6/6/12 and that LN B had told the CNAs to check on and awaken Resident 1 every 30 minutes. She stated that between 2 and 3 am Resident 1 became upset and stated she felt like she was being harassed. Resident 1 told CNA C she wanted to be left alone so she could sleep and asked to speak to LN B. CNA C stated she heard Resident 1 tell LN B that if he did not stop having the CNAs wake her up she would report it to Administrative (Admin) Staff A. LN B told Resident 1 to "go ahead."CNA C said the CNAs told LN B that Resident 1 had said this was harassment but LN B told them to just keep waking her up. She said, at times, LN B would walk with them and made sure they awakened Resident 1.During an interview on 7/17/12 at 3:15 pm, CNA D also confirmed that she worked on the night shift of 6/6/12 and that LN B had told the CNAs to check on and awaken Resident 1 every 30 minutes. She stated that at around 2:30 am Resident 1 said she wanted to be left alone so she could go to sleep. CNA D heard Resident 1 ask LN B if the "girls" could quit coming in every half hour and LN B told her no because he wanted the resident to know how it felt to be "harassed" all the time.During the interview CNA D stated that this was not the first time they had been told to awaken Resident 1 every 30 minutes by LN B. She said a few of the CNAs had written and signed a letter about this situation and had given the letter to Admin Staff A and Admin Staff H prior to 6/6/12.A letter, dated 6/3/12, written by CNAs D, E, F, and G, read as follows: "LN B has been making CNAs go into Resident 1's room every 30 minutes to wake residents (Resident 1 and her roommate) up to ask if they need anything. . . Please deal with this matter. The amount of time LN B is demanding us to be in their room is not only violating their rights but is causing the entire building to be neglected." On 7/18 and 7/24/12, interviews were conducted with CNAs E, F, and G, who confirmed the contents of the letter.During an interview on 9/11/12 at 9:40 am, Admin H confirmed she had received the letter when she came in to work on the morning of 6/4/12. Admin H discussed it with Admin A who was going to discuss the incident with LN B. During an interview on 7/24/12 at 3:55 pm, Admin A confirmed he had received the letter on 6/4/12. Admin A stated he discussed the issue with Resident 1 the same day. He stated Resident 1 told him she did not feel harassed at that time.Admin A stated he called LN B on 6/4/12 and left a message but did not speak to him until 6/7/12. Admin A admitted that he had not been persistent in getting in touch with LN B and the situation of 6/6/12 may have been avoided had he acted on the letter before 6/6/12. During an interview on 7/18/12 at 11:50 am, LN B acknowledged that he had told the CNAs to check on and awaken Resident 1 every 30 minutes.LN B stated that Resident 1 was putting on her call light after 3 am and he felt that, had she wanted to be left alone to sleep, she shouldn't have been putting on her light. LN B stated that he had been fired for misconduct for this incident.The facility's investigative report read as follows, "Because she puts on her call light sometimes as often as every 5 to 10 minutes, LN B asked the CNA staff to awaken her every 30 minutes at a time when she was trying to sleep. The resident was upset that she would be harassed in this way. Employee terminated for gross misconduct." The termination notice read as follows, "On 6/6/12 night shift LN B required CNA staff to awaken Resident 1 every 30 minutes to see if she wanted anything even after the resident asked to be allowed to sleep. This is considered gross misconduct." This violation had a direct relationship to the health, safety, or security of residents. |
| 230000044 |
Willows Center |
230010118 |
B |
28-Jan-14 |
WGNQ11 |
3968 |
F 223 483.13(b), 483.13(c)(1)(i) FREE FROM ABUSE/INVOLUNTARY SECLUSION The resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion.The facility must not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion. The facility failed to protect Resident 1 from verbal and physical abuse when Certified Nurse Aide (CNA) A forcefully pushed the resident to the floor, yelled obscenities at her, and threw a bed cover over her. Resident 1 was witnessed crying immediately after being abused, as she was assisted into her bed. On 6/5/13 at 6:28 pm, the Department of Public Health was sent a faxed notification from the facility titled, "Report of Suspected Dependent Adult/Elder Abuse." The report indicated that on 6/5/13, CNA A, allegedly pushed Resident 1 who fell to the floor. Another staff member, CNA B had witnessed the event. The facility records indicated that on 6/5/13, both the County local Police Departments were also notified. Resident 1 was admitted to the facility on 12/8/11 with diagnoses which included dementia, depression, a history of osteopenia (low bone density) and a compression fracture in her spine. Low bone density contributed to Resident 1's risk for easily broken bones. The Minimum Data Set (MDS-an assessment tool) for Resident 1, dated 3/17/13, indicated Resident 1 was a 95 year old, 100 pound female. Resident 1 required extensive assistance from CNA staff with dressing and was totally dependent on CNA staff for bathing and personal hygiene. The MDS identified Resident 1 as having felt down, depressed or hopeless nearly every day. The Care plan titled, "Psychosocial well being" for Resident 1 was reviewed and indicated that due to dementia, Resident 1 was prone to repetitive requests despite repeated assistance. Staff interventions to assist Resident 1 in coping were to provide supportive feedback and develop trust/rapport. During an observation on 6/19/13 at 1:45 pm, Resident 1 was interviewed while sitting up in her room, she was repeatedly mumbling to herself "somebody help me."During an interview with CNA B on 6/19/13 at 2:25 pm, she stated Resident 1 was usually very confused and says, 'Please help me,' constantly and it is very hard to listen to. She further stated that on 6/5/13, she witnessed Resident 1 standing by her bed and CNA A enter the resident's room. She watched CNA A grab Resident 1 by the right arm and forcefully push her down, causing Resident 1 to fall to the floor. CNA B then heard CNA A "snap" at Resident 1 saying, "I'm not putting up with your bullshit tonight!"On 6/19/13, the facility Administrator provided a copy of an interview statement by CNA B who witnessed the event. It stated after the Resident had been pushed, CNA's A and B picked her up off the floor, put her in her bed and CNA A "threw cover over her (Resident 1)" and left the room. Resident 1 "cried" when she was returned to bed.On 6/19/13, the facility provided an abuse policy. The policy dated, 1/2008, indicated, "Physical abuse may include pushing." The policy indicated verbal abuse is the use of language that willfully includes disparaging terms to residents, regardless of their ability to comprehend." During an interview with the Administrator on 6/19/13 at 9:30 am, she confirmed the abuse report filed on 6/5/13 had been substantiated. The Administrator stated it was,"willful and intentional" behavior by CNA A who had been subsequently discharged and reported to the CNA licensing board.Therefore, the facility failed to protect Resident 1 from verbal and physical abuse when Certified Nurse Aide (CNA) A forcefully pushed the resident to the floor, yelled obscenities at her, and threw a bed cover over her. Resident 1 was witnessed crying immediately after being abused, as she was assisted into her bed. This violation had a direct relationship to the health, safety, or security of patients. |
| 230000029 |
Windsor Chico Creek Care and Rehabilitation Center |
230010255 |
A |
22-Apr-16 |
VLRQ11 |
12621 |
A Citation, Title 22 violations: 72311(a)(1)(A)-Failure to evaluate the patient in the presence of extreme respiratory compromise; (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.72311(a)(2)-Failure to follow the physician's plan of care;(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.72311(a)(3)(B)-Failure to notify the physician of clinical changes; (a) Nursing service shall include, but not be limited to, the following: (3) Notifying the attending physician promptly of: (B) Any sudden and/or marked adverse change in signs, symptoms or behavior exhibited by a patient.72313(a)(1)-Ineffective change in respiratory care without a physician's order;(a) Medications and treatments shall be administered as follows: (1) No medication or treatment shall be administered except on the order of a person lawfully authorized to give such order.72523(a)-Failure to follow facility policy; (a) Each facility shall adopt a written manual on cleaning, disinfecting and sterilizing procedures. The manual shall include procedures to be used in the care of utensils, instruments, solutions, dressings, articles and surfaces and shall be available for use by facility personnel. All procedures shall be carried out in accordance with the manual.The facility failed to evaluate Resident 1's significant change in respiratory condition, implement the physician's plan of care, notify the physician of the resident's significant change in condition, obtain a physician's order prior to administering care, and follow facility policy when: The facility failed to keep Resident 1 ' s oxygen level greater or equal to 90% as indicated in the physician ' s order. Further, when Resident 1 ' s oxygen saturation level fell below 90% and declined, the facility failed to evaluate or report Resident 1's acute respiratory emergency and rapid deterioration to a physician and Registered Nurse (RN). LVN D also increased Resident 1 ' s oxygen flow rate to 4 liters without a physician ' s order or notification to the physician. Resident 1 was found unresponsive and without movement by LVN E on 4/19/13 at approximately 5:30 pm. LVN E failed to evaluate and initiate CPR (cardiopulmonary resuscitation), (breathing and cardiac compressions) for Resident 1, and left the room to check on other residents. Emergency Medical Services (EMS) arrived at the facility on 4/19/13 at 5:39 pm and found Resident 1 sitting in his bed, unresponsive, pale in color, no pupil (eye) reaction (fixed and dilated), vomitus (vomit present), and an electrocardiogram (a record of the heart rate and rhythm) to show "Asystole" (absence of heartbeat). Resident 1 was transported to the hospital where he was pronounced dead on 4/19/13 at 5:59 pm. Resident 1 was a 64 year old male who was admitted to the facility on 4/15/13 with diagnoses that included pneumonia (lung infection), respiratory failure (occurs when not enough oxygen passes from your lungs into your blood) lung cancer and had recently finished chemotherapy treatments (cancer treatments). Review of the Nursing Notes, dated 4/16/13 at 12:15 am, describe Resident 1 as alert, oriented and responsive, pleasant and cooperative.Resident 1 was at the facility to receive and participate in multiple therapy programs (physical therapy, speech therapy and occupational therapy) for a limited period of time with plans to then return home. Further, upon admission to the facility, on 4/15/13, both Resident 1 and his physician (Physician J) signed a Physician Order for Life Sustaining Treatment (POLST) which stated "in the event a person (Resident 1) has no pulse and is not breathing" ... "Attempt Resuscitation/CPR" (provide breathing and chest compressions) and provide "Full Treatment" including ... "intubation (placement of a tube into the lungs to assists with breathing), advanced airway interventions, mechanical ventilations, and defibrillation/cardioversion (shock the heart to start it beating) as indicated. Transfer to the hospital..."Finally, during a review of the clinical record for Resident 1, the physician's orders, dated 4/15/13, stated, "Oxygen via nasal cannula (tube in the nose connected to oxygen), as needed for shortness of breath and keep oxygen saturations (normal level of oxygen in the blood is 90-100%) greater or equal to 90%." There was no specific physician order for the amount of oxygen to be delivered to Resident 1. During an interview with LVN D on 7/16/13 at 2:45 pm, LVN D stated that on 4/19/13, she was assigned to care for Resident 1 and also to orient LVN E, a new LVN employee. While providing care, LVN D observed that Resident 1 seemed short of breath and anxious. LVN D stated, "A CNA reported an abnormal pulse oximetry (a device used to check the oxygen level in the blood) of 80% at 3:15 pm or 3:30 pm." LVN D stated she knew her responsibility was to call the physician if an oxygen reading was 92% or less but she did not. LVN D could not recall if she went to Resident 1's room to assess his status before 4:00 pm. A review of the nurse's notes, dated 4/19/13 and timed at or after 4:00 pm, indicated LVN D had documented the following three notes which appear on the page after a note dated 4/19/13 and timed at 6:00 pm: "4/19/13 - 4:00 pm Resident checked/oxygen sat (saturation, a measure of blood oxygen level) 82% on room air, oxygen started at 2 liters with HHN (hand held nebulizer) treatment (a breathing treatment)." "4/19/13 - 4:15 pm "Resident oxygen sat continues to be 76-80%, oxygen increased to 4 liters (metric measurement).""4/19/13 - 5:00 pm Resident's oxygen sat continues to be in the (low) 80's. HHN treatment repeated. Call light within reach." During an interview with LVN D on 7/16/13 at 2:45 pm, LVN D was asked, "Did you call Resident 1's doctor or report to the RN (Registered Nurse) when Resident 1's oxygen was dropping from 82% to 76-80%?" LVN D stated she did not call Resident 1's physician. When responding to the question regarding reporting to a RN for further assessment when Resident 1 was experiencing respiratory distress, LVN D stated, "I feel like I am capable to do the job more so than the RN's. My skills are just as good if not better." LVN D stated, "Resident 1 was doing about the same or a little bit worse. I told him again he wasn't responding well and I don't know what he understood because there was a language barrier and he spoke Russian. I didn't suction him or send him out." LVN D stated, "I thought it was unusual he was a full code because usually if you are getting chemotherapy (cancer treatment) and have a NG (nasogastric) tube, you are not realizing your status."The facility's Policy and Procedure for "Oxygen", dated July 2008, states: 1."Oxygen may be administered at 2 liters/minute without a physician's order during an acute respiratory emergency or complaint of severe shortness of breath. Notify physician as soon as possible. If the resident has an urgent or life threatening need call "911", and then immediately notify physician. Continue oxygen and supportive care until emergency personnel arrive and take over the care of the resident in accordance with directives of resident or designated agent (such as a POLST)."2."Notify physician immediately and follow physician's orders for oxygen. Initiate CPR if indicated." A review of the nurse's notes dated 4/19/13, indicated LVN D increased Resident 1's oxygen to 4 liters without a physician's order or notification to the physician at 4:15 pm. Review of the facility's Policy and Procedure for "Change of Condition" dated July 2008, read, "It is the policy of this facility to identify, inform the physician and resident (or designated agent), and to intervene to provide medical or nursing care for a resident experiencing an acute medical change of condition in a timely and effective manner."During an interview with LVN E on 7/19/13 at 3:40 pm, LVN E was asked if he knew who found Resident 1 in cardiac arrest (no heart beat). LVN E stated, "I went to his room but his roommate was there. The patient was flat on his back with no movement, laying still. He looked different. His color was very different. Before it was normal but now was so much paler. I was looking at him and he didn't look right at all." When LVN E was asked what he did next, he said, "I left the room and went to check on other residents. After I left the room, I told LVN D something wasn't right. " On 7/18/13 at 4:15 pm, Registered Nurse (RN) A was interviewed. RN A, the charge nurse, when asked if LVN D had reported Resident 1 ' s change in condition to him, stated, " No, (LVN D) did not say anything to me. I stayed at the nurse ' s station and did not go into Resident 1 ' s room until he coded. I didn't know anything about him (Resident 1) until 5:30 pm. " During an interview with the Administrator (ADM) on 7/17/13 at 4:20 pm, she stated her expectations would be that the physician would be contacted. During a record review of the "Ambulance Run Report," dated 10/4/13, from the Emergency Medical Services (EMS), it documents EMS received the call from the facility (911) at 5:36 pm. EMS was dispatched (sent off to a destination or for a purpose) at 5:37 pm with arrival to the facility at 5:39 pm. The report records, "Arrived to find pt (patient) sitting in bed unresponsive ... (facility) Staff was not aware that the pt had stopped breathing ..." The EMS report treatment section records, "Pt assessment was performed. Pt was unresponsive. Pt was placed on the monitor (an electronic device) and noted to be in asystole (absence of any heart activity). CPR was started ..." The assessment specifies, "Airway - Partially Obstructed - Emesis (partially closed by vomit) - Breathing Absent", "Circulation - Pulses - Carotid (neck) - Absent (0)" By 5:54 pm had completed the assessment and transported Resident 1 to the acute hospital, arriving at 5:58 pm with no changes in route. Despite EMS beginning CPR treatment to Resident 1, including cardiac monitor (continuous monitoring for any heart activity), giving an injection of epinephrine (a strong medication used in resuscitating cardiac activity), placing an oral airway (medical device used to open and maintain a patent's airway), and giving oxygen, Resident 1 died. During a combined interview with the DON (Director of Nursing) and Nursing Supervisor on 10/11/13 at 3:05 pm, they stated that the LVN's should contact an RN to assess residents who are not doing well. In a joint interview with the DON and ADM on 10/11/13 at 4 pm, they confirmed that the RN should have been notified to reassess Resident 1, and the physician should have been notified when Resident 1's condition started to deteriorate. They also confirmed that the facility policies for oxygen administration, change of condition, and initiation of CPR were not followed.Therefore, the facility failed to evaluate Resident 1's significant change in respiratory condition, implement the physician's plan of care, notify the physician of the resident's significant change in condition, obtain a physician's order prior to administering care, and follow facility policy when: The facility failed to keep Resident 1 ' s oxygen level greater or equal to 90% as indicated in the physician ' s order. Further, when Resident 1 ' s oxygen saturation level fell below 90% and declined, the facility failed to evaluate or report Resident 1's acute respiratory emergency and rapid deterioration to a physician and Registered Nurse (RN). LVN D also increased Resident 1 ' s oxygen flow rate to 4 liters without a physician ' s order or notification to the physician. Resident 1 was found unresponsive and without movement by LVN E, who failed to evaluate and initiate CPR (cardiopulmonary resuscitation), (breathing and cardiac compressions) as indicated in the POLST for Resident 1, and left the room to check on other residents. These violations either separately or jointly presented an imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result. |
| 230000029 |
Windsor Chico Creek Care and Rehabilitation Center |
230011185 |
B |
07-Jan-15 |
4U3C11 |
5875 |
F 241 483.15(a) Dignity and Respect of Individuality The facility must promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality.The facility failed to ensure that care was provided in a manner that maintained dignity and respect for Resident 1 when he was awakened from sleep on 10/11/12 at approximately 11:00 pm and a urinary catheter procedure (a tube placed into the bladder to drain urine to an outside collection bag) was conducted by three licensed nursing (LNs C, D, and K) and two direct care staff (CNA A and B). Five staff teamed up to conduct a procedure despite Resident 1's objection, asking staff to "stop" and "go away." This failure resulted in Resident 1's increased confusion, agitation, yelling, combativeness, and pain during the procedure.A record review revealed that Resident 1 was admitted to the facility with diagnoses that included Parkinson's disease (a brain disorder that leads to muscle rigidity and difficulty with walking, balance, and coordination), dementia and anxiety disorder.The MDS (minimum data set, a resident assessment), dated 7/28/12, showed that Resident 1 had severe memory impairment and was alert and oriented to person, but was disoriented to time and place and frequently incontinent of bowel and bladder (the inability to control the passage of urine and stool). Review of Resident 1's physician's orders showed a Physician's Telephone Order for Resident 1, dated 10/4/12, to address excoriation to the peri-area (includes the genital, groin, and rectal areas), with preventative skin care every shift, and on 10/11/12 at 5 pm, an order to place a urinary catheter for comfort and pain management. The order indicated that the catheter was to be 16 french in size with a 30 cubic centimeter balloon. The order showed that the reason for the catheter was for Resident 1's comfort and pain management (due to scrotal discomfort). There was no documented medical diagnosis for the catheterization. On 6/19/13 at 4:30 pm, during an interview, LN C explained that on 10/11/12, LN D explained to her that they needed to place a urinary catheter for Resident 1, prior the end of their shift since it had been ordered earlier in the day, and it would not be fair to leave it for the limited night shift staff. LN C explained that Resident 1 was combative, confused, and yelling during the procedure. LN C stated that she "tried to calm him down" by talking him through the procedure and felt bad for Resident 1 when this did not seem to be effective. On 6/19/13 at 5 pm during an interview, Certified Nurse's Assistant (CNA) A stated that she had been a regular caregiver for Resident 1 for six or seven months, prior to the day that Resident 1 was catheterized on 10/11/12. CNA A stated that she remembered it "very vividly" because it was a "traumatic experience" to her. CNA A explained that on 10/11/12, she had already settled Resident 1 in bed for the night when a licensed nurse asked her to be in attendance while a urinary catheter was placed at approximately 10:30 pm. CNA A explained that when they (CNA A, CNA B, LN C, LN D, and LN K) entered the room Resident 1 was asleep, but was awakened for the procedure. In describing Resident 1 during the catheterization procedure, CNA A stated that Resident 1 was confused, screaming, combative, kicking, and explained that she had never seen him that agitated before, adding that the experience was "very upsetting" to her. On 6/24/13 at 12 pm, Director of Nurses (DON) E confirmed that the care provided, as described above, did not show dignity and respect for Resident 1. On 6/24/13 at 4 pm, during an interview, LN D stated he did not remember the details of what happened the evening of 10/11/12. LN D confirmed that LN C was a new employee and was orienting with him that night. LN D explained that he remembers that they attempted a catheterization procedure, but does not remember who was inserting the catheter, whether or not the balloon was inflated, or whether or not the catheter was left in place. LN D confirmed that Resident 1 was combative and may have been experiencing pain during the catheterization procedure. LN D stated he did not remember any follow-up, regarding this incident by administrative nursing staff. On 7/25/13 at 7 am, during an interview, LN K stated that she had been a regular caregiver for Resident 1 during the night shift. LN K explained that on 10/11/12 she had been walking down the hall past Resident 1's room, when LN D called from Resident 1's room to her, asking for her help with the catheterization procedure. LN K stated that there were five people in attendance including her. Two CNAs on either side of his head, two LNs on either side of his hips, and then she was there to help hold his left leg since he was combative and kicking. LN K stated that he was yelling out to "stop it," "go away," and calling them "sons of bitches" during the procedure. LN K stated that a catheterization procedure with a cooperative resident would require the presence of only two staff.Therefore, the facility failed to ensure that care was provided in a manner that maintained dignity and respect for Resident 1, when he was awakened from sleep on 10/11/12 at approximately 11:00 pm and a urinary catheter procedure (a tube placed into the bladder to drain urine to an outside collection bag), was conducted by three licensed nursing (LNs C, D, and K) and two direct care staff (CNA A and B). Five staff teamed up to conduct a procedure despite Resident 8's objection, asking staff to "stop" and "go away." This failure resulted in Resident 1's increased confusion, agitation, yelling, combativeness, and pain during the procedure.These violations had a direct relationship to the health, safety, or security of patients. |
| 230000029 |
Windsor Chico Creek Care and Rehabilitation Center |
230011190 |
A |
07-Jan-15 |
4U3C11 |
21159 |
F 281 483.20(k)(3)(i) Services Provided Meet Professional Standards The services provided or arranged by the facility must meet professional standards of quality.The facility failed to ensure that care provided met professional standards of quality when Licensed Nurses (LNs) C and D failed to follow the facility's policy and accepted standards of care for a urinary catheterization procedure (a procedure during which a tube was placed into the bladder to drain urine to an outside collection bag), failing to include verification of proper placement in the bladder (verified by urine flow into the catheter), prior to the inflation of the catheter balloon, for Resident 1.The balloon is integral to the catheter, designed to keep the catheter securely in place by being inflated with 30 cubic centimeters (approximately 1 ounce) of fluid, after the catheter has been advanced through the urethra (a narrow canal through which urine is discharged from the bladder, and in males, travels the length of the penis before emptying) and proper placement into the bladder is verified.This failure resulted in avoidable psychosocial and physical harm to Resident 1 when he was awakened from sleep, was confused, yelling, combative, and in pain during the procedure, and subsequently sustained severe trauma to his urethra, bled profusely from his penis, suffered severe pain, and had severe bruising and swelling of his penis, scrotum, and groin area. Resident 1 required two emergent transfers to an acute care hospital where he was treated for severe urethral trauma, urinary tract infection (UTI), and severe sepsis with bacteremia (bacterial infection in the blood) secondary to a UTI.A record review revealed that Resident 1 was admitted to the facility on 3/12/10 with diagnoses that included Parkinson's disease (a brain disorder that leads to muscle rigidity and difficulty with walking, balance, and coordination), dementia and anxiety disorder.The MDS (minimum data set, a resident assessment tool), dated 7/28/12, showed that Resident 1 had severe memory impairment, was alert and oriented to person, but was disoriented to time and place, and was frequently incontinent of bowel and bladder (the inability to control the passage of urine and stool). Resident 1 desired a full code status (cardiopulmonary resuscitation (CPR) in the event of cardiac or respiratory arrest, and transfer to hospital for further treatment at a higher level of care, as needed). Review of Resident 1's physician's orders showed an order on 10/11/12 at 5 pm, to place a urinary catheter for comfort and pain management. The order indicated that the catheter was to be 16 french in size with a 30 cubic centimeter balloon. The order showed that the reason for the catheter was for Resident 1's comfort and pain management (due to scrotal discomfort). There was no documented medical diagnosis for the catheterization. The Nurses Progress Notes, dated 10/11/12 at 5 pm, showed that Resident 1 had pain related to scrotal excoriation. The Nurses Progress Notes, dated 10/12/12, showed a late entry for 10/11/12 that documented a urinary catheter had been placed at approximately 11 pm on 10/11/12. The notes indicated that LNs C and D, who were both present during the procedure, had confirmed that the catheter was properly placed in the bladder even though no urine was observed in the catheter. The notes indicated that LNs C and D reasoned that Resident 1's bladder was empty because he had just been incontinent of urine.The facility document titled, "Urinary Catheterization Procedure," dated 7/2008, showed that the balloon should be inflated after proper placement in the bladder had been established, evidenced by urine flow into the catheter. The policy and procedure did not indicate any alternative methods to verify bladder placement, nor identify what to do if no urine flow occurred.On 6/19/13 at 11 am, during an interview, LN F stated that he had been a regular caregiver for Resident 1 since his admission to the facility. LN F explained that he was working on 10/12/12 when Resident 1 came back from the ED. LN F stated that he was "shocked" by what he saw. Resident 1 had severe bruising to his scrotum and groin area that was dark purple in color. LN F stated that Resident 1 seemed to be in a lot of pain. His scrotum was swollen to almost double its normal size. LN F explained that he called Resident 1's physician (MD H) and described Resident 1's status. MD H ordered Norco 5/325 milligrams (a narcotic pain medication) to be given every four hours, as needed for moderate pain. Additionally, the record showed an order for Pyridium 100 milligrams (a medication given for relief of urinary tract pain) to be given three times a day, for three days.On 6/19/13 at 4:30 pm, during an interview, LN C explained that on 10/11/12, LN D told her that they needed to place a urinary catheter for Resident 1, prior to the end of their shift, since it had been ordered earlier in the day, and it "would not be fair to leave it for the limited night shift staff." LN C explained that Resident 1 was combative, confused, and yelling during the procedure. LN C stated that she tried to calm Resident 1 down by talking him through the procedure and felt bad for Resident 1, when this did not seem to be effective. LN C stated she did meet some resistance while attempting to insert the catheter, but denied using any excessive force. LN C did not feel completely confident about the catheters proper placement in the bladder and remembered telling the night shift nurse there had not been any urine in the catheter, and requested it be checked in a short while and removed, if needed. LN C explained that after she heard that Resident 1 had been hospitalized the next day, she "felt terrible" and remembers initiating a discussion where she described this experience to DON J. LN C stated she did not remember any follow-up by administrative nursing staff to ensure that this problem would not recur. There was no in-servicing on proper catheterization procedure or what to do if no urine return, no counseling of the licensed nurses involved, and no auditing of current residents and staff to evaluate catheterization competency.When asked why she did not stop the catheterization procedure, LN C explained that she was a new employee, still on orientation, and did not know Resident 1. LN C stated that everyone else in the room did know Resident 1, so she thought this was his normal level of agitation that could not be relieved. LN C stated that LN D encouraged her to continue with the procedure and when they concluded that the catheter must be in the bladder; LN D reached over and inflated the balloon. LN C stated that in hind sight, she would do things much differently. LN C explained that if she were to do it over, she would not give in to "being intimidated" by the presence of other experienced staff, but instead would ask for Resident 1 to be medicated for pain and/or anxiety, prior to the procedure. LN C further explained that when there was no urine return, she would remove the catheter and stop the procedure. LN C stated that she had been a nurse for over 20 years and had never inflated a catheter's balloon when there was no urine return prior to this day. LN C explained that without urine return into the catheter, it would not be possible to be certain of proper placement in the bladder. On 6/19/13 at 5 pm, during an interview, Certified Nurse's Assistant (CNA) A stated that she had been a regular care giver for Resident 1 for six or seven months. In remembering the evening of 10/11/12, CNA A explained that the experience was still very vivid in her mind because it was so "traumatic" to her. CNA A stated that she had already settled Resident 1 in bed for the night at approximately 10:30 pm when she was asked to be in attendance while a urinary catheter was placed. CNA A explained that when they (CNA A, CNA B, LN C and LN D) entered the room, Resident 1 was asleep, but was awakened for the procedure. In describing Resident 1 during the catheterization procedure, CNA A stated that Resident 1 was confused, screaming, combative, and kicking. She stated that she had never seen Resident 1 that agitated before, adding that the experience was "very upsetting" to her. When asked specifically what she was doing during the procedure, CNA A stated that she was rubbing Resident 1's hand and arm while telling him that "it (the catheterization procedures) was almost over." CNA A stated that she had been in attendance during many catheterizations, and this was the first time she had ever seen the balloon inflated when no urine had been visualized in the catheter.On 6/24/13 at 2:30 pm, during an interview, the Director of Nurses (DON) J explained that she had been working the morning of 10/12/12 when the nurses called her into Resident 1's room. DON J stated that Resident 1 was "bleeding profusely" from his penis. DON J stated that the blood was soaking onto the sheets, towels, and blankets on his bed. DON J explained that they were having difficulty getting the bleeding to stop. Resident 1's physician (MD H) was already in the facility, examined Resident 1, and placed an order to transfer Resident 1 to the emergency room (ED) for evaluation. On 6/24/13 at 4 pm, during an interview, LN D stated he did not remember the details of what happened the evening of 10/11/12. LN D confirmed that LN C was a new employee and was orienting with him that night. LN D explained that he remembers that they attempted a catheterization procedure, but does not remember who was inserting the catheter, whether or not the balloon was inflated, or whether or not the catheter was left in place. LN D confirmed that Resident 1 was combative and may have been experiencing pain during the catheterization procedure. LN D explained that without urine return into the catheter, it would not be possible to be certain of proper placement in the bladder. LN D stated he did not remember any follow-up, regarding this incident by administrative nursing staff to address the incident.On 7/12/13 at 8:45 am, during an interview, Family Member (FM) O explained that after hospitalization, Resident 1 had been transferred to a different skilled nursing facility on 10/26/12 where Resident 1 was in a semi-vegetative state. FM O explained that Resident 1 was not able to eat effectively, requiring that his nutrition be delivered via a feeding tube inserted into his stomach. FM O stated that Resident 1 had lost his personality and ability to make his needs known. FM O stated that the new facility was able to heal Resident 1's scrotal wound with topical treatments, adding that Resident 1 had not been catheterized at all after the experience on 10/11/12. FM O explained that prior to the incident with the "botched" catheterization procedure, Resident 1 interacted with persons in his environment, but now Resident 1 was completely dependent and unable to participate in activities of daily living. FM O stated the "whole family was so sad about what had happened to their father."On 7/24/13 at 7:15 am, during an interview, the facility's nurse consultant who was acting as the current Director of Nurses (DON P), stated that the facility followed accepted standards of practice for their catheterization procedures and that their policy was based on Lippincott's Fundamentals in Nursing manual. The manual included Procedure Guideline 21-3 for the "management of the patient with an indwelling catheter." The guideline showed that it was important to be sure the "catheter is draining properly before inflating the balloon." The rationale for this guidelines indicated that "inadvertent inflation of the balloon within the urethra is painful and causes urethral trauma." The procedure further indicated that "excessive manipulation of the catheter may promote migration of bacteria," and that "Backward and forward displacement of the catheter introduces contaminants into the urinary tract."On 7/25/13 at 7 am, during an interview, LN K stated that she had been a regular caregiver for Resident 1 during the night shift. LN K explained that on 10/11/12 she had been walking down the hall past Resident 1's room, when LN D called to her asking for her help with the catheterization procedure. LN K stated that there were five people in attendance, including her. Two CNAs on either side of his head, two LNs on either side of his hips, and then she was there to help hold his left leg since he was combative and kicking. LN K stated that he was yelling out to "stop it," "go away," and calling them "sons of bitches" during the procedure. LN K stated that a catheterization procedure with a cooperative resident would require the presence of only two staff.Review of the Medication Record, dated 10/2012, showed that Resident 1 was not medicated for pain, prior to the catheterization procedure. The most recent dose of Ativan 0.25mg (ordered to be given every 6 hours as needed for anxiety) had been given at 5 am on 10/11/12.The most recent dose of Tylenol 650 mg (ordered to be given every 4 hours as needed for mild pain) had been given at 12:30 am the night before. The Nurses Progress Notes, dated 10/12/12 at 2:50 am (approximately four hours after the catheter was inserted), indicated that Resident 1 had no urine in the catheter. The notes showed that LN E deflated the balloon and removed the catheter. On 10/12/12 at 10:45 am, a nurse documented that when the CNA checked for Resident 1's incontinence status, "blood was coming out from his penis - MD (medical doctor), is in and look at the resident - MD ordered to send resident to ER (emergency room) for treatment and evaluation since blood continue to come out from penis - LN called 911 and came in at 10:45 to pick up the resident." Documentation on the facility's transfer form (form to communicate important information about a resident to the hospital emergency department), dated 10/12/12, showed that the reason for Resident 1's transfer to the emergency department was "bleeding." No explanation of the source or extent of bleeding was found. The paramedic documentation titled, "Patient Care Report" (form to communicate important information about Resident 1's status to the ED staff), dated 10/12/12, indicated that Resident 1 had less than five cubic centimeters (cc) of blood at the meatus (tip) of his penis. No explanation of the extent of bleeding was found. A review of Resident 1's ED record, dated 10/12/12, indicated that during a telephone consult, Urologist G concluded that since Resident 1 had been incontinent of urine while in the ED, an ultrasound of Resident 1's bladder did not show evidence of urinary retention, and Resident 1 had previous bleeding from catheter trauma, urinary catheterization was not necessary. Documentation noted ecchymosis (seepage of blood into the tissue, that appears dark red to dark purple in color), to the scrotum. No documentation was found to show the extent of bleeding that had occurred in the facility. After approximately two hours in the ED, Resident 1 was transferred back to the facility with physician orders for topical treatments to address his scrotal wound.The Nurses Notes, dated 10/13/12, during the night shift, showed that at 02:00 am, Resident 1's condition worsened; "Eyes open when moved but no response to name." At 0430 Resident 1 developed a fever of 103 degrees, had a congested cough. The notes indicated that MD H was notified and nursing was awaiting a call back. At 0525 am, Resident 1's oxygen saturation (the level of oxygen in the blood) that was below normal at 86% (indicates insufficient oxygen level). The notes indicated that MD H was again called and nursing staff were awaiting a response from MD H. At 05:55 am and again at 6:20 am, the notes indicated that MD H was called and nursing staff were awaiting a response, and Resident 1 was exhibiting a decreased level of consciousness. At 06:30 am, MD H returned the calls previously made by the facility and ordered that Resident 1 be transferred to the local hospital for evaluation and treatment.The paramedic documentation on the Patient Care Report indicated that when they arrived in Resident 1's room on 10/13/12 at 7:05 am, he was lying on his back in bed, was unresponsive, and had a respiratory rate of 8 breaths per minute (the minimum normal respiratory rate for adults is 12 breaths per minute) with periods of apnea (no breathing). The documentation further showed that Resident 1 was only responsive to painful stimuli. Resident 1 had bruising and swelling to his entire genital area. The report indicated that Resident 1 was medicated, with Norco 5/325 milligrams (mg) at 5:25 pm the prior evening, for pain, and had received a Tylenol suppository at 4 am to address his fever.A review of the ED documentation, dated 10/13/12, showed that Urologist G performed a cystoscopy (a procedure that allows the physician to look at the interior lining of the bladder and the urethra) for Resident 1 while he was in the ED. The Cystoscopy report, dated 10/13/12, showed that the part of Resident 1's urethra that passed through his penis was normal, but the bulbar and membranous area (a segment of the urethra between the penis and the bladder) was filled with blood clots and had no recognizable normal urothelium (layer that lines the urethra). There were multiple false passages and evidence of severe trauma. The report indicated that, after 25 minutes, the cystoscopy was terminated, when multiple attempts to find a passage to the bladder were unsuccessful. The report further indicated that Resident 1 had significant scrotal swelling and bruising. There was bruising to the entire scrotum that was "probably secondary to urethral trauma." Urologist G documented that he "did not attempt any catheterization, prior to flexibly cystoscoping the patient, so obviously this trauma was present from previous urethral manipulation" with the Foley catheter. Additionally, the report indicated that as long as Resident 1 was able to decompress his bladder with incontinence and was comfortable, catheterization would not be necessary.The Hospitalist's (Hospital physician) Assessment/Plan, dated 10/16/12, indicated that Resident 1 had urethral trauma, severe bacteremia (bacterial infection in the blood) secondary to a urinary tract infection.A record review indicated that Resident 1's admission to the hospital from 10/13/13 through 10/26/13 required the following treatment and/or interventions: -The Medication Administration Record showed that Morphine 2 mg (a strong narcotic medication) was administered five times for the treatment of Resident 1's severe pain. -Physician's Orders, dated 10/13/12, indicated Resident 1 was treated with multiple antibiotic therapies required for treatment of multiple severe bacterial infections. -Resident 1's scrotum was treated with cooling measures, special positioning requirements, preventative skin care, and a dressing to the wound.-Insertion of a PICC line (a long, flexible tube that is inserted into a vein, typically in the upper arm, and advanced until the catheter tip terminates in a large vein in the chest near the heart) to maintain IV access for the delivery of medications. -A Computed Tomography (CT) scan (an imaging method that uses x-rays to create detailed pictures of cross-sections of the body) of Resident 1's brain on 10/16/12, showed that Resident 1 had suffered a new stroke.- A naso-gastric tube (a tube that is passed through the nose and into the stomach) was placed for maintenance of nutritional needs and administration of medications. -A permanent gastric tube (a tube requiring surgical insertion through the abdomen that delivers nutrition directly to the stomach) was placed on 10/24/12 due to his prolonged inability to swallow. Therefore, the facility failed to ensure that care provided met professional standards of quality when Licensed Nurses (LNs) C and D failed to follow the facility's policy and accepted standards of care for a urinary catheterization procedure (a procedure during which a tube was placed into the bladder to drain urine to an outside collection bag), failing to include verification of proper placement in the bladder (verified by urine flow into the catheter), prior to the inflation of the catheter balloon, for Resident 1. This failure resulted in avoidable psychosocial and physical harm to Resident 1 when he was awakened from sleep, was confused, yelling, combative, and in pain during the procedure, and subsequently sustained severe trauma to his urethra, bled profusely from his penis, suffered severe pain, and had severe bruising and swelling of his penis, scrotum, and groin area. Resident 1 required two emergency transfers to an acute care hospital where he was treated for severe urethral trauma, urinary tract infection (UTI), and severe sepsis with bacteremia (bacterial infection in the blood) secondary to a UTI.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. |
| 230000029 |
Windsor Chico Creek Care and Rehabilitation Center |
230011191 |
B |
07-Jan-15 |
4U3C11 |
5705 |
F 309 483.25 Provide Care/Services for Highest Well BeingEach resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care.The facility failed to provide effective pain management for Resident 1 by failing to assess pain location and intensity level and re-assess pain location and intensity, and evaluate effectiveness of administered pain medication for Resident 1's pain. These failures contributed to ineffective pain management for Resident 1 and unrelieved, uncontrolled pain.A record review revealed that Resident 1 was admitted to the facility with diagnoses that included Parkinson's disease (a brain disorder that leads to muscle rigidity and difficulty with walking, balance, and coordination), dementia and anxiety disorder.The MDS (minimum data set, a resident assessment tool), dated 7/28/12, showed that Resident 3 had severe memory impairment and was alert and oriented to person, but was disoriented to time and place.A review of physician's orders indicated that on 3/12/10, Resident 1's physician ordered Tylenol 325 milligrams (mg), two tablets to be given every 4 hours, as needed, for mild pain. A Physician's Telephone Order for Resident 1, dated 10/4/12, was noted to address excoriation to the peri-area (includes the genital, groin, and rectal areas), with preventative skin care every shift, and on 10/11/12 at 5 pm, an order was noted to place a urinary catheter for comfort and pain management. The order showed that the reason for the catheter was for Resident 1's comfort and pain management (due to scrotal discomfort). There were no medications ordered for moderate or severe pain until 10/12/12 at 3:30 pm when Resident 1's physician ordered Norco (narcotic pain medication) 5/325 mg every 4 hours, as needed for moderate pain. There were no orders to address severe pain.On 7/24/13 at 7:15 am, during an interview with the Director of Nurses (DON) and concurrent review of Resident 1's medication administration records (MARs) for October 2012, it was noted that the MAR document called for nursing documentation of date and time, nursing initials, medication order, reason for medication, and result after medication administration. The following documentation was noted:On 10/5/12 at 01:00 am, Tylenol 650 mg was given for "grimacing" and the documented result was "helpful." There was no documented pain intensity level before or after pain medication was given to evaluate the effectiveness of the medication, and no location of the pain;On 10/6/12 at 01:00 am, Tylenol 650 mg was given for 5/10 pain (moderate pain) and the documented result was "helpful." There was no documented pain intensity level after pain medication was given to evaluate the effectiveness of the medication, and no location of the pain;On 10/9/12 at 12:20 pm, Tylenol 650 mg was given for "acorns hurt" and the documented result was not documented (blank). There was no documented pain intensity level before or after pain medication was given to evaluate the effectiveness of the medication;On 10/10/12 at 05:50 am, Tylenol 650 mg was given for 4/10 pain and the documented result was "effective." There was no documented pain intensity level after pain medication was given to evaluate the effectiveness of the medication, and no location of the pain;On 10/11/12 at 12:30 am, Tylenol 650 mg was given for 5/10 pain and the documented result was "effective." There was no documented pain intensity level after pain medication was given to evaluate the effectiveness of the medication, and no location of the pain;(Resident 1 was improperly catheterized on 10/11/12 at approximately 11:00 pm, resulting in physical harm and pain).On 10/12/12 at 01:30 am, Tylenol 650 mg was given for 8/10 (severe) pain "hollering ouch!" and the documented result was "effective." There was no documented pain intensity level after pain medication was given to evaluate the effectiveness of the medication, and no location of the pain;On 10/12/12 at 06:00 am, Tylenol 650 mg was given for 8/10 (severe) pain "hollering ouch!" and the documented result was "effective." There was no documented pain intensity level after pain medication was given to evaluate the effectiveness of the medication, and no location of the pain;On 10/12/12 at 3:30 pm, Norco 5/325 mg every 4 hours, as needed for moderate pain was ordered.The DON acknowledged that the licensed nursing staff failed to effectively assess, evaluate, and re-evaluate Resident 1's pain to ensure effective, controlled pain relief. It was noted that the only pain medication ordered for Resident 1 was Tylenol 325 mg two tablets every 4 hours, as needed for mild pain. However, Resident 1 was suffering moderate to severe pain and there were no orders to treat moderate or severe pain until 10-12-12 at 3:30 pm, at which time Norco was ordered for moderate pain, but nothing was ordered for severe pain. There was no evidence in Resident 1's record that the physician was notified of or that further treatment to address Resident 1's moderate to severe pain was obtained, until 10/12/12 when Norco was ordered.Therefore, the facility failed to provide effective pain management for Resident 1 by failing to assess pain location and intensity level and re-assess pain location and intensity, and evaluate effectiveness of administered pain medication for Resident 1's pain.These failures contributed to ineffective pain management for Resident 1 and unrelieved, uncontrolled pain.These violations had a direct relationship to the health, safety, or security of patients. |
| 630007351 |
Wynn House |
250009603 |
B |
20-Nov-12 |
QTLF11 |
3665 |
Class B Citation Health and Safety Code 1418.91(a) (b) 1418.91. (a) A long-term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the department immediately, or within 24 hours. (b) A failure to comply with the requirements of this section shall be a class "B" violation.The facility failed to investigate an allegation of abuse after a facility staff suspected FM 1 of taking money from clients' funds. The facility failed to notify the Department (California Department of Public Health) of the allegation of financial abuse, immediately or within 24 hours.A telephone call was made to the complainant on March 5, 2008, at 10:45 a.m. The complainant stated she suspected FM 1(Facility Manager), a former employee, taking money from various clients' trust accounts for her personal use. The complainant stated QMRP 1(Qualified Mental Retardation Professional), who was the first QMRP for the facility, informed the Quality Assurance Director (QAD) that she suspected FM 1 taking money from the client's trust account and that the receipts were not adding up correctly. The complainant stated there was no investigation conducted regarding the issue.On March 19, 2008, at 11:15 a.m., QMRP 1 was interviewed. QMRP 1 stated she worked at the facility with FM 1 for approximately one year. She stated she is now currently working at another home for the corporation. She stated during her time working with FM 1, she suspected that FM 1 was taking money from the clients' funds. She stated there were times that FM 1 was not turning in receipts timely for items purchased for the clients. She stated when staff makes a purchase for the clients; the staff has five days to turn in the receipts. She stated when she brought up her concern to the QAD; she was removed from the facility and was transferred to another facility. She stated the allegation was not investigated.An unannounced visit was made to the facility on March 19, 2008, at 1:45 p.m., for the purpose of investigating the complaint. The personnel record for FM 1 was reviewed on March 19, 2008. FM 1 had been hired by the corporation on October 1, 2001, and was terminated on October 19, 2007, for failing to follow the facility's abuse policy, and failing to communicate with the supervisor regarding an abuse incident. An interview was conducted with the QAD on June 4, 2008. The QAD stated he was unaware of the allegations regarding FM 1. He stated QMRP 1 worked at the facility from May to December 2006. He stated the allegation was not investigated or reported to the Department. He stated he did not have any conversation with QMRP 1 regarding FM 1 abusing the clients' fund.A review of the facility policy and procedure for abuse prevention indicated, "Mistreatment, neglect or abuse can be physical, mental emotional, sexual, or financial. Suspected mistreatment, neglect, or abuse should be reported to the Facility Manager and administrative staff immediately, who will make a preliminary report to the Police Department as necessary, and the licensing agencies... A complete investigation of the allegation will follow." The facility failed to investigate an allegation of financial abuse after a facility staff suspected FM 1 of taking money from clients' funds. The facility failed to notify the CDPH of the allegation of financial abuse. The facility's failure to investigate and report the allegation placed all the clients at risk for potential financial abuse.The above violations caused or occurred under circumstances likely to cause significant humiliation, dignity, anxiety, or other emotional trauma to patients. |
| 250000830 |
WILLIAM DEMAREST CANYON COUNTRY CLUB HOUSE |
250010395 |
B |
30-Jan-14 |
QPX411 |
6589 |
ACCIDENTS W & I 4502 (H) Rights of persons with developmental disabilities. Persons with developmental disabilities have the same legal rights and responsibilities guaranteed all other individuals by the Federal Constitution and laws and the Constitution and laws of the State of California. No otherwise qualified person by reason of having a developmental disability shall be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity, which receives public funds. It is the intent of the Legislature that persons with developmental disability 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. Title 22 - 76860 (a) (4) - Developmental Program Services - Individual Service Plan. Each client shall have an individual service plan that: Identifies the client's developmental, social, behavioral, recreational and physical needs.The facility failed to protect the client's right to be free from harm. On May 18 and 25, 2010, unannounced visits were made to the facility to investigate a complaint regarding an accident.The facility failed to ensure an individual service plan (ISP) objective was developed and implemented for Client A's behavior of poor impulse control manifested by grabbing objects. This failed practice resulted in the Client suffering second degree burns (characterized by redness, blisters and pain, may involve both superficial and deep skin layers,) to both thighs when he grabbed a pot of hot coffee, spilling it on himself. A review of Client A's record was conducted on May 18, 2010. Client A was admitted to the facility on March 11, 2010, with diagnoses of cerebral palsy (spasms to the arms, legs and torso) and severe mental retardation. Review of Client A's, "Occupational Therapy Clinical Observation And Assessment Consultation," completed by the Occupational Therapist (OT) 1, dated March 24, 2010, was conducted on May 18, 2010.An interview was conducted with the Facility Manager (FM), on May 18, 2010, at 10:30 a.m. The FM stated, "The incident occurred on Sunday, May 16, at noon. We had three staff on, and five clients. I was on a one to one with one client in his room. We had another client who was having a behavior of hitting and scratching in the dining area, so the other staff member took him outside. One client was watching television and (Client A) was in front of the slider in the dining room. Direct Care Staff (DCS) 1 was going to start cooking lunch when (Client A) wheeled himself next to the sink where the coffee pot was. He grabbed the pot. It spilled onto his lap." The "Occupational Therapy Clinical observation and Assessment Consultation," dated March 24, 2010, indicated, "Settling into his new ICH (intermediate care facility) placement, the first move for this client in many, many years... He makes his needs and wants known through routine, behavior, gestures and grimacing. He can become more and more agitated when others are agitated, he rocks back and forth, and has bitten himself on the wrist/hand; not usually breaking the skin. Has poor impulse control, will grab objects without regard... Has good active use of his extremities to explore his environment; and will do so with some curiosity." A review of Client A's "Social Assessment," dated March 11, 2010, was conducted on May 18, 2010. The document indicated, "(Client A) at meal times will throw his plate or food on a regular basis. DCS has to supervise and monitor at all times for safety. (Client A) needs some assistance for eating but he will attempt to feed himself if he is sitting there for a long period of time. (Client A) enjoys all his liquids especially coffee and soda which will be monitored by the staff." An interview was conducted with DCS 1 on May 18, 2010, at 11:30 a.m. DCS 1 stated while she was preparing to cook lunch at noon, and was looking in the refrigerator (Client A) pulled the coffee pot off of the counter and poured coffee on himself before she could grab the pot to stop him. DCS 2 took him to the hospital. An interview was conducted with OT 1 on May 24, 2010, at 9:35 a.m. OT 1 stated when he wrote on (Client A's) assessment he had poor impulse control and will grab objects without regard, this meant that (Client A) would have had no idea of the danger of the object he may attempt to grab.On May 18, 2010, at noon, Client A was observed lying in bed, with a blanket covering him, from head to toe. The Facility Manager pulled Client A's blanket down to his ankles. Client was heard to moan softly. Multiple large areas of broken, blistered, and reddened skin were observed on both the upper and back areas of Client A's thighs.An interview was conducted with the Qualified Mental Retardation Professional (QMRP) on May 24, 2010, at 10:30a.m. The QMRP stated at the team meetings, where the ISP goals are developed, he, the OT, the Physical Therapist, and the nurse are present... The goals are then reviewed with the Direct Care Staff. The QMRP further stated an ISP goal was not developed for (Client A) to address his behavior of grabbing objects. During an interview with the QMRP on May 25, 2010, at 8:30 a.m., the QMRP stated Client A was taken to the local hospital emergency department on May 24, 2010, when the client had a temperature of 99 degrees. The QMRP stated Client A was subsequently admitted to the hospital.A review of the, "Emergency Department Record," dated May 24, 2010, (no time documented) indicated, "Bilateral inner thighs with healing burn. Right lateral thigh with non healing 2nd deg. (degree) burn with erythema (reddened area) surrounding burn." The facility failed to ensure an ISP was implemented to address Client A's behavior of grabbing objects, without regard to their potentially inherent danger, which resulted in Client A being admitted to the hospital, after suffering second degree burns to both of his thighs after grabbing a pot of hot coffee, which spilled onto his lap. Therefore, the facility failed to ensure an ISP was developed and implemented for Client A's behavior of poor impulse control manifested by grabbing objects. This failed practice resulted in the Client suffering second degree burns to both thighs when he grabbed a pot of hot coffee, spilling it on himself. The violation of this regulation has a direct relationship to the health and safety of the patient. The violation presented an imminent danger that serious physical harm would result. |
| 970000147 |
WESTLAKE CONVALESCENT HOSPITAL |
910010148 |
B |
16-Sep-13 |
4YIE11 |
4810 |
F224483.13(c) The facility must develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. Based on interview and record review, the facility failed to implement written policies and procedures to ensure Resident 1 had a means to safeguard his wallet and prevent the theft of his debit card, which he preferred to keep in his possession since his admission to the facility. As a result, a facility staff accessed Resident 1?s debit card, and withdrew $1000 from his bank account without his authorization. Not until after the theft, did the facility offer the resident a lock for his drawer and closet. Resident 1 stated he was depressed, sad, and frustrated over the loss of his money. On April 16, 2013, an entity reported incident was investigated regarding unauthorized withdrawal of money from Resident 1's bank account. On June 10, 2013, a review of Resident 1's clinical record indicated he was admitted to the facility on February 26, 2013.The Minimum Data Set (MDS), an assessment and care screening tool, dated March 10, 2013, identified the resident as being alert, cognitively intact, requiring limited assistance from staff with bed mobility, transfer between surfaces, one person assist in dressing, toileting and personal hygiene.Review of the facility's Report of Suspected Dependent Adult/Elder Abuse form dated March 29, 2013, indicated the resident reported his wallet was missing. The investigation indicated the wallet contained the resident's driver's license, social security card, and his ATM (Automated Teller Machine) debit card.A review of the Fraud Statement obtained from the resident's bank dated April 2, 2013, indicated there were five withdrawals of $200.00 equaling $1,000.00 made from Resident 1's debit account.During an interview on May 21, 2013, at 4:30 p.m., Resident 1 stated the facility staff was aware that he was keeping his wallet. The resident stated he checked it in on the property list upon admission. He further stated no one explained to him the facility would not be responsible for lost belongings until his wallet was stolen. After the theft the facility put locks on his drawer and his closet. He stated he always kept his wallet in his pants pocket and would hang his pants in his closet. The resident stated he was depressed, sad, and frustrated over the loss of his money. During an interview on June 10, 2013, at 2:45, the social service designee (SSD) stated that on admission the facility's staff should explain the theft policy and advise the residents to allow social services to safe guard their belongings. It was stated that the facility was aware that the resident kept his wallet in his back pocket since his admission to the facility.The facility's undated Theft Prevention policy and procedure indicated the facility to the extent possible shall prevent theft or loss of a resident's valuables by providing a safe and secure environment. During an interview with the director of nurses (DON) on May 21, 2013, at 3 p.m., after reviewing the resident's medical records, there was no evidence that the risks and benefits of keeping the resident's wallet were explained to the resident. The DON stated they should have explained the risks and benefits of keeping his wallet to the resident to assist him with his decision to keep his wallet himself, and they should have offered him a means to lock his wallet for safekeeping. On July 22, 2013, the Department received a written report from the facility SSD indicating the Los Angeles Police Department (LAPD) had contacted them on July 19, 2013, to assist in identifying the thief. The LAPD stated they had a picture of the thief withdrawing money from the resident's account.On August 2, 2013, during a follow up call to the LAPD by the Department, it was revealed that the facility did not go to identify the thief until July 30, 2013, eleven days after they were called.On August 2, 2013, at 2:30 p.m., during a telephone interview with the administrator, he stated a certified nursing assistant had been arrested for the theft this morning. Therefore, the facility failed to implement written policies and procedures to ensure Resident 1 had a means to safeguard his wallet and prevent the theft of his debit card, which he preferred to keep in his possession since his admission to the facility. As a result, a facility staff accessed Resident 1?s debit card, and withdrew $1000 from his bank account without his authorization. Not until after the theft, did the facility offer the resident a lock for his drawer and closet. Resident 1 stated he was depressed, sad, and frustrated over the loss of his money. This had a direct relationship to the health, safety, and security of Resident 1. |
| 970000054 |
WESTERN CONVALESCENT HOSPITAL |
910010754 |
B |
19-Jun-14 |
ZWAE11 |
3628 |
CALIFORNIA HEALTH AND SAFETY CODE DIVISION 2. CHAPTER 2. ARTICLE 8.5Section 1336.2. (a) (4) (a) Before residents are transferred due to any change in the status of the license or operation of a facility, including a facility closure or voluntary or involuntary termination of a facility?s Medi-Cal or Medicare certification, the facility shall take reasonable steps to transfer affected residents safely and minimize possible transfer trauma by, at a minimum, doing all of the following: (4) At least 30 days in advance of the transfer, inform the resident or the resident?s representative of alternative facilities that are available and adequate to meet resident and family needsBased on observation, interview and record review, the facility failed to provide a written notice of transfer to Patient 1 and/or family member or legal representative at least 30 days before the patient is transferred out of the facility. A construction project to install sprinklers required the facility to remove all patients from the second floor. The project was in response to the facility non-compliance with the federal regulation that requires all long term care facilities to be equipped with a supervised automatic sprinkler system by August 13, 2013. This transfer of patients with less than a 30 day notice is a violation of the patient?s rights. Findings: On April 8, 2014 at 10:52 a.m., the Department received a complaint allegation regarding transfer discharge (T/D) rights. On April 8, 2014 at 2:45 p.m., the Department conducted an onsite visit to monitor the relocation of facility patients due to the facility's sprinkler installation project. According to the Life Safety 2567 (Statement of Deficiencies and Plan of Correction), dated December 11, 2013, the facility was not completely covered with an automatic sprinkler system in accordance with the National Fire Protection Association (NFPA) 13, and the facility lacked a fire sprinkler system. There was no plan to ensure the patients were given the 30 day notification prior to the transfer out of the facility due to the sprinkler system installation project.On the same day during an interview, the administrator disclosed she held a meeting with the facility's task force committee. The committee discussed obtaining approval of the relocation plans for the sprinkler system installation project. A review of clinical records for Patient 1, disclosed there was less than a 30 day timeframe for the Notice of Proposed Transfer/Discharge before the scheduled transfer out of the facility. In addition, the written notice did not include a completion date for the sprinkler system installation project or an expected date for the patient?s return to the facility.During an interview on April 9, 2014, at 9:55 a.m., Patient 1, stated the facility explained the installation of the sprinkler system. The transfer was temporary and the transfer back to the facility would be in approximately two months. The undated facility policy and procedure titled, "Transfer/Discharge", described that when patient transfers/discharges are initiated by the facility, the Notice of Proposed Transfer/Discharge policy will be followed. The notice indicated the facility may proceed with the transfer/discharge at the end of thirty (30) days, even if a decision on the appeal has not been rendered. The facility failed to provide a 30 day written notice of transfer to Patient 1 and/or family member or legal representative at least 30 days before the patient transferred out of the facility. The above violation has a direct relationship to the health safety or security of patients. |
| 970000054 |
WESTERN CONVALESCENT HOSPITAL |
910010757 |
B |
19-Jun-14 |
ZWAE11 |
3461 |
ARTICLE 8.5. Long-Term Care Facility Advance Notification Requirements [1336 - 1336.4] (Article 8.5 added by Stats. 1983, Ch. 799, Sec. 1. ) Section 1336.2. (a) (4) (a) Before residents are transferred due to any change in the status of the license or operation of a facility, including a facility closure or voluntary or involuntary termination of a facility?s Medi-Cal or Medicare certification, the facility shall take reasonable steps to transfer affected residents safely and minimize possible transfer trauma by, at a minimum, doing all of the following: (4) At least 30 days in advance of the transfer, inform the resident or the resident?s representative of alternative facilities that are available and adequate to meet resident and family needs Based on observation, interview and record review, the facility failed to provide a written notice of transfer to Patient 41 and/or family member or legal representative at least 30 days before the patient is transferred out of the facility. A construction project to install sprinklers required the facility to remove all patients from the second floor. The project is in response to the facility non-compliance with the federal regulation that requires all long term care facilities to be equipped with a supervised automatic sprinkler system by August 13, 2013. This transfer of patients with less than a 30 day notice is a violation of the patient?s rights.Findings: On April 8, 2014 at 10:52 a.m., the Department received a complaint allegation regarding transfer discharge (T/D) rights.On April 8, 2014 at 2:45 p.m., the Department conducted an onsite visit to monitor the relocation of facility patients due to the facility's sprinkler installation project.According to the Life Safety 2567 (Statement of Deficiencies and Plan of Correction), dated December 11, 2013, the facility was not completely covered with an automatic sprinkler system in accordance to the National Fire Protection Association (NFPA) 13 and the facility lacked a fire sprinkler system. There was no plan to ensure the patients were given the 30 day notification prior to the transfer out of the facility due to the sprinkler system installation project.On the same day during an interview the administrator disclosed she held a meeting with the facility's task force committee. The committee discussed obtaining approval of the relocation plans for the sprinkler system installation project. A review of clinical records for Patient 41, disclosed less than a 30 day timeframe for the Notice of Proposed Transfer/Discharge before the scheduled transfer out of the facility. In addition, the WRITTEN notice did not include a completion date for the sprinkler system installation project or an expected date for the patient?s return to the facility.The undated facility policy and procedure titled, "Transfer/Discharge", without a date described that when patient transfers/discharges are initiated by the facility, the Notice of Proposed Transfer/Discharge policy will be followed. The notice indicated the facility may proceed with the transfer/discharge at the end of thirty (30) days, even if a decision on the appeal has not been rendered. The facility failed to provide a 30 day written notice of transfer to Patient 41 and/or family member or legal representative least 30 days before the patient transferred out of the facility. The above violation has a direct relationship to the health safety or security of patients. |
| 970000054 |
WESTERN CONVALESCENT HOSPITAL |
910010759 |
B |
19-Jun-14 |
ZWAE11 |
3635 |
CALIFORNIA HEALTH AND SAFETY CODE DIVISION 2. CHAPTER 2. ARTICLE 8.5Section 1336.2. (a) (4) (a) Before residents are transferred due to any change in the status of the license or operation of a facility, including a facility closure or voluntary or involuntary termination of a facility?s Medi-Cal or Medicare certification, the facility shall take reasonable steps to transfer affected residents safely and minimize possible transfer trauma by, at a minimum, doing all of the following: (4) At least 30 days in advance of the transfer, inform the resident or the resident?s representative of alternative facilities that are available and adequate to meet resident and family needs Based on observation, interview and record review, the facility failed to provide a written notice of transfer to Patient 42 and/or family member or legal representative at least 30 days before the patient is transferred out of the facility. A construction project to install sprinklers required the facility to remove all patients from the second floor. The project is in response to the facility non-compliance with the federal regulation that requires all long term care facilities to be equipped with a supervised automatic sprinkler system by August 13, 2013. This transfer of patients with less than a 30 day notice is a violation of the patient?s rights.Findings: On April 8, 2014 at 10:52 a.m., the Department received a complaint allegation regarding transfer discharge (T/D) rights. On April 8, 2014 at 2:45 p.m., the Department conducted an onsite visit to monitor the relocation of facility patients due to the facility's sprinkler installation project.According to the Life Safety 2567 (Statement of Deficiencies and Plan of Correction), dated December 11, 2013, the facility was not completely covered with an automatic sprinkler system in accordance with the National Fire Protection Association (NFPA) 13, and the facility lacked a fire sprinkler system. There was no plan to ensure the patients were given the 30 day notification prior to the transfer out of the facility due to the sprinkler system installation project.On the same day during an interview the administrator disclosed she held a meeting with the facility's task force committee. The committee discussed obtaining approval of the relocation plans for the sprinkler system installation project. A review of clinical records for Patient 42, disclosed less than a 30 day timeframe for the Notice of Proposed Transfer/Discharge before the scheduled transfer out of the facility. In addition, the written notice did not include a completion date for the sprinkler system installation project or an expected date for the patient?s return to the facility. During an interview with Patient 42, on April 11, 2014, at 4:20 p.m., the patient stated the facility explained the installation of the sprinkler system. The transfer was temporary and the transfer back to the facility would be in approximately two months. The undated facility policy and procedure titled, "Transfer/Discharge", described that when patient transfers/discharges are initiated by the facility, the Notice of Proposed Transfer/Discharge policy will be followed. The notice indicated the facility may proceed with the transfer/discharge at the end of thirty (30) days, even if a decision on the appeal has not been rendered. The facility failed to provide a 30 day written notice of transfer to Patient 42 and/or family member or legal representative least 30 days before the patient transferred out of the facility. The above violation has a direct relationship to the health safety or security of patients. |
| 970000054 |
WESTERN CONVALESCENT HOSPITAL |
910010760 |
B |
19-Jun-14 |
ZWAE11 |
3378 |
CALIFORNIA HEALTH AND SAFETY CODE DIVISION 2. CHAPTER 2. ARTICLE 8.5Section 1336.2. (a) (4) (a) Before residents are transferred due to any change in the status of the license or operation of a facility, including a facility closure or voluntary or involuntary termination of a facility?s Medi-Cal or Medicare certification, the facility shall take reasonable steps to transfer affected residents safely and minimize possible transfer trauma by, at a minimum, doing all of the following: (4) At least 30 days in advance of the transfer, inform the resident or the resident?s representative of alternative facilities that are available and adequate to meet resident and family needs Based on observation, interview and record review, the facility failed to provide a written notice of transfer to Patient 43 and/or family member or legal representative at least 30 days before the patient was transferred out of the facility. A construction project to install sprinklers required the facility to remove all patients from the second floor. The project is in response to the facility non-compliance with the federal regulation that requires all long term care facilities to be equipped with a supervised automatic sprinkler system by August 13, 2013. This transfer of patients with less than a 30 day notice is a violation of the patient?s rights. Findings: On April 8, 2014 at 10:52 a.m., the Department received a complaint allegation regarding transfer discharge (T/D) rights.On April 8, 2014 at 2:45 p.m., the Department conducted an onsite visit to monitor the relocation of facility patients due to the facility's sprinkler installation project. According to the Life Safety 2567 (Statement of Deficiencies and Plan of Correction), dated December 11, 2013, the facility was not completely covered with an automatic sprinkler system in accordance with the National Fire Protection Association (NFPA) 13, and the facility lacked a fire sprinkler system. There was no plan to ensure the patients were given the 30 day notification prior to the transfer out of the facility due to the sprinkler system installation project.On the same day during an interview the administrator disclosed she held a meeting with the facility's task force committee. The committee discussed obtaining approval of the relocation plans for the sprinkler system installation project A review of clinical records for Patient 43, disclosed less than a 30 day timeframe for the Notice of Proposed Transfer/Discharge before the scheduled transfer out of the facility. In addition, the written notice did not include a completion date for the sprinkler system installation project or an expected date for the patient?s return to the facility.The undated facility policy and procedure titled, "Transfer/Discharge", described that when patient transfers/discharges are initiated by the facility, the Notice of Proposed Transfer/Discharge policy will be followed. The notice indicated the facility may proceed with the transfer/discharge at the end of thirty (30) days, even if a decision on the appeal has not been rendered. The facility failed to provide a 30 day written notice of transfer to Patient 43 and/or family member or legal representative least 30 days before the patient transferred out of the facility. The above violation has a direct relationship to the health safety or security of patients. |
| 970000054 |
WESTERN CONVALESCENT HOSPITAL |
910010761 |
B |
19-Jun-14 |
ZWAE11 |
3378 |
CALIFORNIA HEALTH AND SAFETY CODE DIVISION 2. CHAPTER 2. ARTICLE 8.5Section 1336.2 (a) (4) (a) Before residents are transferred due to any change in the status of the license or operation of a facility, including a facility closure or voluntary or involuntary termination of a facility?s Medi-Cal or Medicare certification, the facility shall take reasonable steps to transfer affected residents safely and minimize possible transfer trauma by, at a minimum, doing all of the following: (4) At least 30 days in advance of the transfer, inform the resident or the resident?s representative of alternative facilities that are available and adequate to meet resident and family needs Based on observation, interview and record review, the facility failed to provide a written notice of transfer to Patient 44 and/or family member or legal representative at least 30 days before the patient is transferred out of the facility. A construction project to install sprinklers required the facility to remove all patients from the second floor. The project is in response to the facility non-compliance with the federal regulation that requires all long term care facilities to be equipped with a supervised automatic sprinkler system by August 13, 2013. This transfer of patients with less than a 30 day notice is a violation of the patient?s rights.Findings: On April 8, 2014 at 10:52 a.m., the Department received a complaint allegation regarding transfer discharge (T/D) rights. On April 8, 2014 at 2:45 p.m., the Department conducted an onsite visit to monitor the relocation of facility patients due to the facility's sprinkler installation project. According to the Life Safety 2567 (Statement of Deficiencies and Plan of Correction), dated December 11, 2013, the facility was not completely covered with an automatic sprinkler system in accordance with the National Fire Protection Association (NFPA) 13, and the facility lacked a fire sprinkler system. There was no plan to ensure the patients were given the 30 day notification prior to the transfer out of the facility due to the sprinkler system installation project.On the same day during an interview the administrator disclosed she held a meeting with the facility's task force committee. The committee discussed obtaining approval of the relocation plans for the sprinkler system installation project. A review of clinical records for Patient 44, disclosed less than a 30 day timeframe for the Notice of Proposed Transfer/Discharge before the scheduled transfer out of the facility. In addition, the written notice did not include a completion date for the sprinkler system installation project or an expected date for the patient?s return to the facility. The undated facility policy and procedure titled, "Transfer/Discharge", described that when patient transfers/discharges are initiated by the facility, the Notice of Proposed Transfer/Discharge policy will be followed. The notice indicated the facility may proceed with the transfer/discharge at the end of thirty (30) days, even if a decision on the appeal has not been rendered. The facility failed to provide a 30 day written notice of transfer to Patient 44 and/or family member or legal representative least 30 days before the patient transferred out of the facility. The above violation has a direct relationship to the health safety or security of patients. |
| 970000054 |
WESTERN CONVALESCENT HOSPITAL |
910010762 |
B |
19-Jun-14 |
ZWAE11 |
3378 |
CALIFORNIA HEALTH AND SAFETY CODE DIVISION 2. CHAPTER 2. ARTICLE 8.5Section 1336.2 (a) (4) (a) Before residents are transferred due to any change in the status of the license or operation of a facility, including a facility closure or voluntary or involuntary termination of a facility?s Medi-Cal or Medicare certification, the facility shall take reasonable steps to transfer affected residents safely and minimize possible transfer trauma by, at a minimum, doing all of the following: (4) At least 30 days in advance of the transfer, inform the resident or the resident?s representative of alternative facilities that are available and adequate to meet resident and family needs Based on observation, interview and record review, the facility failed to provide a written notice of transfer to Patient 45 and/or family member or legal representative at least 30 days before the patient is transferred out of the facility. A construction project to install sprinklers required the facility to remove all patients from the second floor. The project is in response to the facility non-compliance with the federal regulation that requires all long term care facilities to be equipped with a supervised automatic sprinkler system by August 13, 2013. This transfer of patients with less than a 30 day notice is a violation of the patient?s rights. Findings: On April 8, 2014 at 10:52 a.m., the Department received a complaint allegation regarding transfer discharge (T/D) rights. On April 8, 2014 at 2:45 p.m., the Department conducted an onsite visit to monitor the relocation of facility patients due to the facility's sprinkler installation project.According to the Life Safety 2567 (Statement of Deficiencies and Plan of Correction), dated December 11, 2013, the facility was not completely covered with an automatic sprinkler system in accordance with the National Fire Protection Association (NFPA) 13, and the facility lacked a fire sprinkler system. There was no plan to ensure the patients were given the 30 day notification prior to the transfer out of the facility due to the sprinkler system installation project.On the same day during an interview the administrator disclosed she held a meeting with the facility's task force committee. The committee discussed obtaining approval of the relocation plans for the sprinkler system installation project. A review of clinical records for Patient 45, disclosed less than a 30 day timeframe for the Notice of Proposed Transfer/Discharge before the scheduled transfer out of the facility. In addition, the written notice did not include a completion date for the sprinkler system installation project or an expected date for the patient?s return to the facility. The undated facility policy and procedure titled, "Transfer/Discharge", described that when patient transfers/discharges are initiated by the facility, the Notice of Proposed Transfer/Discharge policy will be followed. The notice indicated the facility may proceed with the transfer/discharge at the end of thirty (30) days, even if a decision on the appeal has not been rendered. The facility failed to provide a 30 day written notice of transfer to Patient 45 and/or family member or legal representative least 30 days before the patient transferred out of the facility. The above violation has a direct relationship to the health safety or security of patients. |
| 970000054 |
WESTERN CONVALESCENT HOSPITAL |
910010763 |
B |
19-Jun-14 |
ZWAE11 |
3377 |
CALIFORNIA HEALTH AND SAFETY CODE DIVISION 2. CHAPTER 2. ARTICLE 8.5Section 1336.2 (a) (4) (a) Before residents are transferred due to any change in the status of the license or operation of a facility, including a facility closure or voluntary or involuntary termination of a facility?s Medi-Cal or Medicare certification, the facility shall take reasonable steps to transfer affected residents safely and minimize possible transfer trauma by, at a minimum, doing all of the following: (4) At least 30 days in advance of the transfer, inform the resident or the resident?s representative of alternative facilities that are available and adequate to meet resident and family needs Based on observation, interview and record review, the facility failed to provide a written notice of transfer to Patient 46 and/or family member or legal representative at least 30 days before the patient is transferred out of the facility. A construction project to install sprinklers required the facility to remove all patients from the second floor. The project is in response to the facility non-compliance with the federal regulation that requires all long term care facilities to be equipped with a supervised automatic sprinkler system by August 13, 2013. This transfer of patients with less than a 30 day notice is a violation of the patient?s rights.Findings: On April 8, 2014 at 10:52 a.m., the Department received a complaint allegation regarding transfer discharge (T/D) rights. On April 8, 2014 at 2:45 p.m., the Department conducted an onsite visit to monitor the relocation of facility patients due to the facility's sprinkler installation project. According to the Life Safety 2567 (Statement of Deficiencies and Plan of Correction), dated December 11, 2013, the facility was not completely covered with an automatic sprinkler system in accordance with the National Fire Protection Association (NFPA) 13 and the facility lacked a fire sprinkler system. There was no plan to ensure the patients were given the 30 day notification prior to the transfer out of the facility due to the sprinkler system installation project.On the same day during an interview the administrator disclosed she held a meeting with the facility's task force committee. The committee discussed obtaining approval of the relocation plans for the sprinkler system installation project. A review of clinical records for Patient 46, disclosed less than a 30 day timeframe for the Notice of Proposed Transfer/Discharge before the scheduled transfer out of the facility. In addition, the written notice did not include a completion date for the sprinkler system installation project or an expected date for the patient?s return to the facility. The undated facility policy and procedure titled, "Transfer/Discharge", described that when patient transfers/discharges are initiated by the facility, the Notice of Proposed Transfer/Discharge policy will be followed. The notice indicated the facility may proceed with the transfer/discharge at the end of thirty (30) days, even if a decision on the appeal has not been rendered. The facility failed to provide a 30 day written notice of transfer to Patient 46 and/or family member or legal representative least 30 days before the patient transferred out of the facility. The above violation has a direct relationship to the health safety or security of patients. |
| 970000054 |
WESTERN CONVALESCENT HOSPITAL |
910010764 |
B |
19-Jun-14 |
ZWAE11 |
3378 |
CALIFORNIA HEALTH AND SAFETY CODE DIVISION 2. CHAPTER 2. ARTICLE 8.5Section 1336.2 (a) (4) (a) Before residents are transferred due to any change in the status of the license or operation of a facility, including a facility closure or voluntary or involuntary termination of a facility?s Medi-Cal or Medicare certification, the facility shall take reasonable steps to transfer affected residents safely and minimize possible transfer trauma by, at a minimum, doing all of the following: (4) At least 30 days in advance of the transfer, inform the resident or the resident?s representative of alternative facilities that are available and adequate to meet resident and family needs Based on observation, interview and record review, the facility failed to provide a written notice of transfer to Patient 47 and/or family member or legal representative at least 30 days before the patient is transferred out of the facility. A construction project to install sprinklers required the facility to remove all patients from the second floor. The project is in response to the facility non-compliance with the federal regulation that requires all long term care facilities to be equipped with a supervised automatic sprinkler system by August 13, 2013. This transfer of patients with less than a 30 day notice is a violation of the patient?s rights.Findings: On April 8, 2014 at 10:52 a.m., the Department received a complaint allegation regarding transfer discharge (T/D) rights. On April 8, 2014 at 2:45 p.m., the Department conducted an onsite visit to monitor the relocation of facility patients due to the facility's sprinkler installation project. According to the Life Safety 2567 (Statement of Deficiencies and Plan of Correction), dated December 11, 2013, the facility was not completely covered with an automatic sprinkler system in accordance with the National Fire Protection Association (NFPA) 13 and the facility lacked a fire sprinkler system. There was no plan to ensure the patients were given the 30 day notification prior to the transfer out of the facility due to the sprinkler system installation project.On the same day during an interview the administrator disclosed she held a meeting with the facility's task force committee. The committee discussed obtaining approval of the relocation plans for the sprinkler system installation project. A review of clinical records for Patient 47, disclosed less than a 30 day time frame for the Notice of Proposed Transfer/Discharge before the scheduled transfer out of the facility. In addition, the written notice did not include a completion date for the sprinkler system installation project or an expected date for the patient?s return to the facility. The undated facility policy and procedure titled, "Transfer/Discharge", described that when patient transfers/discharges are initiated by the facility, the Notice of Proposed Transfer/Discharge policy will be followed. The notice indicated the facility may proceed with the transfer/discharge at the end of thirty (30) days, even if a decision on the appeal has not been rendered. The facility failed to provide a 30 day written notice of transfer to Patient 47 and/or family member or legal representative least 30 days before the patient transferred out of the facility. The above violation has a direct relationship to the health safety or security of patients. |
| 970000054 |
WESTERN CONVALESCENT HOSPITAL |
910010765 |
B |
19-Jun-14 |
ZWAE11 |
3633 |
CALIFORNIA HEALTH AND SAFETY CODE DIVISION 2. CHAPTER 2. ARTICLE 8.5Section 1336.2 (a) (4) (a) Before residents are transferred due to any change in the status of the license or operation of a facility, including a facility closure or voluntary or involuntary termination of a facility?s Medi-Cal or Medicare certification, the facility shall take reasonable steps to transfer affected residents safely and minimize possible transfer trauma by, at a minimum, doing all of the following: (4) At least 30 days in advance of the transfer, inform the resident or the resident?s representative of alternative facilities that are available and adequate to meet resident and family needs Based on observation, interview and record review, the facility failed to provide a written notice of transfer to Patient 48 and/or family member or legal representative at least 30 days before the patient is transferred out of the facility. A construction project to install sprinklers required the facility to remove all patients from the second floor. The project is in response to the facility non-compliance with the federal regulation that requires all long term care facilities to be equipped with a supervised automatic sprinkler system by August 13, 2013. This transfer of patients with less than a 30 day notice is a violation of the patient?s rights.Findings: On April 8, 2014 at 10:52 a.m., the Department received a complaint allegation regarding transfer discharge (T/D) rights. On April 8, 2014 at 2:45 p.m., the Department conducted an onsite visit to monitor the relocation of facility patients due to the facility's sprinkler installation project. According to the Life Safety 2567 (Statement of Deficiencies and Plan of Correction), dated December 11, 2013, the facility was not completely covered with an automatic sprinkler system in accordance with the National Fire Protection Association (NFPA) 13, and the facility lacked a fire sprinkler system. There was no plan to ensure the patients were given the 30 day notification prior to the transfer out of the facility due to the sprinkler system installation project.On the same day during an interview the administrator disclosed she held a meeting with the facility's task force committee. The committee discussed obtaining approval of the relocation plans for the sprinkler system installation project. A review of clinical records for Patient 48 indicated less than a 30 day timeframe for the Notice of Proposed Transfer/Discharge before the scheduled transfer out of the facility. In addition, the written notice did not include a completion date for the sprinkler system installation project or an expected date for the patient?s return to the facility. During an interview with Patient 48, on April 11, 2014 at 6:50 p.m., the patient stated the facility explained the installation of the sprinkler system. The transfer was temporary and the transfer back to the facility would be in approximately two months. The undated facility policy and procedure titled, "Transfer/Discharge", described that when patient transfers/discharges are initiated by the facility, the Notice of Proposed Transfer/Discharge policy will be followed. The notice indicated the facility may proceed with the transfer/discharge at the end of thirty (30) days, even if a decision on the appeal has not been rendered. The facility failed to provide a 30 day written notice of transfer to Patient 48 and/or family member or legal representative least 30 days before the patient transferred out of the facility. The above violation has a direct relationship to the health safety or security of patients. |
| 970000054 |
WESTERN CONVALESCENT HOSPITAL |
910010766 |
B |
19-Jun-14 |
ZWAE11 |
3652 |
CALIFORNIA HEALTH AND SAFETY CODE DIVISION 2. CHAPTER 2. ARTICLE 8.5Section 1336.2 (a) (4) (a) Before residents are transferred due to any change in the status of the license or operation of a facility, including a facility closure or voluntary or involuntary termination of a facility?s Medi-Cal or Medicare certification, the facility shall take reasonable steps to transfer affected residents safely and minimize possible transfer trauma by, at a minimum, doing all of the following: (4) At least 30 days in advance of the transfer, inform the resident or the resident?s representative of alternative facilities that are available and adequate to meet resident and family needs Based on observation, interview and record review, the facility failed to provide a written notice of transfer to Patient 49 and/or family member or legal representative at least 30 days before the patient is transferred out of the facility. A construction project to install sprinklers required the facility to remove all patients from the second floor. The project is in response to the facility non-compliance with the federal regulation that requires all long term care facilities to be equipped with a supervised automatic sprinkler system by August 13, 2013. This transfer of patients with less than a 30 day notice is a violation of the patient?s rights. Findings: On April 8, 2014 at 10:52 a.m., the Department received a complaint allegation regarding transfer discharge (T/D) rights. On April 8, 2014 at 2:45 p.m., the Department conducted an onsite visit to monitor the relocation of facility patients due to the facility's sprinkler installation project. According to the Life Safety 2567 (Statement of Deficiencies and Plan of Correction), dated December 11, 2013, the facility was not completely covered with an automatic sprinkler system in accordance with the National Fire Protection Association (NFPA) 13, and the facility lacked a fire sprinkler system. There was no plan to ensure the patients were given the 30 day notification prior to the transfer out of the facility due to the sprinkler system installation project.On the same day during an interview the administrator disclosed she held a meeting with the facility's task force committee. The committee discussed obtaining approval of the relocation plans for the sprinkler system installation project. A review of clinical records for Patient 49, disclosed less than a 30 day timeframe for the Notice of Proposed Transfer/Discharge before the scheduled transfer out of the facility. In addition, the written notice did not include a completion date for the sprinkler system installation project or an expected date for the patient?s return to the facility. During an interview with Patient 49, on April 11, 2014, at 11:30 a.m., the patient stated the facility explained the installation of the sprinkler system. The transfer was temporary and the transfer back to the facility would be in approximately two months. The undated facility policy and procedure titled, "Transfer/Discharge", without a date described that when patient transfers/discharges are initiated by the facility, the Notice of Proposed Transfer/Discharge policy will be followed. The notice indicated the facility may proceed with the transfer/discharge at the end of thirty (30) days, even if a decision on the appeal has not been rendered. The facility failed to provide a 30 day written notice of transfer to Patient 49 and/or family member or legal representative least 30 days before the patient transferred out of the facility. The above violation has a direct relationship to the health safety or security of patients. |
| 970000054 |
WESTERN CONVALESCENT HOSPITAL |
910010767 |
B |
19-Jun-14 |
ZWAE11 |
3378 |
CALIFORNIA HEALTH AND SAFETY CODE DIVISION 2. CHAPTER 2. ARTICLE 8.5Section 1336.2 (a) (4) (a) Before residents are transferred due to any change in the status of the license or operation of a facility, including a facility closure or voluntary or involuntary termination of a facility?s Medi-Cal or Medicare certification, the facility shall take reasonable steps to transfer affected residents safely and minimize possible transfer trauma by, at a minimum, doing all of the following: (4) At least 30 days in advance of the transfer, inform the resident or the resident?s representative of alternative facilities that are available and adequate to meet resident and family needs Based on observation, interview and record review, the facility failed to provide a written notice of transfer to Patient 50 and/or family member or legal representative at least 30 days before the patient is transferred out of the facility. A construction project to install sprinklers required the facility to remove all patients from the second floor. The project is in response to the facility non-compliance with the federal regulation that requires all long term care facilities to be equipped with a supervised automatic sprinkler system by August 13, 2013. This transfer of patients with less than a 30 day notice is a violation of the patient?s rights. Findings: On April 8, 2014 at 10:52 a.m., the Department received a complaint allegation regarding transfer discharge (T/D) rights. On April 8, 2014 at 2:45 p.m., the Department conducted an onsite visit to monitor the relocation of facility patients due to the facility's sprinkler installation project. According to the Life Safety 2567 (Statement of Deficiencies and Plan of Correction), dated December 11, 2013, the facility was not completely covered with an automatic sprinkler system in accordance with the National Fire Protection Association (NFPA) 13 and the facility lacked a fire sprinkler system. There was no plan to ensure the patients were given the 30 day notification prior to the transfer out of the facility due to the sprinkler system installation project.On the same day during an interview the administrator disclosed she held a meeting with the facility's task force committee. The committee discussed obtaining approval of the relocation plans for the sprinkler system installation project. A review of clinical records for Patient 50, disclosed less than a 30 day timeframe for the Notice of Proposed Transfer/Discharge before the scheduled transfer out of the facility. In addition, the written notice did not include a completion date for the sprinkler system installation project or an expected date for the patient?s return to the facility. The undated facility policy and procedure titled, "Transfer/Discharge", described that when patient transfers/discharges are initiated by the facility, the Notice of Proposed Transfer/Discharge policy will be followed. The notice indicated the facility may proceed with the transfer/discharge at the end of thirty (30) days, even if a decision on the appeal has not been rendered. The facility failed to provide a 30 day written notice of transfer to Patient 50 and/or family member or legal representative least 30 days before the patient transferred out of the facility. The above violation has a direct relationship to the health safety or security of patients. |
| 970000054 |
WESTERN CONVALESCENT HOSPITAL |
910010768 |
B |
19-Jun-14 |
ZWAE11 |
3635 |
CALIFORNIA HEALTH AND SAFETY CODE DIVISION 2. CHAPTER 2. ARTICLE 8.5Section 1336.2 (a) (4) (a) Before residents are transferred due to any change in the status of the license or operation of a facility, including a facility closure or voluntary or involuntary termination of a facility?s Medi-Cal or Medicare certification, the facility shall take reasonable steps to transfer affected residents safely and minimize possible transfer trauma by, at a minimum, doing all of the following: (4) At least 30 days in advance of the transfer, inform the resident or the resident?s representative of alternative facilities that are available and adequate to meet resident and family needs Based on observation, interview and record review, the facility failed to provide a written notice of transfer to Patient 51 and/or family member or legal representative at least 30 days before the patient is transferred out of the facility. A construction project to install sprinklers required the facility to remove all patients from the second floor. The project is in response to the facility non-compliance with the federal regulation that requires all long term care facilities to be equipped with a supervised automatic sprinkler system by August 13, 2013. This transfer of patients with less than a 30 day notice is a violation of the patient?s rights.Findings: On April 8, 2014 at 10:52 a.m., the Department received a complaint allegation regarding transfer discharge (T/D) rights. On April 8, 2014 at 2:45 p.m., the Department conducted an onsite visit to monitor the relocation of facility patients due to the facility's sprinkler installation project. According to the Life Safety 2567 (Statement of Deficiencies and Plan of Correction), dated December 11, 2013, the facility was not completely covered with an automatic sprinkler system in accordance with the National Fire Protection Association (NFPA) 13, and the facility lacked a fire sprinkler system. There was no plan to ensure the patients were given the 30 day notification prior to the transfer out of the facility due to the sprinkler system installation project.On the same day during an interview the administrator disclosed she held a meeting with the facility's task force committee. The committee discussed obtaining approval of the relocation plans for the sprinkler system installation project. A review of clinical records for Patient 51, disclosed less than a 30 day timeframe for the Notice of Proposed Transfer/Discharge before the scheduled transfer out of the facility. In addition, the written notice did not include a completion date for the sprinkler system installation project or an expected date for the patient?s return to the facility. During an interview with Patient 51, on April 10, 2014, at 2:30 p.m., the patient stated the facility explained the installation of the sprinkler system. The transfer was temporary and the transfer back to the facility would be in approximately two months. The undated facility policy and procedure titled, "Transfer/Discharge", described that when patient transfers/discharges are initiated by the facility, the Notice of Proposed Transfer/Discharge policy will be followed. The notice indicated the facility may proceed with the transfer/discharge at the end of thirty (30) days, even if a decision on the appeal has not been rendered. The facility failed to provide a 30 day written notice of transfer to Patient 51 and/or family member or legal representative least 30 days before the patient transferred out of the facility. The above violation has a direct relationship to the health safety or security of patients. |
| 970000054 |
WESTERN CONVALESCENT HOSPITAL |
910010769 |
B |
19-Jun-14 |
ZWAE11 |
3631 |
CALIFORNIA HEALTH AND SAFETY CODE DIVISION 2. CHAPTER 2. ARTICLE 8.5Section 1336.2 (a) (4) (a) Before residents are transferred due to any change in the status of the license or operation of a facility, including a facility closure or voluntary or involuntary termination of a facility?s Medi-Cal or Medicare certification, the facility shall take reasonable steps to transfer affected residents safely and minimize possible transfer trauma by, at a minimum, doing all of the following: (4) At least 30 days in advance of the transfer, inform the resident or the resident?s representative of alternative facilities that are available and adequate to meet resident and family needs Based on observation, interview and record review, the facility failed to provide a written notice of transfer to Patient 52 and/or family member or legal representative at least 30 days before the patient is transferred out of the facility. A construction project to install sprinklers required the facility to remove all patients from the second floor. The project is in response to the facility non-compliance with the federal regulation that requires all long term care facilities to be equipped with a supervised automatic sprinkler system by August 13, 2013. This transfer of patients with less than a 30 day notice is a violation of the patient?s rights.Findings: On April 8, 2014 at 10:52 a.m., the Department received a complaint allegation regarding transfer discharge (T/D) rights. On April 8, 2014 at 2:45 p.m., the Department conducted an onsite visit to monitor the relocation of facility patients due to the facility's sprinkler installation project. According to the Life Safety 2567 (Statement of Deficiencies and Plan of Correction), dated December 11, 2013, the facility was not completely covered with an automatic sprinkler system in accordance to the National Fire Protection Association (NFPA) 13 and the facility lacked a fire sprinkler system. There was no plan to ensure the patients were given the 30 day notification prior to the transfer out of the facility due to the sprinkler system installation project.On the same day during an interview the administrator disclosed she held a meeting with the facility's task force committee. The committee discussed obtaining approval of the relocation plans for the sprinkler system installation project. A review of clinical records for Patient 52, disclosed less than a 30 day timeframe for the Notice of Proposed Transfer/Discharge before the scheduled transfer out of the facility. In addition, the written notice did not include a completion date for the sprinkler system installation project or an expected date for the patient?s return to the facility. During an interview with Patient 52, on April 10, 2014 at 2:30 p.m., the patient stated the facility explained the installation of the sprinkler system. The transfer was temporary and the transfer back to the facility would be in approximately two months. The undated facility policy and procedure titled, "Transfer/Discharge", described that when patient transfers/discharges are initiated by the facility, the Notice of Proposed Transfer/Discharge policy will be followed. The notice indicated the facility may proceed with the transfer/discharge at the end of thirty (30) days, even if a decision on the appeal has not been rendered. The facility failed to provide a 30 day written notice of transfer to Patient 52 and/or family member or legal representative least 30 days before the patient transferred out of the facility. The above violation has a direct relationship to the health safety or security of patients. |
| 970000054 |
WESTERN CONVALESCENT HOSPITAL |
910010770 |
B |
19-Jun-14 |
ZWAE11 |
3378 |
CALIFORNIA HEALTH AND SAFETY CODE DIVISION 2. CHAPTER 2. ARTICLE 8.5Section 1336.2 (a) (4) (a) Before residents are transferred due to any change in the status of the license or operation of a facility, including a facility closure or voluntary or involuntary termination of a facility?s Medi-Cal or Medicare certification, the facility shall take reasonable steps to transfer affected residents safely and minimize possible transfer trauma by, at a minimum, doing all of the following: (4) At least 30 days in advance of the transfer, inform the resident or the resident?s representative of alternative facilities that are available and adequate to meet resident and family needs Based on observation, interview and record review, the facility failed to provide a written notice of transfer to Patient 53 and/or family member or legal representative at least 30 days before the patient is transferred out of the facility. A construction project to install sprinklers required the facility to remove all patients from the second floor. The project is in response to the facility non-compliance with the federal regulation that requires all long term care facilities to be equipped with a supervised automatic sprinkler system by August 13, 2013. This transfer of patients with less than a 30 day notice is a violation of the patient?s rights.Findings: On April 8, 2014 at 10:52 a.m., the Department received a complaint allegation regarding transfer discharge (T/D) rights. On April 8, 2014 at 2:45 p.m., the Department conducted an onsite visit to monitor the relocation of facility patients due to the facility's sprinkler installation project. According to the Life Safety 2567 (Statement of Deficiencies and Plan of Correction), dated December 11, 2013, the facility was not completely covered with an automatic sprinkler system in accordance with the National Fire Protection Association (NFPA) 13, and the facility lacked a fire sprinkler system. There was no plan to ensure the patients were given the 30 day notification prior to the transfer out of the facility due to the sprinkler system installation project.On the same day during an interview the administrator disclosed she held a meeting with the facility's task force committee. The committee discussed obtaining approval of the relocation plans for the sprinkler system installation project. A review of clinical records for Patient 53, disclosed less than a 30 day timeframe for the Notice of Proposed Transfer/Discharge before the scheduled transfer out of the facility. In addition, the written notice did not include a completion date for the sprinkler system installation project or an expected date for the patient?s return to the facility. The undated facility policy and procedure titled, "Transfer/Discharge", described that when patient transfers/discharges are initiated by the facility, the Notice of Proposed Transfer/Discharge policy will be followed. The notice indicated the facility may proceed with the transfer/discharge at the end of thirty (30) days, even if a decision on the appeal has not been rendered. The facility failed to provide a 30 day written notice of transfer to Patient 53 and/or family member or legal representative least 30 days before the patient transferred out of the facility. The above violation has a direct relationship to the health safety or security of patients. |
| 970000054 |
WESTERN CONVALESCENT HOSPITAL |
910010771 |
B |
19-Jun-14 |
ZWAE11 |
3379 |
CALIFORNIA HEALTH AND SAFETY CODE DIVISION 2. CHAPTER 2. ARTICLE 8.5Section 1336.2 (a) (4) (a) Before residents are transferred due to any change in the status of the license or operation of a facility, including a facility closure or voluntary or involuntary termination of a facility?s Medi-Cal or Medicare certification, the facility shall take reasonable steps to transfer affected residents safely and minimize possible transfer trauma by, at a minimum, doing all of the following: (4) At least 30 days in advance of the transfer, inform the resident or the resident?s representative of alternative facilities that are available and adequate to meet resident and family needs Based on observation, interview and record review, the facility failed to provide a written notice of transfer to Patient 54 and/or family member or legal representative at least 30 days before the patient is transferred out of the facility. A construction project to install sprinklers required the facility to remove all patients from the second floor. The project is in response to the facility non-compliance with the federal regulation that requires all long term care facilities to be equipped with a supervised automatic sprinkler system by August 13, 2013. This transfer of patients with less than a 30 day notice is a violation of the patient?s rights. Findings: On April 8, 2014 at 10:52 a.m., the Department received a complaint allegation regarding transfer discharge (T/D) rights. On April 8, 2014 at 2:45 p.m., the Department conducted an onsite visit to monitor the relocation of facility patients due to the facility's sprinkler installation project. According to the Life Safety 2567 (Statement of Deficiencies and Plan of Correction), dated December 11, 2013, the facility was not completely covered with an automatic sprinkler system in accordance with the National Fire Protection Association (NFPA) 13, and the facility lacked a fire sprinkler system. There was no plan to ensure the patients were given the 30 day notification prior to the transfer out of the facility due to the sprinkler system installation project.On the same day during an interview the administrator disclosed she held a meeting with the facility's task force committee. The committee discussed obtaining approval of the relocation plans for the sprinkler system installation project. A review of clinical records for Patient 54, disclosed less than a 30 day timeframe for the Notice of Proposed Transfer/Discharge before the scheduled transfer out of the facility. In addition, the written notice did not include a completion date for the sprinkler system installation project or an expected date for the patient?s return to the facility. The undated facility policy and procedure titled, "Transfer/Discharge", described that when patient transfers/discharges are initiated by the facility, the Notice of Proposed Transfer/Discharge policy will be followed. The notice indicated the facility may proceed with the transfer/discharge at the end of thirty (30) days, even if a decision on the appeal has not been rendered. The facility failed to provide a 30 day written notice of transfer to Patient 54 and/or family member or legal representative least 30 days before the patient transferred out of the facility. The above violation has a direct relationship to the health safety or security of patients. |
| 970000054 |
WESTERN CONVALESCENT HOSPITAL |
910010772 |
B |
19-Jun-14 |
ZWAE11 |
3625 |
CALIFORNIA HEALTH AND SAFETY CODE DIVISION 2. CHAPTER 2. ARTICLE 8.5Section 1336.2. (a) (4) (a) Before residents are transferred due to any change in the status of the license or operation of a facility, including a facility closure or voluntary or involuntary termination of a facility?s Medi-Cal or Medicare certification, the facility shall take reasonable steps to transfer affected residents safely and minimize possible transfer trauma by, at a minimum, doing all of the following: (4) At least 30 days in advance of the transfer, inform the resident or the resident?s representative of alternative facilities that are available and adequate to meet resident and family needs. Based on observation, interview and record review, the facility failed to provide a written notice of transfer to Patient 11 and/or family member or legal representative at least 30 days before the patient is transferred out of the facility. A construction project to install sprinklers required the facility to remove all patients from the second floor. The project is in response to the facility non-compliance with the federal regulation that requires all long term care facilities to be equipped with a supervised automatic sprinkler system by August 13, 2013. This transfer of patients with less than a 30 day notice is a violation of the patient?s rights.Findings: On April 8, 2014 at 10:52 a.m., the Department received a complaint allegation regarding transfer discharge (T/D) rights.On April 8, 2014 at 2:45 p.m., the Department conducted an onsite visit to monitor the relocation of facility patients due to the facility's sprinkler installation project. According to the Life Safety 2567 (Statement of Deficiencies and Plan of Correction), dated December 11, 2013, the facility was not completely covered with an automatic sprinkler system in accordance with the National Fire Protection Association (NFPA) 13, and the facility lacked a fire sprinkler system. There was no plan to ensure the patients were given the 30 day notification prior to the transfer out of the facility due to the sprinkler system installation project.On the same day during an interview, the administrator disclosed she held a meeting with the facility's task force committee. The committee discussed obtaining approval of the relocation plans for the sprinkler system installation project. A review of clinical records for Patient 11, disclosed less than a 30 day timeframe for the Notice of Proposed Transfer/Discharge before the scheduled transfer out of the facility. In addition, the written notice did not include a completion date for the sprinkler system installation project or an expected date for the patient?s return to the facility.During an interview on April 7, 2014, at 3:30 p.m., Patient 11 said the facility explained the installation of the sprinkler system. The transfer was temporary and Patient 11 would be transferred back to the facility in approximately two months. The undated facility policy and procedure titled, "Transfer/Discharge?, described that when patient transfers/discharges are initiated by the facility, the Notice of Proposed Transfer/Discharge policy will be followed. The notice indicated the facility may proceed with the transfer/discharge at the end of thirty (30) days, even if a decision on the appeal has not been rendered. The facility failed to provide a 30 day written notice of transfer to Patient 11 and/or family member or legal representative least 30 days before the patient transferred out of the facility. The above violation has a direct relationship to the health safety or security of patients. |
| 970000054 |
WESTERN CONVALESCENT HOSPITAL |
910010773 |
B |
19-Jun-14 |
ZWAE11 |
3634 |
CALIFORNIA HEALTH AND SAFETY CODE DIVISION 2. CHAPTER 2. ARTICLE 8.5Section 1336.2. (a) (4) (a) Before residents are transferred due to any change in the status of the license or operation of a facility, including a facility closure or voluntary or involuntary termination of a facility?s Medi-Cal or Medicare certification, the facility shall take reasonable steps to transfer affected residents safely and minimize possible transfer trauma by, at a minimum, doing all of the following: (4) At least 30 days in advance of the transfer, inform the resident or the resident?s representative of alternative facilities that are available and adequate to meet resident and family needsBased on observation, interview and record review, the facility failed to provide a written notice of transfer to Patient 12?s family member or legal representative at least 30 days before the patient is transferred out of the facility. A construction project to install sprinklers required the facility to remove all patients from the second floor. The project is in response to the facility non-compliance with the federal regulation that requires all long term care facilities to be equipped with a supervised automatic sprinkler system by August 13, 2013. This transfer of patients with less than a 30 day notice is a violation of the patient?s rights.Findings: On April 8, 2014 at 10:52 a.m., the Department received a complaint allegation regarding transfer discharge (T/D) rights. On April 8, 2014 at 2:45 p.m., the Department conducted an onsite visit to monitor the relocation of facility patients due to the facility's sprinkler installation project. According to the Life Safety 2567 (Statement of Deficiencies and Plan of Correction), dated December 11, 2013, the facility was not completely covered with an automatic sprinkler system in accordance with the National Fire Protection Association (NFPA) 13, and the facility lacked a fire sprinkler system. There was no plan to ensure the patients were given the 30 day notification prior to the transfer out of the facility due to the sprinkler system installation project.On the same day during an interview, the administrator disclosed she held a meeting with the facility's task force committee. The committee discussed obtaining approval of the relocation plans for the sprinkler system installation project. A review of clinical records for Patient 12, disclosed less than a 30 day timeframe for the Notice of Proposed Transfer/Discharge before the scheduled transfer out of the facility. In addition, the written notice did not include a completion date for the sprinkler system installation project or an expected date for the patient?s return to the facility. On April 4, 2014, at 5 p.m., during an interview Patient 12?s family member stated that the facility explained the installation of the sprinkler system. The transfer was temporary and Patient 12 would be transferred back to the facility in approximately two months.The undated facility policy and procedure titled, "Transfer/Discharge", described that when patient transfers/discharges are initiated by the facility, the Notice of Proposed Transfer/Discharge policy will be followed. The notice indicated the facility may proceed with the transfer/discharge at the end of thirty (30) days, even if a decision on the appeal has not been rendered. The facility failed to provide a 30 day written notice of transfer to Patient 12?s family member or legal representative least 30 days before the patient transferred out of the facility. The above violation has a direct relationship to the health safety or security of patients. |
| 970000054 |
WESTERN CONVALESCENT HOSPITAL |
910010774 |
B |
19-Jun-14 |
ZWAE11 |
3379 |
CALIFORNIA HEALTH AND SAFETY CODE DIVISION 2. CHAPTER 2. ARTICLE 8.5Section 1336.2. (a) (4) (a) Before residents are transferred due to any change in the status of the license or operation of a facility, including a facility closure or voluntary or involuntary termination of a facility?s Medi-Cal or Medicare certification, the facility shall take reasonable steps to transfer affected residents safely and minimize possible transfer trauma by, at a minimum, doing all of the following: (4) At least 30 days in advance of the transfer, inform the resident or the resident?s representative of alternative facilities that are available and adequate to meet resident and family needsBased on observation, interview and record review, the facility failed to provide a written notice of transfer to Patient 13 and/or family member or legal representative at least 30 days before the patient is transferred out of the facility. A construction project to install sprinklers required the facility to remove all patients from the second floor. The project is in response to the facility non-compliance with the federal regulation that requires all long term care facilities to be equipped with a supervised automatic sprinkler system by August 13, 2013. This transfer of patients with less than a 30 day notice is a violation of the patient?s rights.Findings: On April 8, 2014 at 10:52 a.m., the Department received a complaint allegation regarding transfer discharge (T/D) rights. On April 8, 2014 at 2:45 p.m., the Department conducted an onsite visit to monitor the relocation of facility patients due to the facility's sprinkler installation project. According to the Life Safety 2567 (Statement of Deficiencies and Plan of Correction), dated December 11, 2013, the facility was not completely covered with an automatic sprinkler system in accordance with the National Fire Protection Association (NFPA) 13, and the facility lacked a fire sprinkler system. There was no plan to ensure the patients were given the 30 day notification prior to the transfer out of the facility due to the sprinkler system installation project.On the same day during an interview, the administrator disclosed she held a meeting with the facility's task force committee. The committee discussed obtaining approval of the relocation plans for the sprinkler system installation project. A review of clinical records for Patient 13, disclosed less than a 30 day timeframe for the Notice of Proposed Transfer/Discharge before the scheduled transfer out of the facility. In addition, the written notice did not include a completion date for the sprinkler system installation project or an expected date for the patient?s return to the facility. The undated facility policy and procedure titled, "Transfer/Discharge", described that when patient transfers/discharges are initiated by the facility, the Notice of Proposed Transfer/Discharge policy will be followed. The notice indicated the facility may proceed with the transfer/discharge at the end of thirty (30) days, even if a decision on the appeal has not been rendered. The facility failed to provide a 30 day written notice of transfer to Patient 13 and/or family member or legal representative least 30 days before the patient transferred out of the facility. The above violation has a direct relationship to the health safety or security of patients. |
| 970000054 |
WESTERN CONVALESCENT HOSPITAL |
910010775 |
B |
19-Jun-14 |
ZWAE11 |
3381 |
CALIFORNIA HEALTH AND SAFETY CODE DIVISION 2. CHAPTER 2. ARTICLE 8.5Section 1336.2. (a) (4) (a) Before residents are transferred due to any change in the status of the license or operation of a facility, including a facility closure or voluntary or involuntary termination of a facility?s Medi-Cal or Medicare certification, the facility shall take reasonable steps to transfer affected residents safely and minimize possible transfer trauma by, at a minimum, doing all of the following: (4) At least 30 days in advance of the transfer, inform the resident or the resident?s representative of alternative facilities that are available and adequate to meet resident and family needs.Based on observation, interview and record review, the facility failed to provide a written notice of transfer to Patient 14 and/or family member or legal representative at least 30 days before the patient is transferred out of the facility. A construction project to install sprinklers required the facility to remove all patients from the second floor. The project is in response to the facility non-compliance with the federal regulation that requires all long term care facilities to be equipped with a supervised automatic sprinkler system by August 13, 2013. This transfer of patients with less than a 30 day notice is a violation of the patient?s rights. Findings: On April 8, 2014 at 10:52 a.m., the Department received a complaint allegation regarding transfer discharge (T/D) rights. On April 8, 2014 at 2:45 p.m., the Department conducted an onsite visit to monitor the relocation of facility patients due to the facility's sprinkler installation project. According to the Life Safety 2567 (Statement of Deficiencies and Plan of Correction), dated December 11, 2013, the facility was not completely covered with an automatic sprinkler system in accordance with the National Fire Protection Association (NFPA) 13, and the facility lacked a fire sprinkler system. There was no plan to ensure the patients were given the 30 day notification prior to the transfer out of the facility due to the sprinkler system installation project.On the same day during an interview, the administrator disclosed she held a meeting with the facility's task force committee. The committee discussed obtaining approval of the relocation plans for the sprinkler system installation project. A review of clinical records for Patient 14, disclosed less than a 30 day timeframe for the Notice of Proposed Transfer/Discharge before the scheduled transfer out of the facility. In addition, the written notice did not include a completion date for the sprinkler system installation project or an expected date for the patient?s return to the facility. The undated facility policy and procedure titled, "Transfer/Discharge", described that when patient transfers/discharges are initiated by the facility, the Notice of Proposed Transfer/Discharge policy will be followed. The notice indicated the facility may proceed with the transfer/discharge at the end of thirty (30) days, even if a decision on the appeal has not been rendered. The facility failed to provide a 30 day written notice of transfer to Patient 14 and/or family member or legal representative least 30 days before the patient transferred out of the facility. The above violation has a direct relationship to the health safety or security of patients. |
| 970000054 |
WESTERN CONVALESCENT HOSPITAL |
910010776 |
B |
19-Jun-14 |
ZWAE11 |
3379 |
CALIFORNIA HEALTH AND SAFETY CODE DIVISION 2. CHAPTER 2. ARTICLE 8.5Section 1336.2 (a) (4) (a) Before residents are transferred due to any change in the status of the license or operation of a facility, including a facility closure or voluntary or involuntary termination of a facility?s Medi-Cal or Medicare certification, the facility shall take reasonable steps to transfer affected residents safely and minimize possible transfer trauma by, at a minimum, doing all of the following: (4) At least 30 days in advance of the transfer, inform the resident or the resident?s representative of alternative facilities that are available and adequate to meet resident and family needs Based on observation, interview and record review, the facility failed to provide a written notice of transfer to Patient 55 and/or family member or legal representative at least 30 days before the patient is transferred out of the facility. A construction project to install sprinklers required the facility to remove all patients from the second floor. The project is in response to the facility non-compliance with the federal regulation that requires all long term care facilities to be equipped with a supervised automatic sprinkler system by August 13, 2013. This transfer of patients with less than a 30 day notice is a violation of the patient?s rights. Findings: On April 8, 2014 at 10:52 a.m., the Department received a complaint allegation regarding transfer discharge (T/D) rights. On April 8, 2014 at 2:45 p.m., the Department conducted an onsite visit to monitor the relocation of facility patients due to the facility's sprinkler installation project. According to the Life Safety 2567 (Statement of Deficiencies and Plan of Correction), dated December 11, 2013, the facility was not completely covered with an automatic sprinkler system in accordance with the National Fire Protection Association (NFPA) 13, and the facility lacked a fire sprinkler system. There was no plan to ensure the patients were given the 30 day notification prior to the transfer out of the facility due to the sprinkler system installation project.On the same day during an interview the administrator disclosed she held a meeting with the facility's task force committee. The committee discussed obtaining approval of the relocation plans for the sprinkler system installation project. A review of clinical records for Patient 55, disclosed less than a 30 day timeframe for the Notice of Proposed Transfer/Discharge before the scheduled transfer out of the facility. In addition, the written notice did not include a completion date for the sprinkler system installation project or an expected date for the patient?s return to the facility. The undated facility policy and procedure titled, "Transfer/Discharge", described that when patient transfers/discharges are initiated by the facility, the Notice of Proposed Transfer/Discharge policy will be followed. The notice indicated the facility may proceed with the transfer/discharge at the end of thirty (30) days, even if a decision on the appeal has not been rendered. The facility failed to provide a 30 day written notice of transfer to Patient 55 and/or family member or legal representative least 30 days before the patient transferred out of the facility. The above violation has a direct relationship to the health safety or security of patients. |
| 970000054 |
WESTERN CONVALESCENT HOSPITAL |
910010777 |
B |
19-Jun-14 |
ZWAE11 |
3378 |
CALIFORNIA HEALTH AND SAFETY CODE DIVISION 2. CHAPTER 2. ARTICLE 8.5Section 1336.2 (a) (4) (a) Before residents are transferred due to any change in the status of the license or operation of a facility, including a facility closure or voluntary or involuntary termination of a facility?s Medi-Cal or Medicare certification, the facility shall take reasonable steps to transfer affected residents safely and minimize possible transfer trauma by, at a minimum, doing all of the following: (4) At least 30 days in advance of the transfer, inform the resident or the resident?s representative of alternative facilities that are available and adequate to meet resident and family needs Based on observation, interview and record review, the facility failed to provide a written notice of transfer to Patient 56 and/or family member or legal representative at least 30 days before the patient is transferred out of the facility. A construction project to install sprinklers required the facility to remove all patients from the second floor. The project is in response to the facility non-compliance with the federal regulation that requires all long term care facilities to be equipped with a supervised automatic sprinkler system by August 13, 2013. This transfer of patients with less than a 30 day notice is a violation of the patient?s rights. Findings: On April 8, 2014 at 10:52 a.m., the Department received a complaint allegation regarding transfer discharge (T/D) rights. On April 8, 2014 at 2:45 p.m., the Department conducted an onsite visit to monitor the relocation of facility patients due to the facility's sprinkler installation project. According to the Life Safety 2567 (Statement of Deficiencies and Plan of Correction), dated December 11, 2013, the facility was not completely covered with an automatic sprinkler system in accordance with the National Fire Protection Association (NFPA) 13 and the facility lacked a fire sprinkler system. There was no plan to ensure the patients were given the 30 day notification prior to the transfer out of the facility due to the sprinkler system installation project.On the same day during an interview the administrator disclosed she held a meeting with the facility's task force committee. The committee discussed obtaining approval of the relocation plans for the sprinkler system installation project. A review of clinical records for Patient 56, disclosed less than a 30 day timeframe for the Notice of Proposed Transfer/Discharge before the scheduled transfer out of the facility. In addition, the written notice did not include a completion date for the sprinkler system installation project or an expected date for the patient?s return to the facility. The undated facility policy and procedure titled, "Transfer/Discharge", described that when patient transfers/discharges are initiated by the facility, the Notice of Proposed Transfer/Discharge policy will be followed. The notice indicated the facility may proceed with the transfer/discharge at the end of thirty (30) days, even if a decision on the appeal has not been rendered. The facility failed to provide a 30 day written notice of transfer to Patient 56 and/or family member or legal representative least 30 days before the patient transferred out of the facility. The above violation has a direct relationship to the health safety or security of patients. |
| 970000054 |
WESTERN CONVALESCENT HOSPITAL |
910010779 |
B |
19-Jun-14 |
ZWAE11 |
3377 |
CALIFORNIA HEALTH AND SAFETY CODE DIVISION 2. CHAPTER 2. ARTICLE 8.5Section 1336.2. (a) (4) (a) Before residents are transferred due to any change in the status of the license or operation of a facility, including a facility closure or voluntary or involuntary termination of a facility?s Medi-Cal or Medicare certification, the facility shall take reasonable steps to transfer affected residents safely and minimize possible transfer trauma by, at a minimum, doing all of the following: (4) At least 30 days in advance of the transfer, inform the resident or the resident?s representative of alternative facilities that are available and adequate to meet resident and family needsBased on observation, interview and record review, the facility failed to provide a written notice of transfer to Patient 15 and/or family member or legal representative at least 30 days before the patient is transferred out of the facility. A construction project to install sprinklers required the facility to remove all patients from the second floor. The project is in response to the facility non-compliance with the federal regulation that requires all long term care facilities to be equipped with a supervised automatic sprinkler system by August 13, 2013. This transfer of patients with less than a 30 day notice is a violation of the patient?s rights. Findings: On April 8, 2014 at 10:52 a.m., the Department received a complaint allegation regarding transfer discharge (T/D) rights.On April 8, 2014 at 2:45 p.m., the Department conducted an onsite visit to monitor the relocation of facility patients due to the facility's sprinkler installation project.According to the Life Safety 2567 (Statement of Deficiencies and Plan of Correction), dated December 11, 2013, the facility was not completely covered with an automatic sprinkler system in accordance with the National Fire Protection Association (NFPA) 13 and the facility lacked a fire sprinkler system. There was no plan to ensure the patients were given the 30 day notification prior to the transfer out of the facility due to the sprinkler system installation project.On the same day during an interview, the administrator disclosed she held a meeting with the facility's task force committee. The committee discussed obtaining approval of the relocation plans for the sprinkler system installation project. A review of clinical records for Patient 15, disclosed less than a 30 day timeframe for the Notice of Proposed Transfer/Discharge before the scheduled transfer out of the facility. In addition, the written notice did not include a completion date for the sprinkler system installation project or an expected date for the patient?s return to the facility. The undated facility policy and procedure titled, "Transfer/Discharge", described that when patient transfers/discharges are initiated by the facility, the Notice of Proposed Transfer/Discharge policy will be followed. The notice indicated the facility may proceed with the transfer/discharge at the end of thirty (30) days, even if a decision on the appeal has not been rendered. The facility failed to provide a 30 day written notice of transfer to Patient 15 and/or family member or legal representative least 30 days before the patient transferred out of the facility. The above violation has a direct relationship to the health safety or security of patients. |
| 970000054 |
WESTERN CONVALESCENT HOSPITAL |
910010780 |
B |
19-Jun-14 |
ZWAE11 |
3380 |
CALIFORNIA HEALTH AND SAFETY CODE DIVISION 2. CHAPTER 2. ARTICLE 8.5Section 1336.2. (a) (4) (a) Before residents are transferred due to any change in the status of the license or operation of a facility, including a facility closure or voluntary or involuntary termination of a facility?s Medi-Cal or Medicare certification, the facility shall take reasonable steps to transfer affected residents safely and minimize possible transfer trauma by, at a minimum, doing all of the following: (4) At least 30 days in advance of the transfer, inform the resident or the resident?s representative of alternative facilities that are available and adequate to meet resident and family needsBased on observation, interview and record review, the facility failed to provide a written notice of transfer to Patient 16 and/or family member or legal representative at least 30 days before the patient is transferred out of the facility. A construction project to install sprinklers required the facility to remove all patients from the second floor. The project is in response to the facility non-compliance with the federal regulation that requires all long term care facilities to be equipped with a supervised automatic sprinkler system by August 13, 2013. This transfer of patients with less than a 30 day notice is a violation of the patient?s rights. Findings: On April 8, 2014 at 10:52 a.m., the Department received a complaint allegation regarding transfer discharge (T/D) rights. On April 8, 2014 at 2:45 p.m., the Department conducted an onsite visit to monitor the relocation of facility patients due to the facility's sprinkler installation project. According to the Life Safety 2567 (Statement of Deficiencies and Plan of Correction), dated December 11, 2013, the facility was not completely covered with an automatic sprinkler system in accordance with the National Fire Protection Association (NFPA) 13, and the facility lacked a fire sprinkler system. There was no plan to ensure the patients were given the 30 day notification prior to the transfer out of the facility due to the sprinkler system installation project.On the same day during an interview, the administrator disclosed she held a meeting with the facility's task force committee. The committee discussed obtaining approval of the relocation plans for the sprinkler system installation project. A review of clinical records for Patient 16, disclosed less than a 30 day timeframe for the Notice of Proposed Transfer/Discharge before the scheduled transfer out of the facility. In addition, the written notice did not include a completion date for the sprinkler system installation project or an expected date for the patient?s return to the facility. The undated facility policy and procedure titled, "Transfer/Discharge", described that when patient transfers/discharges are initiated by the facility, the Notice of Proposed Transfer/Discharge policy will be followed. The notice indicated the facility may proceed with the transfer/discharge at the end of thirty (30) days, even if a decision on the appeal has not been rendered. The facility failed to provide a 30 day written notice of transfer to Patient 16 and/or family member or legal representative least 30 days before the patient transferred out of the facility. The above violation has a direct relationship to the health safety or security of patients. |
| 970000054 |
WESTERN CONVALESCENT HOSPITAL |
910010781 |
B |
19-Jun-14 |
ZWAE11 |
3656 |
CALIFORNIA HEALTH AND SAFETY CODE DIVISION 2. CHAPTER 2. ARTICLE 8.5Section 1336.2. (a) (4) (a) Before residents are transferred due to any change in the status of the license or operation of a facility, including a facility closure or voluntary or involuntary termination of a facility?s Medi-Cal or Medicare certification, the facility shall take reasonable steps to transfer affected residents safely and minimize possible transfer trauma by, at a minimum, doing all of the following: (4) At least 30 days in advance of the transfer, inform the resident or the resident?s representative of alternative facilities that are available and adequate to meet resident and family needs Based on observation, interview and record review, the facility failed to provide a written notice of transfer to Patient 17?s family member or legal representative at least 30 days before the patient is transferred out of the facility. A construction project to install sprinklers required the facility to remove all patients from the second floor. The project is in response to the facility non-compliance with the federal regulation that requires all long term care facilities to be equipped with a supervised automatic sprinkler system by August 13, 2013. This transfer of patients with less than a 30 day notice is a violation of the patient?s rights.Findings: On April 8, 2014 at 10:52 a.m., the Department received a complaint allegation regarding transfer discharge (T/D) rights. On April 8, 2014 at 2:45 p.m., the Department conducted an onsite visit to monitor the relocation of facility patients due to the facility's sprinkler installation project. According to the Life Safety 2567 (Statement of Deficiencies and Plan of Correction), dated December 11, 2013, the facility was not completely covered with an automatic sprinkler system in accordance with the National Fire Protection Association (NFPA) 13, and the facility lacked a fire sprinkler system. There was no plan to ensure the patients were given the 30 day notification prior to the transfer out of the facility due to the sprinkler system installation project.On the same day during an interview the administrator disclosed she held a meeting with the facility's task force committee. The committee discussed obtaining approval of the relocation plans for the sprinkler system installation project. A review of clinical records for Patient 17, disclosed less than a 30 day timeframe for the Notice of Proposed Transfer/Discharge before the scheduled transfer out of the facility. In addition, the written notice did not include a completion date for the sprinkler system installation project or an expected date for the patient?s return to the facility. During an interview with Patient 17?s family member, on April 7, 2014, at 2 p.m., Patient 17?s family member stated the facility explained the installation of the sprinkler system. The transfer was temporary and they would be transferred back to the facility in approximately two months.The undated facility policy and procedure titled, "Transfer/Discharge", described that when patient transfers/discharges are initiated by the facility, the Notice of Proposed Transfer/Discharge policy will be followed. The notice indicated the facility may proceed with the transfer/discharge at the end of thirty (30) days, even if a decision on the appeal has not been rendered. The facility failed to provide a 30 day written notice of transfer to Patient 17?s family member or legal representative least 30 days before the patient transferred out of the facility. The above violation has a direct relationship to the health safety or security of patients. |
| 970000054 |
WESTERN CONVALESCENT HOSPITAL |
910010782 |
B |
19-Jun-14 |
ZWAE11 |
3642 |
CALIFORNIA HEALTH AND SAFETY CODE DIVISION 2. CHAPTER 2. ARTICLE 8.5Section 1336.2. (a) (4) (a) Before residents are transferred due to any change in the status of the license or operation of a facility, including a facility closure or voluntary or involuntary termination of a facility?s Medi-Cal or Medicare certification, the facility shall take reasonable steps to transfer affected residents safely and minimize possible transfer trauma by, at a minimum, doing all of the following: (4) At least 30 days in advance of the transfer, inform the resident or the resident?s representative of alternative facilities that are available and adequate to meet resident and family needs Based on observation, interview and record review, the facility failed to provide a written notice of transfer to Patient 18 and/or family member or legal representative at least 30 days before the patient is transferred out of the facility. A construction project to install sprinklers required the facility to remove all patients from the second floor. The project is in response to the facility non-compliance with the federal regulation that requires all long term care facilities to be equipped with a supervised automatic sprinkler system by August 13, 2013. This transfer of patients with less than a 30 day notice is a violation of the patient?s rights. Findings: On April 8, 2014 at 10:52 a.m., the Department received a complaint allegation regarding transfer discharge (T/D) rights. On April 8, 2014 at 2:45 p.m., the Department conducted an onsite visit to monitor the relocation of facility patients due to the facility's sprinkler installation project. According to the Life Safety 2567 (Statement of Deficiencies and Plan of Correction), dated December 11, 2013, the facility was not completely covered with an automatic sprinkler system in accordance with the National Fire Protection Association (NFPA) 13, and the facility lacked a fire sprinkler system. There was no plan to ensure the patients were given the 30 day notification prior to the transfer out of the facility due to the sprinkler system installation project.On the same day during an interview the administrator disclosed she held a meeting with the facility's task force committee. The committee discussed obtaining approval of the relocation plans for the sprinkler system installation project. A review of clinical records for Patient 18, disclosed less than a 30 day timeframe for the Notice of Proposed Transfer/Discharge before the scheduled transfer out of the facility. In addition, the written notice did not include a completion date for the sprinkler system installation project or an expected date for the patient?s return to the facility. During an interview with Patient 18 on April 2, 2014 at 3:45 p.m., Patient 18 stated the facility explained the installation of the sprinkler system. The transfer was temporary and Patient 18 would be transferred back to the facility in approximately two months.The undated facility policy and procedure titled, "Transfer/Discharge", described that when patient transfers/discharges are initiated by the facility, the Notice of Proposed Transfer/Discharge policy will be followed. The notice indicated the facility may proceed with the transfer/discharge at the end of thirty (30) days, even if a decision on the appeal has not been rendered. The facility failed to provide a 30 day written notice of transfer to Patient 18 and/or family member or legal representative least 30 days before the patient transferred out of the facility. The above violation has a direct relationship to the health safety or security of patients. |
| 970000054 |
WESTERN CONVALESCENT HOSPITAL |
910010783 |
B |
19-Jun-14 |
ZWAE11 |
3635 |
CALIFORNIA HEALTH AND SAFETY CODE DIVISION 2. CHAPTER 2. ARTICLE 8.5Section 1336.2. (a) (4) (a) Before residents are transferred due to any change in the status of the license or operation of a facility, including a facility closure or voluntary or involuntary termination of a facility?s Medi-Cal or Medicare certification, the facility shall take reasonable steps to transfer affected residents safely and minimize possible transfer trauma by, at a minimum, doing all of the following: (4) At least 30 days in advance of the transfer, inform the resident or the resident?s representative of alternative facilities that are available and adequate to meet resident and family needs Based on observation, interview and record review, the facility failed to provide a written notice of transfer to Patient 19 and/or family member or legal representative at least 30 days before the patient is transferred out of the facility. A construction project to install sprinklers required the facility to remove all patients from the second floor. The project is in response to the facility non-compliance with the federal regulation that requires all long term care facilities to be equipped with a supervised automatic sprinkler system by August 13, 2013. This transfer of patients with less than a 30 day notice is a violation of the patient?s rights. Findings: On April 8, 2014 at 10:52 a.m., the Department received a complaint allegation regarding transfer discharge (T/D) rights. On April 8, 2014 at 2:45 p.m., the Department conducted an onsite visit to monitor the relocation of facility patients due to the facility's sprinkler installation project. According to the Life Safety 2567 (Statement of Deficiencies and Plan of Correction), dated December 11, 2013, the facility was not completely covered with an automatic sprinkler system in accordance with the National Fire Protection Association (NFPA) 13, and the facility lacked a fire sprinkler system. There was no plan to ensure the patients were given the 30 day notification prior to the transfer out of the facility due to the sprinkler system installation project.On the same day during an interview the administrator disclosed she held a meeting with the facility's task force committee. The committee discussed obtaining approval of the relocation plans for the sprinkler system installation project. A review of clinical records for Patient 19, disclosed less than a 30 day timeframe for the Notice of Proposed Transfer/Discharge before the scheduled transfer out of the facility. In addition, the written notice did not include a completion date for the sprinkler system installation project or an expected date for the patient?s return to the facility. During an interview with Patient 19 on April 2, 2014, at 3:15 p.m., the patient stated the facility explained the installation of the sprinkler system. The transfer was temporary and the transfer back to the facility would be in approximately two months. The undated facility policy and procedure titled, "Transfer/Discharge", described that when patient transfers/discharges are initiated by the facility, the Notice of Proposed Transfer/Discharge policy will be followed. The notice indicated the facility may proceed with the transfer/discharge at the end of thirty (30) days, even if a decision on the appeal has not been rendered. The facility failed to provide a 30 day written notice of transfer to Patient 19 and/or family member or legal representative least 30 days before the patient transferred out of the facility. The above violation has a direct relationship to the health safety or security of patients. |
| 970000054 |
WESTERN CONVALESCENT HOSPITAL |
910010784 |
B |
19-Jun-14 |
ZWAE11 |
3631 |
CALIFORNIA HEALTH AND SAFETY CODE DIVISION 2. CHAPTER 2. ARTICLE 8.5Section 1336.2. (a) (4) (a) Before residents are transferred due to any change in the status of the license or operation of a facility, including a facility closure or voluntary or involuntary termination of a facility?s Medi-Cal or Medicare certification, the facility shall take reasonable steps to transfer affected residents safely and minimize possible transfer trauma by, at a minimum, doing all of the following: (4) At least 30 days in advance of the transfer, inform the resident or the resident?s representative of alternative facilities that are available and adequate to meet resident and family needs Based on observation, interview and record review, the facility failed to provide a written notice of transfer to Patient 20 and/or family member or legal representative at least 30 days before the patient is transferred out of the facility. A construction project to install sprinklers required the facility to remove all patients from the second floor. The project is in response to the facility non-compliance with the federal regulation that requires all long term care facilities to be equipped with a supervised automatic sprinkler system by August 13, 2013. This transfer of patients with less than a 30 day notice is a violation of the patient?s rights.Findings: On April 8, 2014 at 10:52 a.m., the Department received a complaint allegation regarding transfer discharge (T/D) rights. On April 8, 2014 at 2:45 p.m., the Department conducted an onsite visit to monitor the relocation of facility patients due to the facility's sprinkler installation project. According to the Life Safety 2567 (Statement of Deficiencies and Plan of Correction), dated December 11, 2013, the facility was not completely covered with an automatic sprinkler system in accordance with the National Fire Protection Association (NFPA) 13, and the facility lacked a fire sprinkler system. There was no plan to ensure the patients were given the 30 day notification prior to the transfer out of the facility due to the sprinkler system installation project.On the same day during an interview the administrator disclosed she held a meeting with the facility's task force committee. The committee discussed obtaining approval of the relocation plans for the sprinkler system installation project. A review of clinical records for Patient 20, disclosed less than a 30 day timeframe for the Notice of Proposed Transfer/Discharge before the scheduled transfer out of the facility. In addition, the written notice did not include a completion date for the sprinkler system installation project or an expected date for the patient?s return to the facility. During an interview with Patient 20 on April 2, 2014, at 3 p.m., the patient stated the facility explained the installation of the sprinkler system. The transfer was temporary and the transfer back to the facility would be in approximately two months. The undated facility policy and procedure titled, "Transfer/Discharge", described that when patient transfers/discharges are initiated by the facility, the Notice of Proposed Transfer/Discharge policy will be followed. The notice indicated the facility may proceed with the transfer/discharge at the end of thirty (30) days, even if a decision on the appeal has not been rendered. The facility failed to provide a 30 day written notice of transfer to Patient 20 and/or family member or legal representative least 30 days before the patient transferred out of the facility. The above violation has a direct relationship to the health safety or security of patients. |
| 970000054 |
WESTERN CONVALESCENT HOSPITAL |
910010785 |
B |
19-Jun-14 |
ZWAE11 |
3601 |
CALIFORNIA HEALTH AND SAFETY CODE DIVISION 2. CHAPTER 2. ARTICLE 8.5Section 1336.2. (a) (4) (a) Before residents are transferred due to any change in the status of the license or operation of a facility, including a facility closure or voluntary or involuntary termination of a facility?s Medi-Cal or Medicare certification, the facility shall take reasonable steps to transfer affected residents safely and minimize possible transfer trauma by, at a minimum, doing all of the following: (4) At least 30 days in advance of the transfer, inform the resident or the resident?s representative of alternative facilities that are available and adequate to meet resident and family needs. Based on observation, interview and record review, the facility failed to provide a written notice of transfer to Patient 21 at least 30 days before the patient is transferred out of the facility. A construction project to install sprinklers required the facility to remove all patients from the second floor. The project is in response to the facility non-compliance with the federal regulation that requires all long term care facilities to be equipped with a supervised automatic sprinkler system by August 13, 2013. This transfer of patients with less than a 30 day notice is a violation of the patient?s rights. Findings: On April 8, 2014 at 10:52 a.m., the Department received a complaint allegation regarding transfer discharge (T/D) rights.On April 8, 2014 at 2:45 p.m., the Department conducted an onsite visit to monitor the relocation of facility patients due to the facility's sprinkler installation project.According to the Life Safety 2567 (Statement of Deficiencies and Plan of Correction), dated December 11, 2013, the facility was not completely covered with an automatic sprinkler system in accordance with the National Fire Protection Association (NFPA) 13, and the facility lacked a fire sprinkler system. There was no plan to ensure the patients were given the 30 day notification prior to the transfer out of the facility due to the sprinkler system installation project. On the same day during an interview the administrator disclosed she held a meeting with the facility's task force committee. The committee discussed obtaining approval of the relocation plans for the sprinkler system installation project. A review of clinical records for Patient 21, disclosed less than a 30 day timeframe for the Notice of Proposed Transfer/Discharge before the scheduled transfer out of the facility. In addition, the written notice did not include a completion date for the sprinkler system installation project or an expected date for the patient?s return to the facility.During an interview with Patient 21, on April 2, 2014, at 3 p.m., Patient 21 stated the facility explained the installation of the sprinkler system. The transfer was temporary and the transfer back to the facility would be in approximately two months. The undated facility policy and procedure titled, "Transfer/Discharge", without a date described that when patient transfers/discharges are initiated by the facility, the Notice of Proposed Transfer/Discharge policy will be followed. The notice indicated the facility may proceed with the transfer/discharge at the end of thirty (30) days, even if a decision on the appeal has not been rendered. The facility failed to provide a 30 day written notice of transfer to Patient 21 and/or family member or legal representative least 30 days before the patient transferred out of the facility. The above violation has a direct relationship to the health safety or security of patients. |
| 970000054 |
WESTERN CONVALESCENT HOSPITAL |
910010786 |
B |
19-Jun-14 |
ZWAE11 |
3585 |
CALIFORNIA HEALTH AND SAFETY CODE DIVISION 2. CHAPTER 2. ARTICLE 8.5Section 1336.2. (a) (4) (a) Before residents are transferred due to any change in the status of the license or operation of a facility, including a facility closure or voluntary or involuntary termination of a facility?s Medi-Cal or Medicare certification, the facility shall take reasonable steps to transfer affected residents safely and minimize possible transfer trauma by, at a minimum, doing all of the following: (4) At least 30 days in advance of the transfer, inform the resident or the resident?s representative of alternative facilities that are available and adequate to meet resident and family needs Based on observation, interview and record review, the facility failed to provide a written notice of transfer to Patient 22 at least 30 days before the patient is transferred out of the facility. A construction project to install sprinklers required the facility to remove all patients from the second floor. The project is in response to the facility non-compliance with the federal regulation that requires all long term care facilities to be equipped with a supervised automatic sprinkler system by August 13, 2013. This transfer of patients with less than a 30 day notice is a violation of the patient?s rights.Findings: On April 8, 2014 at 10:52 a.m., the Department received a complaint allegation regarding transfer discharge (T/D) rights.On April 8, 2014 at 2:45 p.m., the Department conducted an onsite visit to monitor the relocation of facility patients due to the facility's sprinkler installation project. According to the Life Safety 2567 (Statement of Deficiencies and Plan of Correction), dated December 11, 2013, the facility was not completely covered with an automatic sprinkler system in accordance with the National Fire Protection Association (NFPA) 13, and the facility lacked a fire sprinkler system. There was no plan to ensure the patients were given the 30 day notification prior to the transfer out of the facility due to the sprinkler system installation project.On the same day during an interview the administrator disclosed she held a meeting with the facility's task force committee. The committee discussed obtaining approval of the relocation plans for the sprinkler system installation project. A review of clinical records for Patient 22, disclosed less than a 30 day timeframe for the Notice of Proposed Transfer/Discharge before the scheduled transfer out of the facility. In addition, the written notice did not include a completion date for the sprinkler system installation project or an expected date for the patient?s return to the facility. During an interview with Patient 22, on April 2, 2014 at 3 p.m., the patient stated the facility explained the installation of the sprinkler system. The transfer was temporary and the transfer back to the facility would be in approximately two months. The undated facility policy and procedure titled, "Transfer/Discharge", described that when patient transfers/discharges are initiated by the facility, the Notice of Proposed Transfer/Discharge policy will be followed. The notice indicated the facility may proceed with the transfer/discharge at the end of thirty (30) days, even if a decision on the appeal has not been rendered. The facility failed to provide a 30 day written notice of transfer to Patient 22 and/or family member or legal representative least 30 days before the patient transferred out of the facility. The above violation has a direct relationship to the health safety or security of patients. |
| 970000054 |
WESTERN CONVALESCENT HOSPITAL |
910010787 |
B |
19-Jun-14 |
ZWAE11 |
3586 |
CALIFORNIA HEALTH AND SAFETY CODE DIVISION 2. CHAPTER 2. ARTICLE 8.5Section 1336.2. (a) (4) (a) Before residents are transferred due to any change in the status of the license or operation of a facility, including a facility closure or voluntary or involuntary termination of a facility?s Medi-Cal or Medicare certification, the facility shall take reasonable steps to transfer affected residents safely and minimize possible transfer trauma by, at a minimum, doing all of the following: (4) At least 30 days in advance of the transfer, inform the resident or the resident?s representative of alternative facilities that are available and adequate to meet resident and family needsBased on observation, interview and record review, the facility failed to provide a written notice of transfer to Patient 23 at least 30 days before the patient is transferred out of the facility. A construction project to install sprinklers required the facility to remove all patients from the second floor. The project is in response to the facility non-compliance with the federal regulation that requires all long term care facilities to be equipped with a supervised automatic sprinkler system by August 13, 2013. This transfer of patients with less than a 30 day notice is a violation of the patient?s rights.Findings: On April 8, 2014 at 10:52 a.m., the Department received a complaint allegation regarding transfer discharge (T/D) rights. On April 8, 2014 at 2:45 p.m., the Department conducted an onsite visit to monitor the relocation of facility patients due to the facility's sprinkle installation project. According to the Life Safety 2567 (Statement of Deficiencies and Plan of Correction), dated December 11, 2013, the facility was not completely covered with an automatic sprinkler system in accordance with the National Fire Protection Association (NFPA) 13, and the facility lacked a fire sprinkler system. There was no plan to ensure the patients were given the 30 day notification prior to the transfer out of the facility due to the sprinkler system installation project.On the same day during an interview the administrator disclosed she held a meeting with the facility's task force committee. The committee discussed obtaining approval of the relocation plans for the sprinkler system installation project. A review of clinical records for Patient 23, disclosed less than a 30 day timeframe for the Notice of Proposed Transfer/Discharge before the scheduled transfer out of the facility. In addition, the written notice did not include a completion date for the sprinkler system installation project or an expected date for the patients? return to the facility. During an interview with Patient 23, on April 2, 2014 at 3:45 p.m. the patient stated the facility explained the installation of the sprinkler system. The transfer was temporary and the transfer back to the facility would be in approximately two months. The undated facility policy and procedure titled, "Transfer/Discharge", described that when patient transfers/discharges are initiated by the facility, the Notice of Proposed Transfer/Discharge policy will be followed. The notice indicated the facility may proceed with the transfer/discharge at the end of thirty (30) days, even if a decision on the appeal has not been rendered. The facility failed to provide a 30 day written notice of transfer to Patient 23 and/or family member or legal representative least 30 days before the patient transferred out of the facility. The above violation has a direct relationship to the health safety or security of patients. |
| 970000054 |
WESTERN CONVALESCENT HOSPITAL |
910010788 |
B |
19-Jun-14 |
ZWAE11 |
3588 |
CALIFORNIA HEALTH AND SAFETY CODE DIVISION 2. CHAPTER 2. ARTICLE 8.5Section 1336.2. (a) (4) (a) Before residents are transferred due to any change in the status of the license or operation of a facility, including a facility closure or voluntary or involuntary termination of a facility?s Medi-Cal or Medicare certification, the facility shall take reasonable steps to transfer affected residents safely and minimize possible transfer trauma by, at a minimum, doing all of the following: (4) At least 30 days in advance of the transfer, inform the resident or the resident?s representative of alternative facilities that are available and adequate to meet resident and family needs Based on observation, interview and record review, the facility failed to provide a written notice of transfer to Patient 24 at least 30 days before the patient is transferred out of the facility. A construction project to install sprinklers required the facility to remove all patients from the second floor. The project is in response to the facility non-compliance with the federal regulation that requires all long term care facilities to be equipped with a supervised automatic sprinkler system by August 13, 2013. This transfer of patients with less than a 30 day notice is a violation of the patient?s rights. Findings: On April 8, 2014 at 10:52 a.m., the Department received a complaint allegation regarding transfer discharge (T/D) rights.On April 8, 2014 at 2:45 p.m., the Department conducted an onsite visit to monitor the relocation of facility patients due to the facility's sprinkler installation project. According to the Life Safety 2567 (Statement of Deficiencies and Plan of Correction), dated December 11, 2013, the facility was not completely covered with an automatic sprinkler system in accordance with the National Fire Protection Association (NFPA) 13, and the facility lacked a fire sprinkler system. There was no plan to ensure the patients were given the 30 day notification prior to the transfer out of the facility due to the sprinkler system installation project.On the same day during an interview the administrator disclosed she held a meeting with the facility's task force committee. The committee discussed obtaining approval of the relocation plans for the sprinkler system installation project. A review of clinical records for Patient 24, disclosed less than a 30 day timeframe for the Notice of Proposed Transfer/Discharge before the scheduled transfer out of the facility. In addition, the written notice did not include a completion date for the sprinkler system installation project or an expected date for the patient?s return to the facility. During an interview with Patient 24, on April 2, 2014 at 3:20 p.m., Patient 24 stated the facility explained the installation of the sprinkler system. The transfer was temporary and the transfer back to the facility would be in approximately two months. The undated facility policy and procedure titled, "Transfer/Discharge", described that when patient transfers/discharges are initiated by the facility, the Notice of Proposed Transfer/Discharge policy will be followed. The notice indicated the facility may proceed with the transfer/discharge at the end of thirty (30) days, even if a decision on the appeal has not been rendered. The facility failed to provide a 30 day written notice of transfer to Patient 24 and/or family member or legal representative least 30 days before the patient transferred out of the facility. The above violation has a direct relationship to the health safety or security of patients. |
| 970000054 |
WESTERN CONVALESCENT HOSPITAL |
910010789 |
B |
19-Jun-14 |
ZWAE11 |
3631 |
CALIFORNIA HEALTH AND SAFETY CODE DIVISION 2. CHAPTER 2. ARTICLE 8.5Section 1336.2. (a) (4) (a) Before residents are transferred due to any change in the status of the license or operation of a facility, including a facility closure or voluntary or involuntary termination of a facility?s Medi-Cal or Medicare certification, the facility shall take reasonable steps to transfer affected residents safely and minimize possible transfer trauma by, at a minimum, doing all of the following: (4) At least 30 days in advance of the transfer, inform the resident or the resident?s representative of alternative facilities that are available and adequate to meet resident and family needs Based on observation, interview and record review, the facility failed to provide a written notice of transfer to Patient 25 and/or family member or legal representative at least 30 days before the patient is transferred out of the facility. A construction project to install sprinklers required the facility to remove all patients from the second floor. The project is in response to the facility non-compliance with the federal regulation that requires all long term care facilities to be equipped with a supervised automatic sprinkler system by August 13, 2013. This transfer of patients with less than a 30 day notice is a violation of the patient?s rights. Findings: On April 8, 2014 at 10:52 a.m., the Department received a complaint allegation regarding transfer discharge (T/D) rights. On April 8, 2014 at 2:45 p.m., the Department conducted an onsite visit to monitor the relocation of facility patients due to the facility's sprinkler installation project. According to the Life Safety 2567 (Statement of Deficiencies and Plan of Correction), dated December 11, 2013, the facility was not completely covered with an automatic sprinkler system in accordance with the National Fire Protection Association (NFPA) 13, and the facility lacked a fire sprinkler system. There was no plan to ensure the patients were given the 30 day notification prior to the transfer out of the facility due to the sprinkler system installation project.On the same day during an interview the administrator disclosed she held a meeting with the facility's task force committee. The committee discussed obtaining approval of the relocation plans for the sprinkler system installation project. A review of clinical records for Patient 25, disclosed less than a 30 day timeframe for the Notice of Proposed Transfer/Discharge before the scheduled transfer out of the facility. In addition, the written notice did not include a completion date for the sprinkler system installation project or an expected date for the patient?s return to the facility. During an interview with Patient 25, on April 2, 2014 at 4 p.m., Patient 25 stated the facility explained the installation of the sprinkler system. The transfer was temporary and the transfer back to the facility would be in approximately two months. The undated facility policy and procedure titled, "Transfer/Discharge", described that when patient transfers/discharges are initiated by the facility, the Notice of Proposed Transfer/Discharge policy will be followed. The notice indicated the facility may proceed with the transfer/discharge at the end of thirty (30) days, even if a decision on the appeal has not been rendered. The facility failed to provide a 30 day written notice of transfer to Patient 25 and/or family member or legal representative least 30 days before the patient transferred out of the facility. The above violation has a direct relationship to the health safety or security of patients. |
| 970000054 |
WESTERN CONVALESCENT HOSPITAL |
910010790 |
B |
19-Jun-14 |
ZWAE11 |
3628 |
CALIFORNIA HEALTH AND SAFETY CODE DIVISION 2. CHAPTER 2. ARTICLE 8.5Section 1336.2. (a) (4) (a) Before residents are transferred due to any change in the status of the license or operation of a facility, including a facility closure or voluntary or involuntary termination of a facility?s Medi-Cal or Medicare certification, the facility shall take reasonable steps to transfer affected residents safely and minimize possible transfer trauma by, at a minimum, doing all of the following: (4) At least 30 days in advance of the transfer, inform the resident or the resident?s representative of alternative facilities that are available and adequate to meet resident and family needsBased on observation, interview and record review, the facility failed to provide a written notice of transfer to Patient 26 and/or family member or legal representative at least 30 days before the patient is transferred out of the facility. A construction project to install sprinklers required the facility to remove all patients from the second floor. The project is in response to the facility non-compliance with the federal regulation that requires all long term care facilities to be equipped with a supervised automatic sprinkler system by August 13, 2013. This transfer of patients with less than a 30 day notice is a violation of the patient?s rights.Findings: On April 8, 2014 at 10:52 a.m., the Department received a complaint allegation regarding transfer discharge (T/D) rights. On April 8, 2014 at 2:45 p.m., the Department conducted an onsite visit to monitor the relocation of facility patients due to the facility's sprinkler installation project. According to the Life Safety 2567 (Statement of Deficiencies and Plan of Correction), dated December 11, 2013, the facility was not completely covered with an automatic sprinkler system in accordance to the National Fire Protection Association (NFPA) 13, and the facility lacked a fire sprinkler system. There was no plan to ensure the patients were given the 30 day notification prior to the transfer out of the facility due to the sprinkler system installation project.On the same day during an interview the administrator disclosed she held a meeting with the facility's task force committee. The committee discussed obtaining approval of the relocation plans for the sprinkler system installation project. A review of clinical records for Patient 26, disclosed less than a 30 day timeframe for the Notice of Proposed Transfer/Discharge before the scheduled transfer out of the facility. In addition, the written notice did not include a completion date for the sprinkler system installation project or an expected date for the patient?s return to the facility. During an interview with Patient 26, on April 2, 2014, at 4 p.m., Patient 26 stated the facility explained the installation of the sprinkler system. The transfer was temporary and the transfer back to the facility would be in approximately two months. The undated facility policy and procedure titled, "Transfer/Discharge", described that when patient transfers/discharges are initiated by the facility, the Notice of Proposed Transfer/Discharge policy will be followed. The notice indicated the facility may proceed with the transfer/discharge at the end of thirty (30) days, even if a decision on the appeal has not been rendered. The facility failed to provide a 30 day written notice of transfer to Patient 26 and/or family member or legal representative least 30 days before the patient transferred out of the facility. The above violation has a direct relationship to the health safety or security of patients. |
| 970000054 |
WESTERN CONVALESCENT HOSPITAL |
910010791 |
B |
19-Jun-14 |
ZWAE11 |
3646 |
CALIFORNIA HEALTH AND SAFETY CODE DIVISION 2. CHAPTER 2. ARTICLE 8.5Section 1336.2 (a) (4) (a) Before residents are transferred due to any change in the status of the license or operation of a facility, including a facility closure or voluntary or involuntary termination of a facility?s Medi-Cal or Medicare certification, the facility shall take reasonable steps to transfer affected residents safely and minimize possible transfer trauma by, at a minimum, doing all of the following: (4) At least 30 days in advance of the transfer, inform the resident or the resident?s representative of alternative facilities that are available and adequate to meet resident and family needs Based on observation, interview and record review, the facility failed to provide a written notice of transfer to Patient 27 and/or family member or legal representative at least 30 days before the patient is transferred out of the facility. A construction project to install sprinklers required the facility to remove all patients from the second floor. The project was in response to the facility non-compliance with the federal regulation that requires all long term care facilities to be equipped with a supervised automatic sprinkler system by August 13, 2013. This transfer of patients with less than a 30 day notice is a violation of the patient?s rights.Findings: On April 8, 2014 at 10:52 a.m., the Department received a complaint allegation regarding transfer discharge (T/D) rights. On April 8, 2014 at 2:45 p.m., the Department conducted an onsite visit to monitor the relocation of facility patients due to the facility's sprinkler installation project. According to the Life Safety 2567 (Statement of Deficiencies and Plan of Correction), dated December 11, 2013, the facility was not completely covered with an automatic sprinkler system in accordance with the National Fire Protection Association (NFPA) 13, and the facility lacked a fire sprinkler system. There was no plan to ensure the patients were given the 30 day notification prior to the transfer out of the facility due to the sprinkler system installation project.On the same day during an interview, the administrator disclosed she held a meeting with the facility's task force committee. The committee discussed obtaining approval of the relocation plans for the sprinkler system installation project. A review of clinical records for Patient 27, disclosed there was less than a 30 day timeframe for the Notice of Proposed Transfer/Discharge before the scheduled transfer out of the facility. In addition, the written notice did not include a completion date for the sprinkler system installation project or an expected date for the patient?s return to the facility.During an interview with Patient 27 on April 9, 2014, at 9:55 a.m., the patient stated the facility explained the installation of the sprinkler system. The transfer was temporary and the transfer back to the facility would be in approximately two months. The undated facility policy and procedure titled, "Transfer/Discharge",described that when patient transfers/discharges are initiated by the facility, the Notice of Proposed Transfer/Discharge policy will be followed. The notice indicated the facility may proceed with the transfer/discharge at the end of thirty (30) days, even if a decision on the appeal has not been rendered. The facility failed to provide a 30 day written notice of transfer to Patient 27 and/or family member or legal representative at least 30 days before the patient transferred out of the facility. The above violation has a direct relationship to the health safety or security of patients. |
| 970000054 |
WESTERN CONVALESCENT HOSPITAL |
910010792 |
B |
19-Jun-14 |
ZWAE11 |
3633 |
CALIFORNIA HEALTH AND SAFETY CODE DIVISION 2. CHAPTER 2. ARTICLE 8.5Section 1336.2 (a) (4) (a) Before residents are transferred due to any change in the status of the license or operation of a facility, including a facility closure or voluntary or involuntary termination of a facility?s Medi-Cal or Medicare certification, the facility shall take reasonable steps to transfer affected residents safely and minimize possible transfer trauma by, at a minimum, doing all of the following: (4) At least 30 days in advance of the transfer, inform the resident or the resident?s representative of alternative facilities that are available and adequate to meet resident and family needs Based on observation, interview and record review, the facility failed to provide a written notice of transfer to Patient 28 and/or family member or legal representative at least 30 days before the patient is transferred out of the facility. A construction project to install sprinklers required the facility to remove all patients from the second floor. The project is in response to the facility non-compliance with the federal regulation that requires all long term care facilities to be equipped with a supervised automatic sprinkler system by August 13, 2013. This transfer of patients with less than a 30 day notice is a violation of the patient?s rights. Findings: On April 8, 2014 at 10:52 a.m., the Department received a complaint allegation regarding transfer discharge (T/D) rights. On April 8, 2014 at 2:45 p.m., the Department conducted an onsite visit to monitor the relocation of facility patients due to the facility's sprinkler installation project. According to the Life Safety 2567 (Statement of Deficiencies and Plan of Correction), dated December 11, 2013, the facility was not completely covered with an automatic sprinkler system in accordance with the National Fire Protection Association (NFPA) 13, and the facility lacked a fire sprinkler system. There was no plan to ensure the patients were given the 30 day notification prior to the transfer out of the facility due to the sprinkler system installation project. On the same day during an interview the administrator disclosed she held a meeting with the facility's task force committee. The committee discussed obtaining approval of the relocation plans for the sprinkler system installation project. A review of clinical records for Patient 28, disclosed less than a 30 day timeframe for the Notice of Proposed Transfer/Discharge before the scheduled transfer out of the facility. In addition, the written notice did not include a completion date for the sprinkler system installation project or an expected date for the patient?s return to the facility. During an interview with Patient 28, on April 9 2014, at 9:55 a.m.,patient 28 stated the facility explained the installation of the sprinkler system. The transfer was temporary and the transfer back to the facility would be in approximately two months. The undated facility policy and procedure titled, "Transfer/Discharge", described that when patient transfers/discharges are initiated by the facility, the Notice of Proposed Transfer/Discharge policy will be followed. The notice indicated the facility may proceed with the transfer/discharge at the end of thirty (30) days, even if a decision on the appeal has not been rendered. The facility failed to provide a 30 day written notice of transfer to Patient 28 and/or family member or legal representative least 30 days before the patient transferred out of the facility. The above violation has a direct relationship to the health safety or security of patients. |
| 970000054 |
WESTERN CONVALESCENT HOSPITAL |
910010793 |
B |
19-Jun-14 |
ZWAE11 |
3635 |
CALIFORNIA HEALTH AND SAFETY CODE DIVISION 2. CHAPTER 2. ARTICLE 8.5Section 1336.2. (a) (4) (a) Before residents are transferred due to any change in the status of the license or operation of a facility, including a facility closure or voluntary or involuntary termination of a facility?s Medi-Cal or Medicare certification, the facility shall take reasonable steps to transfer affected residents safely and minimize possible transfer trauma by, at a minimum, doing all of the following: (4) At least 30 days in advance of the transfer, inform the resident or the resident?s representative of alternative facilities that are available and adequate to meet resident and family needs Based on observation, interview and record review, the facility failed to provide a written notice of transfer to Patient 29 and/or family member or legal representative at least 30 days before the patient is transferred out of the facility. A construction project to install sprinklers required the facility to remove all patients from the second floor. The project is in response to the facility non-compliance with the federal regulation that requires all long term care facilities to be equipped with a supervised automatic sprinkler system by August 13, 2013. This transfer of patients with less than a 30 day notice is a violation of the patient?s rights. Findings: On April 8, 2014 at 10:52 a.m., the Department received a complaint allegation regarding transfer discharge (T/D) rights. On April 8, 2014 at 2:45 p.m., the Department conducted an onsite visit to monitor the relocation of facility patients due to the facility's sprinkler installation project.According to the Life Safety 2567 (Statement of Deficiencies and Plan of Correction), dated December 11, 2013, the facility was not completely covered with an automatic sprinkler system in accordance with the National Fire Protection Association (NFPA) 13, and the facility lacked a fire sprinkler system. There was no plan to ensure the patients were given the 30 day notification prior to the transfer out of the facility due to the sprinkler system installation project.On the same day during an interview the administrator disclosed she held a meeting with the facility's task force committee. The committee discussed obtaining approval of the relocation plans for the sprinkler system installation project. A review of clinical records for Patient 29, disclosed less than a 30 day timeframe for the Notice of Proposed Transfer/Discharge before the scheduled transfer out of the facility. In addition, the written notice did not include a completion date for the sprinkler system installation project or an expected date for the patient?s return to the facility.During an interview with Patient 29, on April 2, 2014, at 4 p.m., Patient 29 stated the facility explained the installation of the sprinkler system. The transfer was temporary and the transfer back to the facility would be in approximately two months. The undated facility policy and procedure titled, "Transfer/Discharge", date described that when patient transfers/discharges are initiated by the facility, the Notice of Proposed Transfer/Discharge policy will be followed. The notice indicated the facility may proceed with the transfer/discharge at the end of thirty (30) days, even if a decision on the appeal has not been rendered. The facility failed to provide a 30 day written notice of transfer to Patient 29 and/or family member or legal representative least 30 days before the patient transferred out of the facility. The above violation has a direct relationship to the health safety or security of patients. |
| 970000054 |
WESTERN CONVALESCENT HOSPITAL |
910010794 |
B |
19-Jun-14 |
ZWAE11 |
3378 |
CALIFORNIA HEALTH AND SAFETY CODE DIVISION 2. CHAPTER 2. ARTICLE 8.5Section 1336.2. (a) (4) (a) Before residents are transferred due to any change in the status of the license or operation of a facility, including a facility closure or voluntary or involuntary termination of a facility?s Medi-Cal or Medicare certification, the facility shall take reasonable steps to transfer affected residents safely and minimize possible transfer trauma by, at a minimum, doing all of the following: (4) At least 30 days in advance of the transfer, inform the resident or the resident?s representative of alternative facilities that are available and adequate to meet resident and family needs Based on observation, interview and record review, the facility failed to provide a written notice of transfer to Patient 30 and/or family member or legal representative at least 30 days before the patient is transferred out of the facility. A construction project to install sprinklers required the facility to remove all patients from the second floor. The project is in response to the facility non-compliance with the federal regulation that requires all long term care facilities to be equipped with a supervised automatic sprinkler system by August 13, 2013. This transfer of patients with less than a 30 day notice is a violation of the patient?s rights. Findings: On April 8, 2014 at 10:52 a.m., the Department received a complaint allegation regarding transfer discharge (T/D) rights. On April 8, 2014 at 2:45 p.m., the Department conducted an onsite visit to monitor the relocation of facility patients due to the facility's sprinkler installation project. According to the Life Safety 2567 (Statement of Deficiencies and Plan of Correction), dated December 11, 2013, the facility was not completely covered with an automatic sprinkler system in accordance to the National Fire Protection Association (NFPA) 13, and the facility lacked a fire sprinkler system. There was no plan to ensure the patients were given the 30 day notification prior to the transfer out of the facility due to the sprinkler system installation project.On the same day during an interview the administrator disclosed she held a meeting with the facility's task force committee. The committee discussed obtaining approval of the relocation plans for the sprinkler system installation project. A review of clinical records for Patient 30, disclosed less than a 30 day timeframe for the Notice of Proposed Transfer/Discharge before the scheduled transfer out of the facility. In addition, the written notice did not include a completion date for the sprinkler system installation project or an expected date for the patient?s return to the facility. The undated facility policy and procedure titled, "Transfer/Discharge", described that when patient transfers/discharges are initiated by the facility, the Notice of Proposed Transfer/Discharge policy will be followed. The notice indicated the facility may proceed with the transfer/discharge at the end of thirty (30) days, even if a decision on the appeal has not been rendered. The facility failed to provide a 30 day written notice of transfer to Patient 30 and/or family member or legal representative least 30 days before the patient transferred out of the facility. The above violation has a direct relationship to the health safety or security of patients. |
| 970000054 |
WESTERN CONVALESCENT HOSPITAL |
910010795 |
B |
19-Jun-14 |
ZWAE11 |
3378 |
CALIFORNIA HEALTH AND SAFETY CODE DIVISION 2. CHAPTER 2. ARTICLE 8.5Section 1336.2 (a) (4) (a) Before residents are transferred due to any change in the status of the license or operation of a facility, including a facility closure or voluntary or involuntary termination of a facility?s Medi-Cal or Medicare certification, the facility shall take reasonable steps to transfer affected residents safely and minimize possible transfer trauma by, at a minimum, doing all of the following: (4) At least 30 days in advance of the transfer, inform the resident or the resident?s representative of alternative facilities that are available and adequate to meet resident and family needs Based on observation, interview and record review, the facility failed to provide a written notice of transfer to Patient 31 and/or family member or legal representative at least 30 days before the patient is transferred out of the facility. A construction project to install sprinklers required the facility to remove all patients from the second floor. The project is in response to the facility non-compliance with the federal regulation that requires all long term care facilities to be equipped with a supervised automatic sprinkler system by August 13, 2013. This transfer of patients with less than a 30 day notice is a violation of the patient?s rights. Findings: On April 8, 2014 at 10:52 a.m., the Department received a complaint allegation regarding transfer discharge (T/D) rights. On April 8, 2014 at 2:45 p.m., the Department conducted an onsite visit to monitor the relocation of facility patients due to the facility's sprinkler installation project. According to the Life Safety 2567 (Statement of Deficiencies and Plan of Correction), dated December 11, 2013, the facility was not completely covered with an automatic sprinkler system in accordance with the National Fire Protection Association (NFPA) 13, and the facility lacked a fire sprinkler system. There was no plan to ensure the patients were given the 30 day notification prior to the transfer out of the facility due to the sprinkler system installation project.On the same day during an interview the administrator disclosed she held a meeting with the facility's task force committee. The committee discussed obtaining approval of the relocation plans for the sprinkler system installation project. A review of clinical records for Patient 31, disclosed less than a 30 day timeframe for the Notice of Proposed Transfer/Discharge before the scheduled transfer out of the facility. In addition, the written notice did not include a completion date for the sprinkler system installation project or an expected date for the patient?s return to the facility. The undated facility policy and procedure titled, "Transfer/Discharge",described that when patient transfers/discharges are initiated by the facility, the Notice of Proposed Transfer/Discharge policy will be followed. The notice indicated the facility may proceed with the transfer/discharge at the end of thirty (30) days, even if a decision on the appeal has not been rendered. The facility failed to provide a 30 day written notice of transfer to Patient 31 and/or family member or legal representative least 30 days before the patient transferred out of the facility. The above violation has a direct relationship to the health safety or security of patients. |
| 970000054 |
WESTERN CONVALESCENT HOSPITAL |
910010796 |
B |
19-Jun-14 |
ZWAE11 |
3633 |
CALIFORNIA HEALTH AND SAFETY CODE DIVISION 2. CHAPTER 2. ARTICLE 8.5Section 1336.2(a) (4) (a) Before residents are transferred due to any change in the status of the license or operation of a facility, including a facility closure or voluntary or involuntary termination of a facility?s Medi-Cal or Medicare certification, the facility shall take reasonable steps to transfer affected residents safely and minimize possible transfer trauma by, at a minimum, doing all of the following: (4) At least 30 days in advance of the transfer, inform the resident or the resident?s representative of alternative facilities that are available and adequate to meet resident and family needs Based on observation, interview and record review, the facility failed to provide a written notice of transfer to Patient 32 and/or family member or legal representative at least 30 days before the patient is transferred out of the facility. A construction project to install sprinklers required the facility to remove all patients from the second floor. The project is in response to the facility non-compliance with the federal regulation that requires all long term care facilities to be equipped with a supervised automatic sprinkler system by August 13, 2013. This transfer of patients with less than a 30 day notice is a violation of the patient?s rights. Findings: On April 8, 2014 at 10:52 a.m., the Department received a complaint allegation regarding transfer discharge (T/D) rights. On April 8, 2014 at 2:45 p.m., the Department conducted an onsite visit to monitor the relocation of facility patients due to the facility's sprinkler installation project. According to the Life Safety 2567 (Statement of Deficiencies and Plan of Correction), dated December 11, 2013, the facility was not completely covered with an automatic sprinkler system in accordance with the National Fire Protection Association (NFPA) 13, and the facility lacked a fire sprinkler system. There was no plan to ensure the patients were given the 30 day notification prior to the transfer out of the facility due to the sprinkler system installation project.On the same day during an interview the administrator disclosed she held a meeting with the facility's task force committee. The committee discussed obtaining approval of the relocation plans for the sprinkler system installation project. A review of clinical records for Patient 32, disclosed less than a 30 day timeframe for the Notice of Proposed Transfer/Discharge before the scheduled transfer out of the facility. In addition, the written notice did not include a completion date for the sprinkler system installation project or an expected date for the patient?s return to the facility. During an interview with Patient 32, on April 2, 2014, at 3:30 p.m., Patient 32 stated the facility explained the installation of the sprinkler system. The transfer was temporary and the transfer back to the facility would be in approximately two months. The undated facility policy and procedure titled, "Transfer/Discharge", described that when patient transfers/discharges are initiated by the facility, the Notice of Proposed Transfer/Discharge policy will be followed. The notice indicated the facility may proceed with the transfer/discharge at the end of thirty (30) days, even if a decision on the appeal has not been rendered. The facility failed to provide a 30 day written notice of transfer to Patient 32 and/or family member or legal representative least 30 days before the patient transferred out of the facility. The above violation has a direct relationship to the health safety or security of patients. |
| 970000054 |
WESTERN CONVALESCENT HOSPITAL |
910010797 |
B |
19-Jun-14 |
ZWAE11 |
3394 |
CALIFORNIA HEALTH AND SAFETY CODE DIVISION 2. CHAPTER 2. ARTICLE 8.5Section 1336.2. (a) (4) (a) Before residents are transferred due to any change in the status of the license or operation of a facility, including a facility closure or voluntary or involuntary termination of a facility?s Medi-Cal or Medicare certification, the facility shall take reasonable steps to transfer affected residents safely and minimize possible transfer trauma by, at a minimum, doing all of the following: (4) At least 30 days in advance of the transfer, inform the resident or the resident?s representative of alternative facilities that are available and adequate to meet resident and family needs Based on observation, interview and record review, the facility failed to provide a written notice of transfer to Patient 33 and/or family member or legal representative at least 30 days before the patient is transferred out of the facility. A construction project to install sprinklers required the facility to remove all patients from the second floor. The project is in response to the facility non-compliance with the federal regulation that requires all long term care facilities to be equipped with a supervised automatic sprinkler system by August 13, 2013. This transfer of patients with less than a 30 day notice is a violation of the patient?s rights. Findings: On April 8, 2014 at 10:52 a.m., the Department received a complaint allegation regarding transfer discharge (T/D) rights. On April 8, 2014 at 2:45 p.m., the Department conducted an onsite visit to monitor the relocation of facility patients due to the facility's sprinkler installation project. According to the Life Safety 2567 (Statement of Deficiencies and Plan of Correction), dated December 11, 2013, the facility was not completely covered with an automatic sprinkler system in accordance with the National Fire Protection Association (NFPA) 13, and the facility lacked a fire sprinkler system. There was no plan to ensure the patients were given the 30 day notification prior to the transfer out of the facility due to the sprinkler system installation project.On the same day during an interview the administrator disclosed she held a meeting with the facility's task force committee. The committee discussed obtaining approval of the relocation plans for the sprinkler system installation project. A review of clinical records for Patient 33, disclosed less than a 30 day timeframe for the Notice of Proposed Transfer/Discharge before the scheduled transfer out of the facility. In addition, the written notice did not include a completion date for the sprinkler system installation project or an expected date for the patient?s return to the facility.The undated facility policy and procedure titled, "Transfer/Discharge", without a date described that when patient transfers/discharges are initiated by the facility, the Notice of Proposed Transfer/Discharge policy will be followed. The notice indicated the facility may proceed with the transfer/discharge at the end of thirty (30) days, even if a decision on the appeal has not been rendered. The facility failed to provide a 30 day written notice of transfer to Patient 33 and/or family member or legal representative least 30 days before the patient transferred out of the facility. The above violation has a direct relationship to the health safety or security of patients. |
| 970000054 |
WESTERN CONVALESCENT HOSPITAL |
910010798 |
B |
19-Jun-14 |
ZWAE11 |
3379 |
CALIFORNIA HEALTH AND SAFETY CODE DIVISION 2. CHAPTER 2. ARTICLE 8.5Section 1336.2 (a) (4) (a) Before residents are transferred due to any change in the status of the license or operation of a facility, including a facility closure or voluntary or involuntary termination of a facility?s Medi-Cal or Medicare certification, the facility shall take reasonable steps to transfer affected residents safely and minimize possible transfer trauma by, at a minimum, doing all of the following: (4) At least 30 days in advance of the transfer, inform the resident or the resident?s representative of alternative facilities that are available and adequate to meet resident and family needs Based on observation, interview and record review, the facility failed to provide a written notice of transfer to Patient 34 and/or family member or legal representative at least 30 days before the patient is transferred out of the facility. A construction project to install sprinklers required the facility to remove all patients from the second floor. The project is in response to the facility non-compliance with the federal regulation that requires all long term care facilities to be equipped with a supervised automatic sprinkler system by August 13, 2013. This transfer of patients with less than a 30 day notice is a violation of the patient?s rights. Findings: On April 8, 2014 at 10:52 a.m., the Department received a complaint allegation regarding transfer discharge (T/D) rights. On April 8, 2014 at 2:45 p.m., the Department conducted an onsite visit to monitor the relocation of facility patients due to the facility's sprinkler installation project. According to the Life Safety 2567 (Statement of Deficiencies and Plan of Correction), dated December 11, 2013, the facility was not completely covered with an automatic sprinkler system in accordance with the National Fire Protection Association (NFPA) 13 , and the facility lacked a fire sprinkler system. There was no plan to ensure the patients were given the 30 day notification prior to the transfer out of the facility due to the sprinkler system installation project.On the same day during an interview the administrator disclosed she held a meeting with the facility's task force committee. The committee discussed obtaining approval of the relocation plans for the sprinkler system installation project. A review of clinical records for Patient 34, disclosed less than a 30 day timeframe for the Notice of Proposed Transfer/Discharge before the scheduled transfer out of the facility. In addition, the written notice did not include a completion date for the sprinkler system installation project or an expected date for the patient?s return to the facility.The undated facility policy and procedure titled, "Transfer/Discharge", described that when patient transfers/discharges are initiated by the facility, the Notice of Proposed Transfer/Discharge policy will be followed. The notice indicated the facility may proceed with the transfer/discharge at the end of thirty (30) days, even if a decision on the appeal has not been rendered. The facility failed to provide a 30 day written notice of transfer to Patient 34 and/or family member or legal representative least 30 days before the patient transferred out of the facility. The above violation has a direct relationship to the health safety or security of patients. |
| 970000054 |
WESTERN CONVALESCENT HOSPITAL |
910010799 |
B |
19-Jun-14 |
ZWAE11 |
3373 |
CALIFORNIA HEALTH AND SAFETY CODE DIVISION 2. CHAPTER 2. ARTICLE 8.5Section 1336.2 (a) (4) (a) Before residents are transferred due to any change in the status of the license or operation of a facility, including a facility closure or voluntary or involuntary termination of a facility?s Medi-Cal or Medicare certification, the facility shall take reasonable steps to transfer affected residents safely and minimize possible transfer trauma by, at a minimum, doing all of the following: (4) At least 30 days in advance of the transfer, inform the resident or the resident?s representative of alternative facilities that are available and adequate to meet resident and family needs Based on observation, interview and record review, the facility failed to provide a written notice of transfer to Patient 35 and/or family member or legal representative at least 30 days before the patient is transferred out of the facility. A construction project to install sprinklers required the facility to remove all patients from the second floor. The project is in response to the facility non-compliance with the federal regulation that requires all long term care facilities to be equipped with a supervised automatic sprinkler system by August 13, 2013. This transfer of patients with less than a 30 day notice is a violation of the patient?s rights.Findings: On April 8, 2014 at 10:52 a.m., the Department received a complaint allegation regarding transfer discharge (T/D) rights.On April 8, 2014 at 2:45 p.m., the Department conducted an onsite visit to monitor the relocation of facility patients due to the facility's sprinkler installation project. According to the Life Safety 2567 (Statement of Deficiencies and Plan of Correction), dated December 11, 2013, the facility was not completely covered with an automatic sprinkler system in accordance to the National Fire Protection Association (NFPA) 13 and the facility lacked a fire sprinkler system. There was no plan to ensure the patients were given the 30 day notification prior to the transfer out of the facility due to the sprinkler system installation project.On the same day during an interview the administrator disclosed she held a meeting with the facility's task force committee. The committee discussed obtaining approval of the relocation plans for the sprinkler system installation project. A review of clinical records for Patient 35, disclosed less than a 30 day timeframe for the Notice of Proposed Transfer/Discharge before the scheduled transfer out of the facility. In addition, the written notice did not include a completion date for the sprinkler system installation project or an expected date for the patient?s return to the facility.The undated facility policy and procedure titled, "Transfer/Discharge", described that when patient transfers/discharges are initiated by the facility, the Notice of Proposed Transfer/Discharge policy will be followed. The notice indicated the facility may proceed with the transfer/discharge at the end of thirty (30) days, even if a decision on the appeal has not been rendered. The facility failed to provide a 30 day written notice of transfer to Patient 35 and/or family member or legal representative least 30 days before the patient transferred out of the facility. The above violation has a direct relationship to the health safety or security of patients. |
| 970000054 |
WESTERN CONVALESCENT HOSPITAL |
910010800 |
B |
19-Jun-14 |
ZWAE11 |
3376 |
CALIFORNIA HEALTH AND SAFETY CODE DIVISION 2. CHAPTER 2. ARTICLE 8.5Section 1336.2. (a) (4) (a) Before residents are transferred due to any change in the status of the license or operation of a facility, including a facility closure or voluntary or involuntary termination of a facility?s Medi-Cal or Medicare certification, the facility shall take reasonable steps to transfer affected residents safely and minimize possible transfer trauma by, at a minimum, doing all of the following: (4) At least 30 days in advance of the transfer, inform the resident or the resident?s representative of alternative facilities that are available and adequate to meet resident and family needs Based on observation, interview and record review, the facility failed to provide a written notice of transfer to Patient 36 and/or family member or legal representative at least 30 days before the patient is transferred out of the facility. A construction project to install sprinklers required the facility to remove all patients from the second floor. The project is in response to the facility non-compliance with the federal regulation that requires all long term care facilities to be equipped with a supervised automatic sprinkler system by August 13, 2013. This transfer of patients with less than a 30 day notice is a violation of the patient?s rights. Findings: On April 8, 2014 at 10:52 a.m., the Department received a complaint allegation regarding transfer discharge (T/D) rights. On April 8, 2014 at 2:45 p.m., the Department conducted an onsite visit to monitor the relocation of facility patients due to the facility's sprinkler installation project. According to the Life Safety 2567 (Statement of Deficiencies and Plan of Correction), dated December 11, 2013, the facility was not completely covered with an automatic sprinkler system in accordance to the National Fire Protection Association (NFPA) 13 and the facility lacked a fire sprinkler system. There was no plan to ensure the patients were given the 30 day notification prior to the transfer out of the facility due to the sprinkler system installation project.On the same day during an interview the administrator disclosed she held a meeting with the facility's task force committee. The committee discussed obtaining approval of the relocation plans for the sprinkler system installation project. A review of clinical records for Patient 36, disclosed less than a 30 day timeframe for the Notice of Proposed Transfer/Discharge before the scheduled transfer out of the facility. In addition, the written notice did not include a completion date for the sprinkler system installation project or an expected date for the patient?s return to the facility.The undated facility policy and procedure titled, ?Transfer/Discharge", described that when patient transfers/discharges are initiated by the facility, the Notice of Proposed Transfer/Discharge policy will be followed. The notice indicated the facility may proceed with the transfer/discharge at the end of thirty (30) days, even if a decision on the appeal has not been rendered. The facility failed to provide a 30 day written notice of transfer to Patient 36 and/or family member or legal representative least 30 days before the patient transferred out of the facility. The above violation has a direct relationship to the health safety or security of patients. |
| 970000054 |
WESTERN CONVALESCENT HOSPITAL |
910010801 |
B |
19-Jun-14 |
ZWAE11 |
3626 |
CALIFORNIA HEALTH AND SAFETY CODE DIVISION 2. CHAPTER 2. ARTICLE 8.5Section 1336.2. (a) (4) (a) Before residents are transferred due to any change in the status of the license or operation of a facility, including a facility closure or voluntary or involuntary termination of a facility?s Medi-Cal or Medicare certification, the facility shall take reasonable steps to transfer affected residents safely and minimize possible transfer trauma by, at a minimum, doing all of the following: (4) At least 30 days in advance of the transfer, inform the resident or the resident?s representative of alternative facilities that are available and adequate to meet resident and family needs Based on observation, interview and record review, the facility failed to provide a written notice of transfer to Patient 37 and/or family member or legal representative at least 30 days before the patient is transferred out of the facility. A construction project to install sprinklers required the facility to remove all patients from the second floor. The project is in response to the facility non-compliance with the federal regulation that requires all long term care facilities to be equipped with a supervised automatic sprinkler system by August 13, 2013. This transfer of patients with less than a 30 day notice is a violation of the patient?s rights.Findings: On April 8, 2014 at 10:52 a.m., the Department received a complaint allegation regarding transfer discharge (T/D) rights.On April 8, 2014 at 2:45 p.m., the Department conducted an onsite visit to monitor the relocation of facility patients due to the facility's sprinkler installation project. According to the Life Safety 2567 (Statement of Deficiencies and Plan of Correction), dated December 11, 2013, the facility was not completely covered with an automatic sprinkler system in accordance to the National Fire Protection Association (NFPA) 13 and the facility lacked a fire sprinkler system. There was no plan to ensure the patients were given the 30 day notification prior to the transfer out of the facility due to the sprinkler system installation project.On the same day during an interview the administrator disclosed she held a meeting with the facility's task force committee. The committee discussed obtaining approval of the relocation plans for the sprinkler system installation project. A review of clinical records for Patient 37, disclosed less than a 30 day timeframe for the Notice of Proposed Transfer/Discharge before the scheduled transfer out of the facility. In addition, the written notice did not include a completion date for the sprinkler system installation project or an expected date for the patient?s return to the facility.During an interview with Patient 37, on April 4, 2014, at 3 p.m., Patient 37 stated the facility explained the installation of the sprinkler system. The transfer was temporary and the transfer back to the facility would be in approximately two months. The undated facility policy and procedure titled, "Transfer/Discharge", described that when patient transfers/discharges are initiated by the facility, the Notice of Proposed Transfer/Discharge policy will be followed. The notice indicated the facility may proceed with the transfer/discharge at the end of thirty (30) days, even if a decision on the appeal has not been rendered. The facility failed to provide a 30 day written notice of transfer to Patient 37 and/or family member or legal representative least 30 days before the patient transferred out of the facility. The above violation has a direct relationship to the health safety or security of patients. |
| 970000054 |
WESTERN CONVALESCENT HOSPITAL |
910010802 |
B |
19-Jun-14 |
ZWAE11 |
3629 |
CALIFORNIA HEALTH AND SAFETY CODE DIVISION 2. CHAPTER 2. ARTICLE 8.5Section 1336.2. (a) (4) (a) Before residents are transferred due to any change in the status of the license or operation of a facility, including a facility closure or voluntary or involuntary termination of a facility?s Medi-Cal or Medicare certification, the facility shall take reasonable steps to transfer affected residents safely and minimize possible transfer trauma by, at a minimum, doing all of the following: (4) At least 30 days in advance of the transfer, inform the resident or the resident?s representative of alternative facilities that are available and adequate to meet resident and family needs Based on observation, interview and record review, the facility failed to provide a written notice of transfer to Patient 38 and/or family member or legal representative at least 30 days before the patient is transferred out of the facility. A construction project to install sprinklers required the facility to remove all patients from the second floor. The project is in response to the facility non-compliance with the federal regulation that requires all long term care facilities to be equipped with a supervised automatic sprinkler system by August 13, 2013. This transfer of patients with less than a 30 day notice is a violation of the patient?s rights.Findings: On April 8, 2014 at 10:52 a.m., the Department received a complaint allegation regarding transfer discharge (T/D) rights. On April 8, 2014 at 2:45 p.m., the Department conducted an onsite visit to monitor the relocation of facility patients due to the facility's sprinkler installation project. According to the Life Safety 2567 (Statement of Deficiencies and Plan of Correction), dated December 11, 2013, the facility was not completely covered with an automatic sprinkler system in accordance with the National Fire Protection Association (NFPA) 13, and the facility lacked a fire sprinkler system. There was no plan to ensure the patients were given the 30 day notification prior to the transfer out of the facility due to the sprinkler system installation project.On the same day during an interview the administrator disclosed she held a meeting with the facility's task force committee. The committee discussed obtaining approval of the relocation plans for the sprinkler system installation project. A review of clinical records for Patient 38, disclosed less than a 30 day timeframe for the Notice of Proposed Transfer/Discharge before the scheduled transfer out of the facility. In addition, the written notice did not include a completion date for the sprinkler system installation project or an expected date for the patient?s return to the facility. During an interview with Patient 38 on April 4, 2014 at 3 p.m., Patient 24 stated the facility explained the installation of the sprinkler system. The transfer was temporary and the transfer back to the facility would be in approximately two months. The undated facility policy and procedure titled, "Transfer/Discharge", described that when patient transfers/discharges are initiated by the facility, the Notice of Proposed Transfer/Discharge policy will be followed. The notice indicated the facility may proceed with the transfer/discharge at the end of thirty (30) days, even if a decision on the appeal has not been rendered. The facility failed to provide a 30 day written notice of transfer to Patient 38 and/or family member or legal representative least 30 days before the patient transferred out of the facility. The above violation has a direct relationship to the health safety or security of patients. |
| 970000054 |
WESTERN CONVALESCENT HOSPITAL |
910010803 |
B |
19-Jun-14 |
ZWAE11 |
3630 |
CALIFORNIA HEALTH AND SAFETY CODE DIVISION 2. CHAPTER 2. ARTICLE 8.5Section 1336.2. (a) (4) (a) Before residents are transferred due to any change in the status of the license or operation of a facility, including a facility closure or voluntary or involuntary termination of a facility?s Medi-Cal or Medicare certification, the facility shall take reasonable steps to transfer affected residents safely and minimize possible transfer trauma by, at a minimum, doing all of the following: (4) At least 30 days in advance of the transfer, inform the resident or the resident?s representative of alternative facilities that are available and adequate to meet resident and family needs Based on observation, interview and record review, the facility failed to provide a written notice of transfer to Patient 39 and/or family member or legal representative at least 30 days before the patient is transferred out of the facility. A construction project to install sprinklers required the facility to remove all patients from the second floor. The project is in response to the facility non-compliance with the federal regulation that requires all long term care facilities to be equipped with a supervised automatic sprinkler system by August 13, 2013. This transfer of patients with less than a 30 day notice is a violation of the patient?s rights. Findings: On April 8, 2014 at 10:52 a.m., the Department received a complaint allegation regarding transfer discharge (T/D) rights.On April 8, 2014 at 2:45 p.m., the Department conducted an onsite visit to monitor the relocation of facility patients due to the facility's sprinkler installation project.According to the Life Safety 2567 (Statement of Deficiencies and Plan of Correction), dated December 11, 2013, the facility was not completely covered with an automatic sprinkler system in accordance with the National Fire Protection Association (NFPA) 13, and the facility lacked a fire sprinkler system. There was no plan to ensure the patients were given the 30 day notification prior to the transfer out of the facility due to the sprinkler system installation project.On the same day during an interview the administrator disclosed she held a meeting with the facility's task force committee. The committee discussed obtaining approval of the relocation plans for the sprinkler system installation project. A review of clinical records for Patient 39, disclosed less than a 30 day timeframe for the Notice of Proposed Transfer/Discharge before the scheduled transfer out of the facility. In addition, the written notice did not include a completion date for the sprinkler system installation project or an expected date for the patient?s return to the facility. During an interview with Patient 39 on April 4, 2014, at 3 p.m., the patient stated the facility explained the installation of the sprinkler system. The transfer was temporary and the transfer back to the facility would be in approximately two months. The undated facility policy and procedure titled, "Transfer/Discharge", described that when patient transfers/discharges are initiated by the facility, the Notice of Proposed Transfer/Discharge policy will be followed. The notice indicated the facility may proceed with the transfer/discharge at the end of thirty (30) days, even if a decision on the appeal has not been rendered. The facility failed to provide a 30 day written notice of transfer to Patient 39 and/or family member or legal representative least 30 days before the patient transferred out of the facility. The above violation has a direct relationship to the health safety or security of patients. |
| 970000054 |
WESTERN CONVALESCENT HOSPITAL |
910010804 |
B |
19-Jun-14 |
ZWAE11 |
3380 |
CALIFORNIA HEALTH AND SAFETY CODE DIVISION 2. CHAPTER 2. ARTICLE 8.5Section 1336.2. (a) (4) (a) Before residents are transferred due to any change in the status of the license or operation of a facility, including a facility closure or voluntary or involuntary termination of a facility?s Medi-Cal or Medicare certification, the facility shall take reasonable steps to transfer affected residents safely and minimize possible transfer trauma by, at a minimum, doing all of the following: (4) At least 30 days in advance of the transfer, inform the resident or the resident?s representative of alternative facilities that are available and adequate to meet resident and family needs Based on observation, interview and record review, the facility failed to provide a written notice of transfer to Patient 40 and/or family member or legal representative at least 30 days before the patient is transferred out of the facility. A construction project to install sprinklers required the facility to remove all patients from the second floor. The project is in response to the facility non-compliance with the federal regulation that requires all long term care facilities to be equipped with a supervised automatic sprinkler system by August 13, 2013. This transfer of patients with less than a 30 day notice is a violation of the patient?s rights. Findings: On April 8, 2014 at 10:52 a.m., the Department received a complaint allegation regarding transfer discharge (T/D) rights. On April 8, 2014 at 2:45 p.m., the Department conducted an onsite visit to monitor the relocation of facility patients due to the facility's sprinkler installation project. According to the Life Safety 2567 (Statement of Deficiencies and Plan of Correction), dated December 11, 2013, the facility was not completely covered with an automatic sprinkler system in accordance with the National Fire Protection Association (NFPA) 13, and the facility lacked a fire sprinkler system. There was no plan to ensure the patients were given the 30 day notification prior to the transfer out of the facility due to the sprinkler system installation project.On the same day during an interview the administrator disclosed she held a meeting with the facility's task force committee. The committee discussed obtaining approval of the relocation plans for the sprinkler system installation project. A review of clinical records for Patient 40, disclosed less than a 30 day timeframe for the Notice of Proposed Transfer/Discharge before the scheduled transfer out of the facility. In addition, the written notice did not include a completion date for the sprinkler system installation project or an expected date for the patient?s return to the facility. The undated facility policy and procedure titled, "Transfer/Discharge", described that when patient transfers/discharges are initiated by the facility, the Notice of Proposed Transfer/Discharge policy will be followed. The notice indicated the facility may proceed with the transfer/discharge at the end of thirty (30) days, even if a decision on the appeal has not been rendered. The facility failed to provide a 30 day written notice of transfer to Patient 40 and/or family member or legal representative least 30 days before the patient transferred out of the facility. The above violation has a direct relationship to the health safety or security of patients. |
| 970000054 |
WESTERN CONVALESCENT HOSPITAL |
910010805 |
B |
19-Jun-14 |
ZWAE11 |
3378 |
CALIFORNIA HEALTH AND SAFETY CODE DIVISION 2. CHAPTER 2. ARTICLE 8.5Section 1336.2 (a) (4) (a) Before residents are transferred due to any change in the status of the license or operation of a facility, including a facility closure or voluntary or involuntary termination of a facility?s Medi-Cal or Medicare certification, the facility shall take reasonable steps to transfer affected residents safely and minimize possible transfer trauma by, at a minimum, doing all of the following: (4) At least 30 days in advance of the transfer, inform the resident or the resident?s representative of alternative facilities that are available and adequate to meet resident and family needs Based on observation, interview and record review, the facility failed to provide a written notice of transfer to Patient 57 and/or family member or legal representative at least 30 days before the patient is transferred out of the facility. A construction project to install sprinklers required the facility to remove all patients from the second floor. The project is in response to the facility non-compliance with the federal regulation that requires all long term care facilities to be equipped with a supervised automatic sprinkler system by August 13, 2013. This transfer of patients with less than a 30 day notice is a violation of the patient?s rights.Findings: On April 8, 2014 at 10:52 a.m., the Department received a complaint allegation regarding transfer discharge (T/D) rights. On April 8, 2014 at 2:45 p.m., the Department conducted an onsite visit to monitor the relocation of facility patients due to the facility's sprinkler installation project. According to the Life Safety 2567 (Statement of Deficiencies and Plan of Correction), dated December 11, 2013, the facility was not completely covered with an automatic sprinkler system in accordance with the National Fire Protection Association (NFPA) 13, and the facility lacked a fire sprinkler system. There was no plan to ensure the patients were given the 30 day notification prior to the transfer out of the facility due to the sprinkler system installation project.On the same day during an interview the administrator disclosed she held a meeting with the facility's task force committee. The committee discussed obtaining approval of the relocation plans for the sprinkler system installation project. A review of clinical records for Patient 57, disclosed less than a 30 day timeframe for the Notice of Proposed Transfer/Discharge before the scheduled transfer out of the facility. In addition, the written notice did not include a completion date for the sprinkler system installation project or an expected date for the patient?s return to the facility. The undated facility policy and procedure titled, "Transfer/Discharge", described that when patient transfers/discharges are initiated by the facility, the Notice of Proposed Transfer/Discharge policy will be followed. The notice indicated the facility may proceed with the transfer/discharge at the end of thirty (30) days, even if a decision on the appeal has not been rendered. The facility failed to provide a 30 day written notice of transfer to Patient 57 and/or family member or legal representative least 30 days before the patient transferred out of the facility. The above violation has a direct relationship to the health safety or security of patients. |
| 970000054 |
WESTERN CONVALESCENT HOSPITAL |
910010806 |
B |
19-Jun-14 |
ZWAE11 |
3392 |
CALIFORNIA HEALTH AND SAFETY CODE DIVISION 2. CHAPTER 2. ARTICLE 8.5Section 1336.2 (a) (4) (a) Before residents are transferred due to any change in the status of the license or operation of a facility, including a facility closure or voluntary or involuntary termination of a facility?s Medi-Cal or Medicare certification, the facility shall take reasonable steps to transfer affected residents safely and minimize possible transfer trauma by, at a minimum, doing all of the following: (4) At least 30 days in advance of the transfer, inform the resident or the resident?s representative of alternative facilities that are available and adequate to meet resident and family needs Based on observation, interview and record review, the facility failed to provide a written notice of transfer to Patient 58 and/or family member or legal representative at least 30 days before the patient is transferred out of the facility. A construction project to install sprinklers required the facility to remove all patients from the second floor. The project is in response to the facility non-compliance with the federal regulation that requires all long term care facilities to be equipped with a supervised automatic sprinkler system by August 13, 2013. This transfer of patients with less than a 30 day notice is a violation of the patient?s rights. Findings: On April 8, 2014 at 10:52 a.m., the Department received a complaint allegation regarding transfer discharge (T/D) rights. On April 8, 2014 at 2:45 p.m., the Department conducted an onsite visit to monitor the relocation of facility patients due to the facility's sprinkler installation project. According to the Life Safety 2567 (Statement of Deficiencies and Plan of Correction), dated December 11, 2013, the facility was not completely covered with an automatic sprinkler system in accordance to the National Fire Protection Association (NFPA) 13, and the facility lacked a fire sprinkler system. There was no plan to ensure the patients were given the 30 day notification prior to the transfer out of the facility due to the sprinkler system installation project.On the same day during an interview the administrator disclosed she held a meeting with the facility's task force committee. The committee discussed obtaining approval of the relocation plans for the sprinkler system installation project. A review of clinical records for Patient 58, disclosed less than a 30 day timeframe for the Notice of Proposed Transfer/Discharge before the scheduled transfer out of the facility. In addition, the written notice did not include a completion date for the sprinkler system installation project or an expected date for the patient?s return to the facility. The undated facility policy and procedure titled, "Transfer/Discharge", without a date described that when patient transfers/discharges are initiated by the facility, the Notice of Proposed Transfer/Discharge policy will be followed. The notice indicated the facility may proceed with the transfer/discharge at the end of thirty (30) days, even if a decision on the appeal has not been rendered. The facility failed to provide a 30 day written notice of transfer to Patient 58 and/or family member or legal representative least 30 days before the patient transferred out of the facility. The above violation has a direct relationship to the health safety or security of patients. |
| 970000054 |
WESTERN CONVALESCENT HOSPITAL |
910010807 |
B |
19-Jun-14 |
ZWAE11 |
3641 |
CALIFORNIA HEALTH AND SAFETY CODE DIVISION 2. CHAPTER 2. ARTICLE 8.5Section 1336.2 (a) (4) (a) Before residents are transferred due to any change in the status of the license or operation of a facility, including a facility closure or voluntary or involuntary termination of a facility?s Medi-Cal or Medicare certification, the facility shall take reasonable steps to transfer affected residents safely and minimize possible transfer trauma by, at a minimum, doing all of the following: (4) At least 30 days in advance of the transfer, inform the resident or the resident?s representative of alternative facilities that are available and adequate to meet resident and family needs Based on observation, interview and record review, the facility failed to provide a written notice of transfer to Patient 59 and/or family member or legal representative at least 30 days before the patient is transferred out of the facility. A construction project to install sprinklers required the facility to remove all patients from the second floor. The project is in response to the facility non-compliance with the federal regulation that requires all long term care facilities to be equipped with a supervised automatic sprinkler system by August 13, 2013. This transfer of patients with less than a 30 day notice is a violation of the patient?s rights.Findings: On April 8, 2014 at 10:52 a.m., the Department received a complaint allegation regarding transfer discharge (T/D) rights. On April 8, 2014 at 2:45 p.m., the Department conducted an onsite visit to monitor the relocation of facility patients due to the facility's sprinkler installation project. According to the Life Safety 2567 (Statement of Deficiencies and Plan of Correction), dated December 11, 2013, the facility was not completely covered with an automatic sprinkler system in accordance with the National Fire Protection Association (NFPA) 13 and the facility lacked a fire sprinkler system. There was no plan to ensure the patients were given the 30 day notification prior to the transfer out of the facility due to the sprinkler system installation project.On the same day during an interview the administrator disclosed she held a meeting with the facility's task force committee. The committee discussed obtaining approval of the relocation plans for the sprinkler system installation project. A review of clinical records for Patient 59, disclosed less than a 30 day timeframe for the Notice of Proposed Transfer/Discharge before the scheduled transfer out of the facility. In addition, the written notice did not include a completion date for the sprinkler system installation project or an expected date for the patient?s return to the facility. During an interview with Patient 59, on April 11, 2014 at 6:15 p.m., the patient stated the facility explained the installation of the sprinkler system. The transfer was temporary and the transfer back to the facility would be in approximately two months. The undated facility policy and procedure titled, "Transfer/Discharge", described that when patient transfers/discharges are initiated by the facility, the Notice of Proposed Transfer/Discharge policy will be followed. The notice indicated the facility may proceed with the transfer/discharge at the end of thirty (30) days, even if a decision on the appeal has not been rendered. The facility failed to provide provide a 30 day written notice of transfer to Patient 59 and/or family member or legal representative least 30 days before the patient transferred out of the facility. The above violation has a direct relationship to the health safety or security of patients. |
| 970000054 |
WESTERN CONVALESCENT HOSPITAL |
910010808 |
B |
19-Jun-14 |
ZWAE11 |
3378 |
CALIFORNIA HEALTH AND SAFETY CODE DIVISION 2. CHAPTER 2. ARTICLE 8.5Section 1336.2 (a) (4) (a) Before residents are transferred due to any change in the status of the license or operation of a facility, including a facility closure or voluntary or involuntary termination of a facility?s Medi-Cal or Medicare certification, the facility shall take reasonable steps to transfer affected residents safely and minimize possible transfer trauma by, at a minimum, doing all of the following: (4) At least 30 days in advance of the transfer, inform the resident or the resident?s representative of alternative facilities that are available and adequate to meet resident and family needs Based on observation, interview and record review, the facility failed to provide a written notice of transfer to Patient 60 and/or family member or legal representative at least 30 days before the patient is transferred out of the facility. A construction project to install sprinklers required the facility to remove all patients from the second floor. The project is in response to the facility non-compliance with the federal regulation that requires all long term care facilities to be equipped with a supervised automatic sprinkler system by August 13, 2013. This transfer of patients with less than a 30 day notice is a violation of the patient?s rights.Findings: On April 8, 2014 at 10:52 a.m., the Department received a complaint allegation regarding transfer discharge (T/D) rights. On April 8, 2014 at 2:45 p.m., the Department conducted an onsite visit to monitor the relocation of facility patients due to the facility's sprinkler installation project. According to the Life Safety 2567 (Statement of Deficiencies and Plan of Correction), dated December 11, 2013, the facility was not completely covered with an automatic sprinkler system in accordance with the National Fire Protection Association (NFPA) 13, and the facility lacked a fire sprinkler system. There was no plan to ensure the patients were given the 30 day notification prior to the transfer out of the facility due to the sprinkler system installation project.On the same day during an interview the administrator disclosed she held a meeting with the facility's task force committee. The committee discussed obtaining approval of the relocation plans for the sprinkler system installation project. A review of clinical records for Patient 60, disclosed less than a 30 day timeframe for the Notice of Proposed Transfer/Discharge before the scheduled transfer out of the facility. In addition, the written notice did not include a completion date for the sprinkler system installation project or an expected date for the patient?s return to the facility. The undated facility policy and procedure titled, "Transfer/Discharge", described that when patient transfers/discharges are initiated by the facility, the Notice of Proposed Transfer/Discharge policy will be followed. The notice indicated the facility may proceed with the transfer/discharge at the end of thirty (30) days, even if a decision on the appeal has not been rendered. The facility failed to provide a 30 day written notice of transfer to Patient 60 and/or family member or legal representative least 30 days before the patient transferred out of the facility. The above violation has a direct relationship to the health safety or security of patients. |
| 970000054 |
WESTERN CONVALESCENT HOSPITAL |
910010809 |
B |
19-Jun-14 |
ZWAE11 |
3378 |
CALIFORNIA HEALTH AND SAFETY CODE DIVISION 2. CHAPTER 2. ARTICLE 8.5Section 1336.2 (a) (4) (a) Before residents are transferred due to any change in the status of the license or operation of a facility, including a facility closure or voluntary or involuntary termination of a facility?s Medi-Cal or Medicare certification, the facility shall take reasonable steps to transfer affected residents safely and minimize possible transfer trauma by, at a minimum, doing all of the following: (4) At least 30 days in advance of the transfer, inform the resident or the resident?s representative of alternative facilities that are available and adequate to meet resident and family needs Based on observation, interview and record review, the facility failed to provide a written notice of transfer to Patient 61 and/or family member or legal representative at least 30 days before the patient is transferred out of the facility. A construction project to install sprinklers required the facility to remove all patients from the second floor. The project is in response to the facility non-compliance with the federal regulation that requires all long term care facilities to be equipped with a supervised automatic sprinkler system by August 13, 2013. This transfer of patients with less than a 30 day notice is a violation of the patient?s rights.Findings: On April 8, 2014 at 10:52 a.m., the Department received a complaint allegation regarding transfer discharge (T/D) rights. On April 8, 2014 at 2:45 p.m., the Department conducted an onsite visit to monitor the relocation of facility patients due to the facility's sprinkler installation project. According to the Life Safety 2567 (Statement of Deficiencies and Plan of Correction), dated December 11, 2013, the facility was not completely covered with an automatic sprinkler system in accordance with the National Fire Protection Association (NFPA) 13, and the facility lacked a fire sprinkler system. There was no plan to ensure the patients were given the 30 day notification prior to the transfer out of the facility due to the sprinkler system installation project.On the same day during an interview the administrator disclosed she held a meeting with the facility's task force committee. The committee discussed obtaining approval of the relocation plans for the sprinkler system installation project. A review of clinical records for Patient 61, disclosed less than a 30 day timeframe for the Notice of Proposed Transfer/Discharge before the scheduled transfer out of the facility. In addition, the written notice did not include a completion date for the sprinkler system installation project or an expected date for the patient?s return to the facility. The undated facility policy and procedure titled, "Transfer/Discharge", described that when patient transfers/discharges are initiated by the facility, the Notice of Proposed Transfer/Discharge policy will be followed. The notice indicated the facility may proceed with the transfer/discharge at the end of thirty (30) days, even if a decision on the appeal has not been rendered. The facility failed to provide a 30 day written notice of transfer to Patient 61 and/or family member or legal representative least 30 days before the patient transferred out of the facility. The above violation has a direct relationship to the health safety or security of patients. |
| 970000054 |
WESTERN CONVALESCENT HOSPITAL |
910010810 |
B |
19-Jun-14 |
ZWAE11 |
3631 |
CALIFORNIA HEALTH AND SAFETY CODE DIVISION 2. CHAPTER 2. ARTICLE 8.5Section 1336.2 (a) (4) (a) Before residents are transferred due to any change in the status of the license or operation of a facility, including a facility closure or voluntary or involuntary termination of a facility?s Medi-Cal or Medicare certification, the facility shall take reasonable steps to transfer affected residents safely and minimize possible transfer trauma by, at a minimum, doing all of the following: (4) At least 30 days in advance of the transfer, inform the resident or the resident?s representative of alternative facilities that are available and adequate to meet resident and family needs Based on observation, interview and record review, the facility failed to provide a written notice of transfer to Patient 62 and/or family member or legal representative at least 30 days before the patient is transferred out of the facility. A construction project to install sprinklers required the facility to remove all patients from the second floor. The project is in response to the facility non-compliance with the federal regulation that requires all long term care facilities to be equipped with a supervised automatic sprinkler system by August 13, 2013. This transfer of patients with less than a 30 day notice is a violation of the patient?s rights. Findings: On April 8, 2014 at 10:52 a.m., the Department received a complaint allegation regarding transfer discharge (T/D) rights. On April 8, 2014 at 2:45 p.m., the Department conducted an onsite visit to monitor the relocation of facility patients due to the facility's sprinkler installation project. According to the Life Safety 2567 (Statement of Deficiencies and Plan of Correction), dated December 11, 2013, the facility was not completely covered with an automatic sprinkler system in accordance with the National Fire Protection Association (NFPA) 13 and the facility lacked a fire sprinkler system. There was no plan to ensure the patients were given the 30 day notification prior to the transfer out of the facility due to the sprinkler system installation project.On the same day during an interview the administrator disclosed she held a meeting with the facility's task force committee. The committee discussed obtaining approval of the relocation plans for the sprinkler system installation project. A review of clinical records for Patient 62, disclosed less than a 30 day timeframe for the Notice of Proposed Transfer/Discharge before the scheduled transfer out of the facility. In addition, the written notice did not include a completion date for the sprinkler system installation project or an expected date for the patient?s return to the facility. During an interview with Patient 62, on April 11, 2014 at 4 p.m., the patient stated the facility explained the installation of the sprinkler system. The transfer was temporary and the transfer back to the facility would be in approximately two months. The undated facility policy and procedure titled, "Transfer/Discharge", described that when patient transfers/discharges are initiated by the facility, the Notice of Proposed Transfer/Discharge policy will be followed. The notice indicated the facility may proceed with the transfer/discharge at the end of thirty (30) days, even if a decision on the appeal has not been rendered. The facility failed to provide a 30 day written notice of transfer to Patient 62 and/or family member or legal representative least 30 days before the patient transferred out of the facility. The above violation has a direct relationship to the health safety or security of patients. |
| 970000054 |
WESTERN CONVALESCENT HOSPITAL |
910010811 |
B |
19-Jun-14 |
ZWAE11 |
3633 |
CALIFORNIA HEALTH AND SAFETY CODE DIVISION 2. CHAPTER 2. ARTICLE 8.5Section 1336.2 (a) (4) (a) Before residents are transferred due to any change in the status of the license or operation of a facility, including a facility closure or voluntary or involuntary termination of a facility?s Medi-Cal or Medicare certification, the facility shall take reasonable steps to transfer affected residents safely and minimize possible transfer trauma by, at a minimum, doing all of the following: (4) At least 30 days in advance of the transfer, inform the resident or the resident?s representative of alternative facilities that are available and adequate to meet resident and family needs Based on observation, interview and record review, the facility failed to provide a written notice of transfer to Patient 63 and/or family member or legal representative at least 30 days before the patient is transferred out of the facility. A construction project to install sprinklers required the facility to remove all patients from the second floor. The project is in response to the facility non-compliance with the federal regulation that requires all long term care facilities to be equipped with a supervised automatic sprinkler system by August 13, 2013. This transfer of patients with less than a 30 day notice is a violation of the patient?s rights. Findings: On April 8, 2014 at 10:52 a.m., the Department received a complaint allegation regarding transfer discharge (T/D) rights. On April 8, 2014 at 2:45 p.m., the Department conducted an onsite visit to monitor the relocation of facility patients due to the facility's sprinkler installation project. According to the Life Safety 2567 (Statement of Deficiencies and Plan of Correction), dated December 11, 2013, the facility was not completely covered with an automatic sprinkler system in accordance with the National Fire Protection Association (NFPA) 13, and the facility lacked a fire sprinkler system. There was no plan to ensure the patients were given the 30 day notification prior to the transfer out of the facility due to the sprinkler system installation project.On the same day during an interview the administrator disclosed she held a meeting with the facility's task force committee. The committee discussed obtaining approval of the relocation plans for the sprinkler system installation project. A review of clinical records for Patient 63, disclosed less than a 30 day timeframe for the Notice of Proposed Transfer/Discharge before the scheduled transfer out of the facility. In addition, the written notice did not include a completion date for the sprinkler system installation project or an expected date for the patient?s return to the facility. During an interview with Patient 63, on April 10, 2014, at 4 p.m., the patient stated the facility explained the installation of the sprinkler system. The transfer was temporary and the transfer back to the facility would be in approximately two months. The undated facility policy and procedure titled, "Transfer/Discharge", described that when patient transfers/discharges are initiated by the facility, the Notice of Proposed Transfer/Discharge policy will be followed. The notice indicated the facility may proceed with the transfer/discharge at the end of thirty (30) days, even if a decision on the appeal has not been rendered. The facility failed to provide a 30 day written notice of transfer to Patient 63 and/or family member or legal representative least 30 days before the patient transferred out of the facility. The above violation has a direct relationship to the health safety or security of patients. |
| 970000054 |
WESTERN CONVALESCENT HOSPITAL |
910010812 |
B |
19-Jun-14 |
ZWAE11 |
3377 |
CALIFORNIA HEALTH AND SAFETY CODE DIVISION 2. CHAPTER 2. ARTICLE 8.5Section 1336.2 (a) (4) (a) Before residents are transferred due to any change in the status of the license or operation of a facility, including a facility closure or voluntary or involuntary termination of a facility?s Medi-Cal or Medicare certification, the facility shall take reasonable steps to transfer affected residents safely and minimize possible transfer trauma by, at a minimum, doing all of the following: (4) At least 30 days in advance of the transfer, inform the resident or the resident?s representative of alternative facilities that are available and adequate to meet resident and family needs Based on observation, interview and record review, the facility failed to provide a written notice of transfer to Patient 64 and/or family member or legal representative at least 30 days before the patient is transferred out of the facility. A construction project to install sprinklers required the facility to remove all patients from the second floor. The project is in response to the facility non-compliance with the federal regulation that requires all long term care facilities to be equipped with a supervised automatic sprinkler system by August 13, 2013. This transfer of patients with less than a 30 day notice is a violation of the patient?s rights.Findings: On April 8, 2014 at 10:52 a.m., the Department received a complaint allegation regarding transfer discharge (T/D) rights. On April 8, 2014 at 2:45 p.m., the Department conducted an onsite visit to monitor the relocation of facility patients due to the facility's sprinkler installation project. According to the Life Safety 2567 (Statement of Deficiencies and Plan of Correction), dated December 11, 2013, the facility was not completely covered with an automatic sprinkler system in accordance with the National Fire Protection Association (NFPA) 13 and the facility lacked a fire sprinkler system. There was no plan to ensure the patients were given the 30 day notification prior to the transfer out of the facility due to the sprinkler system installation project.On the same day during an interview the administrator disclosed she held a meeting with the facility's task force committee. The committee discussed obtaining approval of the relocation plans for the sprinkler system installation project. A review of clinical records for Patient 64, disclosed less than a 30 day timeframe for the Notice of Proposed Transfer/Discharge before the scheduled transfer out of the facility. In addition, the written notice did not include a completion date for the sprinkler system installation project or an expected date for the patient?s return to the facility. The undated facility policy and procedure titled, "Transfer/Discharge", described that when patient transfers/discharges are initiated by the facility, the Notice of Proposed Transfer/Discharge policy will be followed. The notice indicated the facility may proceed with the transfer/discharge at the end of thirty (30) days, even if a decision on the appeal has not been rendered. The facility failed to provide a 30 day written notice of transfer to Patient 64 and/or family member or legal representative least 30 days before the patient transferred out of the facility. The above violation has a direct relationship to the health safety or security of patients. |
| 970000054 |
WESTERN CONVALESCENT HOSPITAL |
910010813 |
B |
19-Jun-14 |
ZWAE11 |
3377 |
CALIFORNIA HEALTH AND SAFETY CODE DIVISION 2. CHAPTER 2. ARTICLE 8.5Sectio 1336.2 (a) (4) (a) Before residents are transferred due to any change in the status of the license or operation of a facility, including a facility closure or voluntary or involuntary termination of a facility?s Medi-Cal or Medicare certification, the facility shall take reasonable steps to transfer affected residents safely and minimize possible transfer trauma by, at a minimum, doing all of the following: (4) At least 30 days in advance of the transfer, inform the resident or the resident?s representative of alternative facilities that are available and adequate to meet resident and family needs Based on observation, interview and record review, the facility failed to provide a written notice of transfer to Patient 65 and/or family member or legal representative at least 30 days before the patient is transferred out of the facility. A construction project to install sprinklers required the facility to remove all patients from the second floor. The project is in response to the facility non-compliance with the federal regulation that requires all long term care facilities to be equipped with a supervised automatic sprinkler system by August 13, 2013. This transfer of patients with less than a 30 day notice is a violation of the patient?s rights. Findings: On April 8, 2014 at 10:52 a.m., the Department received a complaint allegation regarding transfer discharge (T/D) rights. On April 8, 2014 at 2:45 p.m., the Department conducted an onsite visit to monitor the relocation of facility patients due to the facility's sprinkler installation project. According to the Life Safety 2567 (Statement of Deficiencies and Plan of Correction), dated December 11, 2013, the facility was not completely covered with an automatic sprinkler system in accordance with the National Fire Protection Association (NFPA) 13 and the facility lacked a fire sprinkler system. There was no plan to ensure the patients were given the 30 day notification prior to the transfer out of the facility due to the sprinkler system installation project.On the same day during an interview the administrator disclosed she held a meeting with the facility's task force committee. The committee discussed obtaining approval of the relocation plans for the sprinkler system installation project. A review of clinical records for Patient 65, disclosed less than a 30 day timeframe for the Notice of Proposed Transfer/Discharge before the scheduled transfer out of the facility. In addition, the written notice did not include a completion date for the sprinkler system installation project or an expected date for the patient?s return to the facility. The undated facility policy and procedure titled, "Transfer/Discharge", described that when patient transfers/discharges are initiated by the facility, the Notice of Proposed Transfer/Discharge policy will be followed. The notice indicated the facility may proceed with the transfer/discharge at the end of thirty (30) days, even if a decision on the appeal has not been rendered. The facility failed to provide a 30 day written notice of transfer to Patient 65 and/or family member or legal representative least 30 days before the patient transferred out of the facility. The above violation has a direct relationship to the health safety or security of patients. |
| 970000054 |
WESTERN CONVALESCENT HOSPITAL |
910010814 |
B |
19-Jun-14 |
ZWAE11 |
3379 |
CALIFORNIA HEALTH AND SAFETY CODE DIVISION 2. CHAPTER 2. ARTICLE 8.5Section 1336.2 (a) (4) (a) Before residents are transferred due to any change in the status of the license or operation of a facility, including a facility closure or voluntary or involuntary termination of a facility?s Medi-Cal or Medicare certification, the facility shall take reasonable steps to transfer affected residents safely and minimize possible transfer trauma by, at a minimum, doing all of the following: (4) At least 30 days in advance of the transfer, inform the resident or the resident?s representative of alternative facilities that are available and adequate to meet resident and family needs Based on observation, interview and record review, the facility failed to provide a written notice of transfer to Patient 66 and/or family member or legal representative at least 30 days before the patient is transferred out of the facility. A construction project to install sprinklers required the facility to remove all patients from the second floor. The project is in response to the facility non-compliance with the federal regulation that requires all long term care facilities to be equipped with a supervised automatic sprinkler system by August 13, 2013. This transfer of patients with less than a 30 day notice is a violation of the patient?s rights. Findings: On April 8, 2014 at 10:52 a.m., the Department received a complaint allegation regarding transfer discharge (T/D) rights. On April 8, 2014 at 2:45 p.m., the Department conducted an onsite visit to monitor the relocation of facility patients due to the facility's sprinkler installation project. According to the Life Safety 2567 (Statement of Deficiencies and Plan of Correction), dated December 11, 2013, the facility was not completely covered with an automatic sprinkler system in accordance with the National Fire Protection Association (NFPA) 13, and the facility lacked a fire sprinkler system. There was no plan to ensure the patients were given the 30 day notification prior to the transfer out of the facility due to the sprinkler system installation project.On the same day during an interview the administrator disclosed she held a meeting with the facility's task force committee. The committee discussed obtaining approval of the relocation plans for the sprinkler system installation project. A review of clinical records for Patient 66, disclosed less than a 30 day timeframe for the Notice of Proposed Transfer/Discharge before the scheduled transfer out of the facility. In addition, the written notice did not include a completion date for the sprinkler system installation project or an expected date for the patient?s return to the facility. The undated facility policy and procedure titled, "Transfer/Discharge", described that when patient transfers/discharges are initiated by the facility, the Notice of Proposed Transfer/Discharge policy will be followed. The notice indicated the facility may proceed with the transfer/discharge at the end of thirty (30) days, even if a decision on the appeal has not been rendered. The facility failed to provide a 30 day written notice of transfer to Patient 66 and/or family member or legal representative least 30 days before the patient transferred out of the facility. The above violation has a direct relationship to the health safety or security of patients. |
| 970000054 |
WESTERN CONVALESCENT HOSPITAL |
910010815 |
B |
19-Jun-14 |
ZWAE11 |
3391 |
CALIFORNIA HEALTH AND SAFETY CODE DIVISION 2. CHAPTER 2. ARTICLE 8.5Section 1336.2 (a) (4) (a) Before residents are transferred due to any change in the status of the license or operation of a facility, including a facility closure or voluntary or involuntary termination of a facility?s Medi-Cal or Medicare certification, the facility shall take reasonable steps to transfer affected residents safely and minimize possible transfer trauma by, at a minimum, doing all of the following: (4) At least 30 days in advance of the transfer, inform the resident or the resident?s representative of alternative facilities that are available and adequate to meet resident and family needs Based on observation, interview and record review, the facility failed to provide a written notice of transfer to Patient 67 and/or family member or legal representative at least 30 days before the patient transferred out of the facility. A construction project to install sprinklers required the facility to remove all patients from the second floor. The project is in response to the facility non-compliance with the federal regulation that requires all long term care facilities to be equipped with a supervised automatic sprinkler system by August 13, 2013. This transfer of patients with less than a 30 day notice is a violation of the patient?s rights. Findings: On April 8, 2014 at 10:52 a.m., the Department received a complaint allegation regarding transfer discharge (T/D) rights. On April 8, 2014 at 2:45 p.m., the Department conducted an onsite visit to monitor the relocation of facility patients due to the facility's sprinkler installation project. According to the Life Safety 2567 (Statement of Deficiencies and Plan of Correction), dated December 11, 2013, the facility was not completely covered with an automatic sprinkler system in accordance with the National Fire Protection Association (NFPA) 13, and the facility lacked a fire sprinkler system. There was no plan to ensure the patients were given the 30 day notification prior to the transfer out of the facility due to the sprinkler system installation project.On the same day during an interview the administrator disclosed she held a meeting with the facility's task force committee. The committee discussed obtaining approval of the relocation plans for the sprinkler system installation project. A review of clinical records for Patient 67, disclosed less than a 30 day timeframe for the Notice of Proposed Transfer/Discharge before the scheduled transfer out of the facility. In addition, the written notice did not include a completion date for the sprinkler system installation project or an expected date for the patient?s return to the facility. The undated facility policy and procedure titled, "Transfer/Discharge", without a date described that when patient transfers/discharges are initiated by the facility, the Notice of Proposed Transfer/Discharge policy will be followed. The notice indicated the facility may proceed with the transfer/discharge at the end of thirty (30) days, even if a decision on the appeal has not been rendered. The facility failed to provide a 30 day written notice of transfer to Patient 67 and/or family member or legal representative least 30 days before the patient transferred out of the facility. The above violation has a direct relationship to the health safety or security of patients. |
| 970000054 |
WESTERN CONVALESCENT HOSPITAL |
910010816 |
B |
19-Jun-14 |
ZWAE11 |
3394 |
CALIFORNIA HEALTH AND SAFETY CODE DIVISION 2. CHAPTER 2. ARTICLE 8.5Section 1336.2 (a) (4) (a) Before residents are transferred due to any change in the status of the license or operation of a facility, including a facility closure or voluntary or involuntary termination of a facility?s Medi-Cal or Medicare certification, the facility shall take reasonable steps to transfer affected residents safely and minimize possible transfer trauma by, at a minimum, doing all of the following: (4) At least 30 days in advance of the transfer, inform the resident or the resident?s representative of alternative facilities that are available and adequate to meet resident and family needs Based on observation, interview and record review, the facility failed to provide a written notice of transfer to Patient 68 and/or family member or legal representative at least 30 days before the patient is transferred out of the facility. A construction project to install sprinklers required the facility to remove all patients from the second floor. The project is in response to the facility non-compliance with the federal regulation that requires all long term care facilities to be equipped with a supervised automatic sprinkler system by August 13, 2013. This transfer of patients with less than a 30 day notice is a violation of the patient?s rights. Findings: On April 8, 2014 at 10:52 a.m., the Department received a complaint allegation regarding transfer discharge (T/D) rights. On April 8, 2014 at 2:45 p.m., the Department conducted an onsite visit to monitor the relocation of facility patients due to the facility's sprinkler installation project. According to the Life Safety 2567 (Statement of Deficiencies and Plan of Correction), dated December 11, 2013, the facility was not completely covered with an automatic sprinkler system in accordance with the National Fire Protection Association (NFPA) 13, and the facility lacked a fire sprinkler system. There was no plan to ensure the patients were given the 30 day notification prior to the transfer out of the facility due to the sprinkler system installation project.On the same day during an interview the administrator disclosed she held a meeting with the facility's task force committee. The committee discussed obtaining approval of the relocation plans for the sprinkler system installation project. A review of clinical records for Patient 68, disclosed less than a 30 day timeframe for the Notice of Proposed Transfer/Discharge before the scheduled transfer out of the facility. In addition, the written notice did not include a completion date for the sprinkler system installation project or an expected date for the patient?s return to the facility. The undated facility policy and procedure titled, "Transfer/Discharge", without a date described that when patient transfers/discharges are initiated by the facility, the Notice of Proposed Transfer/Discharge policy will be followed. The notice indicated the facility may proceed with the transfer/discharge at the end of thirty (30) days, even if a decision on the appeal has not been rendered. The facility failed to provide a 30 day written notice of transfer to Patient 68 and/or family member or legal representative least 30 days before the patient transferred out of the facility. The above violation has a direct relationship to the health safety or security of patients. |
| 970000054 |
WESTERN CONVALESCENT HOSPITAL |
910010823 |
B |
19-Jun-14 |
ZWAE11 |
3618 |
CALIFORNIA HEALTH AND SAFETY CODE DIVISION 2. CHAPTER 2. ARTICLE 8.5Section 1336.2. (a) (4) (a) Before residents are transferred due to any change in the status of the license or operation of a facility, including a facility closure or voluntary or involuntary termination of a facility?s Medi-Cal or Medicare certification, the facility shall take reasonable steps to transfer affected residents safely and minimize possible transfer trauma by, at a minimum, doing all of the following: (4) At least 30 days in advance of the transfer, inform the resident or the resident?s representative of alternative facilities that are available and adequate to meet resident and family needs Based on observation, interview and record review, the facility failed to provide a written notice of transfer to Patient 2 and/or family member or legal representative at least 30 days before the patient is transferred out of the facility. A construction project to install sprinklers required the facility to remove all patients from the second floor. The project is in response to the facility non-compliance with the federal regulation that requires all long term care facilities to be equipped with a supervised automatic sprinkler system by August 13, 2013. This transfer of patients with less than a 30 day notice is a violation of the patient?s rights.Findings:On April 8, 2014 at 10:52 a.m., the Department received a complaint allegation regarding transfer discharge (T/D) rights.On April 8, 2014 at 2:45 p.m., the Department conducted an onsite visit to monitor the relocation of facility patients due to the facility's sprinkler installation project.According to the Life Safety 2567 (Statement of Deficiencies and Plan of Correction), dated December 11, 2013, the facility was not completely covered with an automatic sprinkler system in accordance with the National Fire Protection Association (NFPA) 13 and the facility lacked a fire sprinkler system. There was no plan to ensure the patients were given the 30 day notification prior to the transfer out of the facility due to the sprinkler system installation project.On the same day during an interview, the administrator disclosed she held a meeting with the facility's task force committee. The committee discussed obtaining approval of the relocation plans for the sprinkler system installation project. A review of clinical records for Patient 2, disclosed less than a 30 day timeframe for the Notice of Proposed Transfer/Discharge before the scheduled transfer out of the facility. In addition, the written notice did not include a completion date for the sprinkler system installation project or an expected date for the patient?s return to the facility.During an interview on April 9, 2014 at 9:55 a.m., Patient 2 stated the facility explained the installation of the sprinkler system. This voluntary transfer was temporary and the transfer back to the facility would be in approximately two months.The undated facility policy and procedure titled, "Transfer/Discharge", described that when patient transfers/discharges are initiated by the facility, the Notice of Proposed Transfer/Discharge policy will be followed. The notice indicated the facility may proceed with the transfer/discharge at the end of thirty (30) days, even if a decision on the appeal has not been rendered. The facility failed to provide a 30 day written notice of transfer to Patient 2 and/or family member or legal representative least 30 days before the patient transferred out of the facility. The above violation has a direct relationship to the health safety or security of patients. |
| 970000054 |
WESTERN CONVALESCENT HOSPITAL |
910010824 |
B |
19-Jun-14 |
ZWAE11 |
3372 |
CALIFORNIA HEALTH AND SAFETY CODE DIVISION 2. CHAPTER 2. ARTICLE 8.5Section 1336.2. (a) (4) (a) Before residents are transferred due to any change in the status of the license or operation of a facility, including a facility closure or voluntary or involuntary termination of a facility?s Medi-Cal or Medicare certification, the facility shall take reasonable steps to transfer affected residents safely and minimize possible transfer trauma by, at a minimum, doing all of the following: (4) At least 30 days in advance of the transfer, inform the resident or the resident?s representative of alternative facilities that are available and adequate to meet resident and family needsBased on observation, interview and record review, the facility failed to provide a written notice of transfer to Patient 3 and/or family member or legal representative at least 30 days before the patient is transferred out of the facility. A construction project to install sprinklers required the facility to remove all patients from the second floor. The project is in response to the facility non-compliance with the federal regulation that requires all long term care facilities to be equipped with a supervised automatic sprinkler system by August 13, 2013. This transfer of patients with less than a 30 day notice is a violation of the patient?s rights.Findings: On April 8, 2014 at 10:52 a.m., the Department received a complaint allegation regarding transfer discharge (T/D) rights.On April 8, 2014 at 2:45 p.m., the Department conducted an onsite visit to monitor the relocation of facility patients due to the facility's sprinkler installation project.According to the Life Safety 2567 (Statement of Deficiencies and Plan of Correction), dated December 11, 2013, the facility was not completely covered with an automatic sprinkler system in accordance withthe National Fire Protection Association (NFPA) 13, and the facility lacked a fire sprinkler system. There was no plan to ensure the patients were given the 30 day notification prior to the transfer out of the facility due to the sprinkler system installation project.On the same day during an interview, the administrator disclosed she held a meeting with the facility's task force committee. The committee discussed obtaining approval of the relocation plans for the sprinkler system installation project. A review of clinical records for Patient 3, disclosed less than a 30 day timeframe for the Notice of Proposed Transfer/Discharge before the scheduled transfer out of the facility. In addition, the written notice did not include a completion date for the sprinkler system installation project or an expected date for the patient?s return to the facility.The undated facility policy and procedure titled, "Transfer/Discharge", described that when patient transfers/discharges are initiated by the facility, the Notice of Proposed Transfer/Discharge policy will be followed. The notice indicated the facility may proceed with the transfer/discharge at the end of thirty (30) days, even if a decision on the appeal has not been rendered. The facility failed to provide a 30 day written notice of transfer to Patient 3 and/or family member or legal representative least 30 days before the patient transferred out of the facility. The above violation has a direct relationship to the health safety or security of patients. |
| 970000054 |
WESTERN CONVALESCENT HOSPITAL |
910010825 |
B |
19-Jun-14 |
ZWAE11 |
3611 |
CALIFORNIA HEALTH AND SAFETY CODE DIVISION 2. CHAPTER 2. ARTICLE 8.5Section 1336.2. (a) (4) (a) Before residents are transferred due to any change in the status of the license or operation of a facility, including a facility closure or voluntary or involuntary termination of a facility?s Medi-Cal or Medicare certification, the facility shall take reasonable steps to transfer affected residents safely and minimize possible transfer trauma by, at a minimum, doing all of the following: (4) At least 30 days in advance of the transfer, inform the resident or the resident?s representative of alternative facilities that are available and adequate to meet resident and family needs Based on observation, interview and record review, the facility failed to provide a written notice of transfer to Patient 4 and/or family member or legal representative at least 30 days before the patient is transferred out of the facility. A construction project to install sprinklers required the facility to remove all patients from the second floor. The project is in response to the facility non-compliance with the federal regulation that requires all long term care facilities to be equipped with a supervised automatic sprinkler system by August 13, 2013. This transfer of patients with less than a 30 day notice is a violation of the patient?s rights.Findings:On April 8, 2014 at 10:52 a.m., the Department received a complaint allegation regarding transfer discharge (T/D) rights.On April 8, 2014 at 2:45 p.m., the Department conducted an onsite visit to monitor the relocation of facility patients due to the facility's sprinkler installation project. According to the Life Safety 2567 (Statement of Deficiencies and Plan of Correction), dated December 11, 2013, the facility was not completely covered with an automatic sprinkler system in accordance with the National Fire Protection Association (NFPA) 13 and the facility lacked a fire sprinkler system. There was no plan to ensure the patients were given the 30 day notification prior to the transfer out of the facility due to the sprinkler system installation project.On the same day during an interview, the administrator disclosed she held a meeting with the facility's task force committee. The committee discussed obtaining approval of the relocation plans for the sprinkler system installation project. A review of clinical records for Patient 4, disclosed less than a 30 day timeframe for the Notice of Proposed Transfer/Discharge before the scheduled transfer out of the facility. In addition, the written notice did not include a completion date for the sprinkler system installation project or an expected date for the patient?s return to the facility. During an interview on April 9, 2014 at 11:45 a.m., Patient 4, stated the facility explained the installation of the sprinkler system. The was temporary and Patient 4 would be transferred back to the facility in approximately two months.The undated facility policy and procedure titled, "Transfer/Discharge", described that when patient transfers/discharges are initiated by the facility, the Notice of Proposed Transfer/Discharge policy will be followed. The notice indicated the facility may proceed with the transfer/discharge at the end of thirty (30) days, even if a decision on the appeal has not been rendered. The facility failed to provide a 30 day written notice of transfer to Patient 4 and/or family member or legal representative least 30 days before the patient transferred out of the facility. The above violation has a direct relationship to the health safety or security of patients. |
| 970000054 |
WESTERN CONVALESCENT HOSPITAL |
910010826 |
B |
19-Jun-14 |
ZWAE11 |
3622 |
CALIFORNIA HEALTH AND SAFETY CODE DIVISION 2. CHAPTER 2. ARTICLE 8.5Section 1336.2. (a) (4) (a) Before residents are transferred due to any change in the status of the license or operation of a facility, including a facility closure or voluntary or involuntary termination of a facility?s Medi-Cal or Medicare certification, the facility shall take reasonable steps to transfer affected residents safely and minimize possible transfer trauma by, at a minimum, doing all of the following: (4) At least 30 days in advance of the transfer, inform the resident or the resident?s representative of alternative facilities that are available and adequate to meet resident and family needs Based on observation, interview and record review, the facility failed to provide a written notice of transfer to Patient 6 and/or family member or legal representative at least 30 days before the patient is transferred out of the facility. A construction project to install sprinklers required the facility to remove all patients from the second floor. The project is in response to the facility non-compliance with the federal regulation that requires all long term care facilities to be equipped with a supervised automatic sprinkler system by August 13, 2013. This transfer of patients with less than a 30 day notice is a violation of the patient?s rights. Findings: On April 8, 2014 at 10:52 a.m., the Department received a complaint allegation regarding transfer discharge (T/D) rights.On April 8, 2014 at 2:45 p.m., the Department conducted an onsite visit to monitor the relocation of facility patients due to the facility's sprinkler installation project.According to the Life Safety 2567 (Statement of Deficiencies and Plan of Correction), dated December 11, 2013, the facility was not completely covered with an automatic sprinkler system in accordance with the National Fire Protection Association (NFPA) 13 and the facility lacked a fire sprinkler system. There was no plan to ensure the patients were given the 30 day notification prior to the transfer out of the facility due to the sprinkler system installation project.On the same day, during an interview, the administrator disclosed she held a meeting with the facility's task force committee. The committee discussed obtaining approval of the relocation plans for the sprinkler system installation project. A review of clinical records for Patient 6, disclosed less than a 30 day timeframe for the Notice of Proposed Transfer/Discharge before the scheduled transfer out of the facility. In addition, the written notice did not include a completion date for the sprinkler system installation project or an expected date for the patient?s return to the facility. During an interview, on April 9, 2014 at 12:30 p.m., Patient 6 stated the facility explained the installation of the sprinkler system; the transfer was temporary and Patient 6 would be transferred back to the facility in approximately two months.The undated facility policy and procedure titled, "Transfer/Discharge", described that when patient transfers/discharges are initiated by the facility, the Notice of Proposed Transfer/Discharge policy will be followed. The notice indicated the facility may proceed with the transfer/discharge at the end of thirty (30) days, even if a decision on the appeal has not been rendered. The facility failed to provide a 30 day written notice of transfer to Patient 6 and/or family member or legal representative least 30 days before the patient transferred out of the facility. The above violation has a direct relationship to the health safety or security of patients. |
| 970000054 |
WESTERN CONVALESCENT HOSPITAL |
910010828 |
B |
19-Jun-14 |
ZWAE11 |
1 |
0 |
| 970000054 |
WESTERN CONVALESCENT HOSPITAL |
910010829 |
B |
19-Jun-14 |
ZWAE11 |
3657 |
CALIFORNIA HEALTH AND SAFETY CODE DIVISION 2. CHAPTER 2. ARTICLE 8.5Section 1336.2. (a) (4) (a) Before residents are transferred due to any change in the status of the license or operation of a facility, including a facility closure or voluntary or involuntary termination of a facility?s Medi-Cal or Medicare certification, the facility shall take reasonable steps to transfer affected residents safely and minimize possible transfer trauma by, at a minimum, doing all of the following: (4) At least 30 days in advance of the transfer, inform the resident or the resident?s representative of alternative facilities that are available and adequate to meet resident and family needs Based on observation, interview and record review, the facility failed to provide a written Notice of transfer to Patient 7 and/or family member or legal representative at least 30 days before the patient is transferred out of the facility. A construction project to install sprinklers required the facility to remove all patients from the second floor. The project is in response to the facility non-compliance with the federal regulation that requires all long term care facilities to be equipped with a supervised automatic sprinkler system by August 13, 2013. This transfer of patients with less than a 30 day notice is a violation of the patient?s rights. Findings: On April 8, 2014 at 10:52 a.m., the Department received a complaint allegation regarding transfer discharge (T/D) rights. On April 8, 2014 at 2:45 p.m., the Department conducted an onsite visit to monitor the relocation of facility patients due to the facility's sprinkler installation project. According to the Life Safety 2567 (Statement of Deficiencies and Plan of Correction), dated December 11, 2013, the facility was not completely covered with an automatic sprinkler system in accordance with the National Fire Protection Association (NFPA) 13 and the facility lacked a fire sprinkler system. There was no plan to ensure the patients were given the 30 day notification prior to the transfer out of the facility due to the sprinkler system installation project.On the same day during an interview, the administrator disclosed she held a meeting with the facility's task force committee. The committee discussed obtaining approval of the relocation plans for the sprinkler system installation project. A review of clinical records for Patient 7, disclosed less than a 30 day timeframe for the Notice of Proposed Transfer/Discharge before the scheduled transfer out of the facility. In addition, the written notice did not include a completion date for the sprinkler system installation project or an expected date for the patient?s return to the facility. During an interview on April 9, 2014 at 2:15 p.m., Patient 7, stated the facility explained the installation of the sprinkler system. The transfer was temporary and Patient 7 would be transferred back to the facility in approximately two months.The undated facility policy and procedure titled, "Transfer/Discharge", described that when patient transfers/discharges are initiated by the facility, the Notice of Proposed Transfer/Discharge policy will be followed. The notice indicated the facility may proceed with the transfer/discharge at the end of thirty (30) days, even if a decision on the appeal has not been rendered. The facility failed to provide a 30 day written notice of transfer to Patient 7 and/or family member or legal representative least 30 days before the patient transferred out of the facility. The above violation has a direct relationship to the health safety or security of patients. |
| 970000054 |
WESTERN CONVALESCENT HOSPITAL |
910010830 |
B |
19-Jun-14 |
ZWAE11 |
3413 |
CALIFORNIA HEALTH AND SAFETY CODE DIVISION 2. CHAPTER 2. ARTICLE 8.5Section 1336.2. (a) (4) (a) Before residents are transferred due to any change in the status of the license or operation of a facility, including a facility closure or voluntary or involuntary termination of a facility?s Medi-Cal or Medicare certification, the facility shall take reasonable steps to transfer affected residents safely and minimize possible transfer trauma by, at a minimum, doing all of the following:(4) At least 30 days in advance of the transfer, inform the resident or the resident?s representative of alternative facilities that are available and adequate to meet resident and family needsBased on observation, interview and record review, the facility failed to provide a written notice of transfer to Patient 8 and/or family member or legal representative at least 30 days before the patient is transferred out of the facility. A construction project to install sprinklers required the facility to remove all patients from the second floor. The project is in response to the facility non-compliance with the federal regulation that requires all long term care facilities to be equipped with a supervised automatic sprinkler system by August 13, 2013. This transfer of patients with less than a 30 day notice is a violation of the patient?s rights.Findings: On April 8, 2014 at 10:52 a.m., the Department received a complaint allegation regarding transfer discharge (T/D) rights. On April 8, 2014 at 2:45 p.m., the Department conducted an onsite visit to monitor the relocation of facility patients due to the facility's sprinkler installation project. According to the Life Safety 2567 (Statement of Deficiencies and Plan of Correction), dated December 11, 2013, the facility was not completely covered with an automatic sprinkler system in accordance with the National Fire Protection Association (NFPA) 13, and the facility lacked a fire sprinkler system. There was no plan to ensure the patients were given the 30 day notification prior to the transfer out of the facility due to the sprinkler system installation project.On the same day during an interview, the administrator disclosed she held a meeting with the facility's task force committee. The committee discussed obtaining approval of the relocation plans for the sprinkler system installation project. A review of clinical records for Patient 8, disclosed less than a 30 day timeframe for the Notice of Proposed Transfer/Discharge before the scheduled transfer out of the facility. In addition, the written notice did not include a completion date for the sprinkler system installation project or an expected date for the patient?s return to the facility. The undated facility policy and procedure titled, "Transfer/Discharge", described that when patient transfers/discharges are initiated by the facility, the Notice of Proposed Transfer/Discharge policy will be followed. The notice indicated the facility may proceed with the transfer/discharge at the end of thirty (30) days, even if a decision on the appeal has not been rendered. The facility failed to provide a 30 day written notice of transfer to Patient 8 and/or family member or legal representative least 30 days before the patient transferred out of the facility. The above violation has a direct relationship to the health safety or security of patients. |
| 970000054 |
WESTERN CONVALESCENT HOSPITAL |
910010831 |
B |
19-Jun-14 |
ZWAE11 |
3340 |
CALIFORNIA HEALTH AND SAFETY CODE DIVISION 2. CHAPTER 2. ARTICLE 8.5Section 1336.2. (a) (4) (a) Before residents are transferred due to any change in the status of the license or operation of a facility, including a facility closure or voluntary or involuntary termination of a facility?s Medi-Cal or Medicare certification, the facility shall take reasonable steps to transfer affected residents safely and minimize possible transfer trauma by, at a minimum, doing all of the following: (4) At least 30 days in advance of the transfer, inform the resident or the resident?s representative of alternative facilities that are available and adequate to meet resident and family needs Based on observation, interview and record review, the facility failed to provide a written notice of transfer to Patient 9 at least 30 days before the patient is transferred out of the facility. A construction project to install sprinklers required the facility to remove all patients from the second floor. The project is in response to the facility non-compliance with the federal regulation that requires all long term care facilities to be equipped with a supervised automatic sprinkler system by August 13, 2013. This transfer of patients with less than a 30 day notice is a violation of the patient?s rights.Findings: a. On April 8, 2014 at 10:52 a.m., the Department received a complaint allegation regarding transfer discharge (T/D) rights. On April 8, 2014 at 2:45 p.m., the Department conducted an onsite visit to monitor the relocation of facility patients due to the facility's sprinkler installation project. According to the Life Safety 2567 (Statement of Deficiencies and Plan of Correction), dated December 11, 2013, the facility was not completely covered with an automatic sprinkler system in accordance with the National Fire Protection Association (NFPA) 13, and the facility lacked a fire sprinkler system. There was no plan to ensure the patients were given the 30 day notification prior to the transfer out of the facility due to the sprinkler system installation project.On the same day during an interview, the administrator disclosed she held a meeting with the facility's task force committee. The committee discussed obtaining approval of the relocation plans for the sprinkler system installation project. A review of clinical records for Patient 9, disclosed less than a 30 day timeframe for the Notice of Proposed Transfer/Discharge before the scheduled transfer out of the facility. In addition, the written notice did not include a completion date for the sprinkler system installation project or an expected date for the patient?s return to the facility. The undated facility policy and procedure titled, "Transfer/Discharge", without a date described that when patient transfers/discharges are initiated by the facility, the Notice of Proposed Transfer/Discharge policy will be followed. The notice indicated the facility may proceed with the transfer/discharge at the end of thirty (30) days, even if a decision on the appeal has not been rendered. The facility failed to provide a 30 day written notice of transfer to Patient 9 least 30 days before the patient transferred out of the facility. The above violation has a direct relationship to the health safety or security of patients. |
| 970000054 |
WESTERN CONVALESCENT HOSPITAL |
910010832 |
B |
19-Jun-14 |
ZWAE11 |
3415 |
CALIFORNIA HEALTH AND SAFETY CODE DIVISION 2. CHAPTER 2. ARTICLE 8.5Section 1336.2. (a) (4) (a) Before residents are transferred due to any change in the status of the license or operation of a facility, including a facility closure or voluntary or involuntary termination of a facility?s Medi-Cal or Medicare certification, the facility shall take reasonable steps to transfer affected residents safely and minimize possible transfer trauma by, at a minimum, doing all of the following: (4) At least 30 days in advance of the transfer, inform the resident or the resident?s representative of alternative facilities that are available and adequate to meet resident and family needsBased on observation, interview and record review, the facility failed to provide a written notice of transfer to Patient 10 and/or family member or legal representative at least 30 days before the patient is transferred out of the facility. A construction project to install sprinklers required the facility to remove all patients from the second floor. The project is in response to the facility non-compliance with the federal regulation that requires all long term care facilities to be equipped with a supervised automatic sprinkler system by August 13, 2013. This transfer of patients with less than a 30 day notice is a violation of the patient?s rights. Findings: a. On April 8, 2014 at 10:52 a.m., the Department received a complaint allegation regarding transfer discharge (T/D) rights. On April 8, 2014 at 2:45 p.m., the Department conducted an onsite visit to monitor the relocation of facility patients due to the facility's sprinkler installation project. According to the Life Safety 2567 (Statement of Deficiencies and Plan of Correction), dated December 11, 2013, the facility was not completely covered with an automatic sprinkler system in accordance with the National Fire Protection Association (NFPA) 13, and the facility lacked a fire sprinkler system. There was no plan to ensure the patients were given the 30 day notification prior to the transfer out of the facility due to the sprinkler system installation project.On the same day during an interview, the administrator disclosed she held a meeting with the facility's task force committee. The committee discussed obtaining approval of the relocation plans for the sprinkler system installation project. A review of clinical records for Patient 10 disclosed less than a 30 day timeframe for the Notice of Proposed Transfer/Discharge before the scheduled transfer out of the facility. In addition, the written notice did not include a completion date for the sprinkler system installation project or an expected date for the patient?s return to the facility. The undated facility policy and procedure titled, "Transfer/Discharge", described that when patient transfers/discharges are initiated by the facility, the Notice of Proposed Transfer/Discharge policy will be followed. The notice indicated the facility may proceed with the transfer/discharge at the end of thirty (30) days, even if a decision on the appeal has not been rendered. The facility failed to provide a 30 day written notice of transfer to Patient 10 and/or family member or legal representative least 30 days before the patient transferred out of the facility. The above violation has a direct relationship to the health safety or security of patients. |
| 970000054 |
WESTERN CONVALESCENT HOSPITAL |
910010833 |
B |
19-Jun-14 |
ZWAE11 |
3425 |
CALIFORNIA HEALTH AND SAFETY CODE DIVISION 2. CHAPTER 2. ARTICLE 8.5Section 1336.2. (a) (4) (a) Before residents are transferred due to any change in the status of the license or operation of a facility, including a facility closure or voluntary or involuntary termination of a facility?s Medi-Cal or Medicare certification, the facility shall take reasonable steps to transfer affected residents safely and minimize possible transfer trauma by, at a minimum, doing all of the following: (4) At least 30 days in advance of the transfer, inform the resident or the resident?s representative of alternative facilities that are available and adequate to meet resident and family needsBased on observation, interview and record review, the facility failed to provide a written notice of transfer to Patient 5 and/or family member or legal representative at least 30 days before the patient is transferred out of the facility. A construction project to install sprinklers required the facility to remove all patients from the second floor. The project was in response to the facility non-compliance with the federal regulation that requires all long term care facilities to be equipped with a supervised automatic sprinkler system by August 13, 2013. This transfer of patients with less than a 30 day notice is a violation of the patient?s rights. Findings: On April 8, 2014 at 10:52 a.m., the Department received a complaint allegation regarding transfer discharge (T/D) rights. On April 8, 2014 at 2:45 p.m., the Department conducted an onsite visit to monitor the relocation of facility patients due to the facility's sprinkler installation project. According to the Life Safety 2567 (Statement of Deficiencies and Plan of Correction), dated December 11, 2013, the facility was not completely covered with an automatic sprinkler system in accordance with the National Fire Protection Association (NFPA) 13, and the facility lacked a fire sprinkler system. There was no plan to ensure the patients were given the 30 day notification prior to the transfer out of the facility due to the sprinkler system installation project.On the same day during an interview, the administrator disclosed she held a meeting with the facility's task force committee. The committee discussed obtaining approval of the relocation plans for the sprinkler system installation project. A review of clinical records for Patient 5, disclosed there was less than a 30 day timeframe for the Notice of Proposed Transfer/Discharge before the scheduled transfer out of the facility. In addition, the written notice did not include a completion date for the sprinkler system installation project or an expected date for the patient?s return to the facility. The undated facility policy and procedure titled, "Transfer/Discharge", described that when patient transfers/discharges are initiated by the facility, the Notice of Proposed Transfer/Discharge policy will be followed. The notice indicated the facility may proceed with the transfer/discharge at the end of thirty (30) days, even if a decision on the appeal has not been rendered. The facility failed to provide a 30 day written notice of transfer to Patient 5 and/or family member or legal representative at least 30 days before the patient transferred out of the facility. The above violation has a direct relationship to the health safety or security of patients. |
| 970000054 |
WESTERN CONVALESCENT HOSPITAL |
910012200 |
A |
19-Apr-16 |
K7YD11 |
13414 |
483.25 Quality of Care Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care.483.25 (h) The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. On 8/28/15, at 9 a.m., an unannounced visit was made to the facility to investigate a complaint regarding Resident 1 sustaining a fall at the facility which resulted in a fracture (break) of the right thigh bone (femur) with protrusion of the bone (the femur was sticking out).Based on interview, and record review, the facility failed to ensure Resident 1, who was assessed as high risk for fall and injury due to memory problem, confusion, poor judgment, physical limitations, unstable balance, medication use, and in need of one-person assistance for transfer and walking, was provided with supervision and assistance to prevent fall and injury by failing to: 1. Ensure Resident 1 was monitored for unassisted transfers and walking. 2. Ensure promptly physician notification regarding Resident 1?s increased behavioral manifestation and inability to respond to re-direction interventions. 3. Implement care plan interventions of monitoring for possible adverse effects from the psychotropic (affect the person?s mental activity and behavior) medication use and notify the physician if any, and providing one on one (1:1 ? one staff to resident ratio) visit for behavioral management. 4. Implement the facility?s policy and procedure on Change of Condition to notify the physician and family when the resident?s condition changes such as agitation, anxiety, or refusing care. 5. Ensure the Licensed Vocational Nurse (LVN) implemented the Nursing Care Essential Duties and Responsibilities as per the job description for LVN which included monitoring residents condition, making ongoing assessments and interventions related to changes of condition, monitoring behavior, and provide interventions as indicated.On the night of 8/10/15 through the early morning of 8/11/15 Resident 1 exhibited restlessness, aggressiveness, had multiple attempts to walk, did not respond to redirection, and sustained a fall with injuries, which included fracture with protrusion of the right femur.A review of the Admission Face Sheet indicated Resident 1 was admitted to the facility, on 8/5/15, at 4:30 p.m., with diagnoses which included Alzheimer's disease/dementia (disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning), insomnia (inability to sleep), and depression (low mood and dislike to activity that can affect a person's thoughts, behavior, feelings and sense of well-being). The Admission Assessment dated 8/5/15, indicated Resident 1 was alert, required one-person assistance with transfers, walking, and personal hygiene.A review of the Fall Risk Assessment, dated 8/5/15, indicated Resident 1 was always disoriented to person, place, and time, and had a previous fall in the past 2 - 6 months and was assessed as having a score was 30 (a total score of eight or above represented a high risk for falls). The fall risk assessment also indicated Resident 1 received 1 - 2 medications within the past seven days, but a review of the routine medication physician's orders, dated 8/5/16, indicated Resident 1 received a total of eleven different medications.The Physician?s Orders dated 8/5/15 indicated Resident 1 received antidepressant Remeron 15 milligram (mg) every night for depression. The manufacturer?s recommends to be alert to change in mood or symptoms, report any new or worsening symptoms to the doctor, such as behavior changes, anxiety, hostility, aggressiveness or hyperactive (mentally or physically), decreased need for sleep, unusual risk-taking behavior, agitation, or hallucinations.A care plan developed on 8/5/15 for Resident 1?s use of psychotropic medication related to depression had a goal for the resident to be free from adverse drug reactions. The nursing interventions included monitoring for adverse drug effects every shift, report timely to the physician any behavioral decompensation (changes) and adverse drug reactions.A care plan developed on 8/5/15 for Resident 1?s potential for falls due to Alzheimer's disease/dementia, depression, and history of falls, included in the interventions monitoring the resident's whereabouts to keep the resident safe and free from injuries.A care plan developed on 8/5/15 for the resident?s behavioral problems, included in the interventions assessing the potential cause or reason for the behavior, redirect the resident, provide safe environment, and monitor the resident to ensure safety.A care plan developed on 8/5/15, for Resident 1?s combative behavior and physical aggression due to Alzheimer's disease, the interventions included utilizing alternative interventions such as redirection, providing 1:1 visit as needed for behavioral management. A care plan developed on 8/6/15 for Resident 1?s risk for spontaneous pathological fracture related to osteoporosis and osteopenia, included in the interventions providing a safe and hazard free environment, assist with transfers and ambulation, and medicate as needed.A review of the Psychotropic Assessment form, undated, indicated Resident 1 had diagnoses of depression and mood disorder. The behavior problem, behavior exhibited, and behavior intervention remained blank. There were no team recommendations, no date of when to notify the physician, no documentation of the medications ordered, or if consent was obtained. A review of the Change of Condition/Interact Assessment Form dated 8/11/15, indicated at around 5 a.m., Resident 1 was sitting in her wheelchair saying she wanted to get her car keys to go home and check on her kids. Resident 1 then started to get out of her wheelchair and Certified Nurse Assistant 1 (CNA 1) assisted the resident to sit back down. The Change of Condition form indicated Resident 1 became aggressive, managed to get out of the wheelchair, attempted to walk, and fell on the floor. CNA 1 and licensed vocational nurse (LVN 1) assisted the resident back to the wheelchair while Registered Nurse 1 did a body assessment. Resident 1 was noted with protrusion of bone on right thigh and she was complaining of pain. The physician was notified at 5:30 a.m. and an order to transfer Resident 1 to general acute care hospital (GACH) was obtained.Further record review since Resident 1?s admission disclosed no documented evidence the resident?s behavior was not controllable or continuous.During an interview, on 9/16/15, at 1:15 p.m., the certified nurse assistant (CNA 1) stated on 8/10/15, at the beginning of her shift at 11 p.m., she received Resident 1 in the wheelchair. CNA 1 stated Resident 1 remained in the wheelchair from 11 p.m. to 5 a.m., because there were unsuccessful attempts to put her back to bed. CNA 1 stated she had 16 residents that day and she was not assigned to give the resident 1:1 supervision to manage Resident 1's behavior.CNA 1 stated she was tired of telling the resident to sit back down and not get out from her wheelchair. Resident 1 was very agitated throughout the night and kept saying she needed the keys to her car. Resident 1 was very aggressive and tried to hit, scratch and swung her arms at CNA 1.CNA 1 stated Resident 1 would get a hold of the rails in the hallway and used it to get out of the wheelchair and move along the wall. CNA 1 stated she had to put the resident back into the wheelchair 4 times that night and asked the licensed nurse (LVN 1) if he could give Resident 1 something for her agitation so they could put her back to bed, but LVN 1 told her Resident 1 did not have any medication for agitation and it was too late in the night to call the physician. At approximately 5 a.m. on 8/11/15, CNA 1 stated she was coming out of another resident's room when she saw Resident 1 getting out of her wheelchair again and ran to assist her but it was too late. Resident 1 fell to the floor and as she was assisting the resident back into the wheelchair. Resident 1 continued to be very combative and aggressive towards her.A review of the CNA Assignment Sheet, dated 8/10/15 to 8/11/15 was conducted with the director of nursing (DON), which indicated CNA 1 was assigned to provide care to 16 residents.On 9/16/15, at 2 p.m., during an interview, LVN 1 stated that at the start of his shift at 11 p.m., Resident 1 was already restless and screaming. He stated, "It was like she was hallucinating and saying she needed her keys to drive home, and that she needed to be home to take care of her little kids." LVN 1 stated he tried to get Resident 1 to go back to bed, but it only made her angrier. Throughout the night, Resident 1 continued to scream and shout, and he made more than 3 to 4 attempts to put her back to bed and kept getting up from her wheelchair. LVN 1 stated he wished CNA 1 could provide the resident with 1:1 care but she had 15 other residents to take care of that night. LVN 1 also explained he did not call the physician because it was late at night. LVN 1 added he was the medication nurse and was busy and could not always observe Resident 1.On 9/16/15, at 3 p.m., during an interview, Registered Nurse 1 (RN 1) stated she was aware Resident 1 was agitated and aggressive towards staff but she did not call the physician because it was late at night.On 9/15/15, at 10 a.m., during an interview, Family Member 1 not being aware Resident 1 was agitated or aggressive towards the staff, or that the resident remained in the wheelchair all night. According to the facility's undated policy and procedure titled, "Change of Condition," when a resident condition changes for any reason the facility would implement proper care and follow-up by using a monitoring system using a Nursing 24 Hour Report Form. The licensed nurses would ensure proper assessment and documentation changes by notifying the physician and the family. The physician must be called promptly when the resident's condition changes such as agitation, anxiety, or refusing care.According to the facility's "Job Description," for LVN dated 2/13/13, the Essential Duties and Responsibilities include monitoring residents condition, make ongoing assessment and interventions related to the change of condition, behavior and provide interventions as indicated.During an interview, on 9/16/15, at 1:55 p.m., the Director of Nursing (DON) stated she could not provide any documentation the staff implemented the above policy. At 3:55 p.m., the DON stated the licensed nurses should have notified the physician of Resident 1's agitation and aggressive behavior, and to obtain appropriate intervention such as medication and the nursing staff should have closely monitored the resident during that time for her safety.A review of the Licensed Nurses Notes dated 8/11/15, indicated Resident 1 was transferred to a general acute care hospital (GACH) on 8/11/15, at 7:25 a.m., via ambulance where an x-ray on the right hip taken at 9:54 a.m. disclosed a displaced oblique fracture of the proximal femoral diaphysis (break in the right thigh).The facility failed to ensure Resident 1, who was assessed as high risk for fall and injury due to memory problem, confusion, poor judgment, physical limitations, unstable balance, medication use, and in need of one-person assistance for transfer and walking, was provided with supervision and assistance to prevent fall and injury by failing to: 1. Ensure Resident 1 was monitored for unassisted transfers and walking. 2. Ensure promptly physician notification regarding Resident 1?s increased behavioral manifestation and inability to respond to re-direction interventions. 3. Implement care plan interventions of monitoring for possible adverse effects from the psychotropic (affect the person?s mental activity and behavior) medication use and notify the physician if any, and providing one on one (1:1 ? one staff to resident ratio) visit for behavioral management. 4. Implement the facility?s policy and procedure on Change of Condition to notify the physician and family when the resident?s condition changes such as agitation, anxiety, or refusing care. 5. Ensure the Licensed Vocational Nurse (LVN) implemented the Nursing Care Essential Duties and Responsibilities as per the job description for LVN which included monitoring residents condition, making ongoing assessments and interventions related to changes of condition, monitoring behavior, and provide interventions as indicated.On the night of 8/10/15 through the early morning of 8/11/15 Resident 1 exhibited restlessness, aggressiveness, had multiple attempts to walk, did not respond to redirection, and sustained a fall with injuries, which included fracture with protrusion of the right femur.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. |
| 920000058 |
WINDSOR GARDENS HEALTHCARE CENTER OF THE VALLEY |
920010859 |
AA |
23-Sep-14 |
CW3N11 |
11246 |
Code of Federal Regulations F323: Quality of Care - 483.25(h)The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents.The facility's licensed nursing staff failed to ensure that Resident 1, who was assessed as having difficulties in swallowing, was not given oral medication mixed in applesauce. This violation resulted in the resident choking on the medications in applesauce, her oxygen levels decreased, the paramedics were called and upon arrival they had to intubate the resident (inserted a tube through the nose or mouth into the trachea to keep an open airway to deliver oxygen to the lungs). Resident 1 was transferred to the general acute care hospital (GACH) where she expired two days later as a result of aspiration pneumonia (infection of the lungs that develops due to the entrance of foreign materials, usually oral or stomach contents, into the lungs, often caused by an inability to swallow; the bacteria are different than those seen in more common types of pneumonia).On July 23, 2013, and September 17, 2013, the Department of Public Health received two complaints that alleged Resident 1 was given oral medication mixed in applesauce that resulted in choking and aspiration.According to the admission record, Resident 1 was admitted to the facility on January 24, 2013, with diagnoses that included aftercare for healing traumatic fracture of the hip and chronic airway obstruction (long term lung disorder making breathing difficult).A review of the Progress Notes regarding the Admission Summary, dated January 24, 2013, indicated Resident 1 was awake, alert, verbally responsive, and oriented times one (level of alertness). A review of the facility's history and physical examination record dated January 25, 2013, indicated the resident had the capacity to understand and make decisions and had a fair rehabilitation potential.The Minimum Data Set (MDS), an assessment and screening tool, dated January 26, 2013, which was in progress and incomplete, indicated Resident 1 required extensive assistance with eating. According to the Progress Notes of January 26, 2013, the entry written at 10:52 a.m., indicated a line of events that started at 7 a.m. The notes indicated that at 7:30 a.m., Certified Nursing Assistant 1 (CNA 1), who was assigned to feed Resident 1, had reported to Registered Nurse 1 (RN 1) that the resident had difficulty swallowing when CNA 1 fed her breakfast. RN 1 went to the resident's room and assessed her, validating the resident had difficulty of swallowing. The documentation indicated there was no aspiration/congestion/coughing at the time of the assessment. The next event documented in the Progress Note indicated at 7:45 a.m., RN 1 informed the on-call physician about the resident's difficulty swallowing and obtained an order for a speech therapy evaluation and follow-up treatment, which was noted and carried out. RN 1 documented the speech therapist (ST) was in the building "and made aware," and Resident 1 was seen and evaluated by the ST. A review of the Speech Therapy Progress Note dated January 26, 2013, obtained via fax that was stamped January 28, 2013, at 6:13 p.m., indicated a ST screen was done because nursing reported that the resident was choking with the current regular and thin liquid diet. The resident was coughing with oatmeal after the CNA fed her one bite. The ST recommended discontinuing feeding the resident at breakfast due to coughing and demonstrating decreased arousal levels. The ST documented the CNA reported the resident demonstrated decreased alertness the day before, and recommended nursing to obtain ST evaluation orders. During a telephone interview with RN 1, on June 10, 2014, at 10:03 a.m., she stated on January 26, 2013, CNA 1 informed her that Resident 1 was able to tolerate 10 percent of hot cereal, able to sip a little water, but had difficulty swallowing. RN 1 stated she went in the resident's room and assessed her to have a swallowing problem as indicated in her written Progress Note. RN 1 stated she called the physician and obtained an order for a ST evaluation, and she observed the ST in the resident's room, and that was the reason she documented "seen and evaluated by ST." When asked whether she received verbal or written communication from the ST, RN 1 stated she couldn't remember. When asked if she had communicated her assessment to the medication nurse, licensed vocational nurse 1 (LVN 1), she said he was aware. According to the physician's order and the medication administration record (MAR), the medications administered on January 26, 2013, during the morning medication-pass were the following:1. Librium 25 milligrams (mg)2. Metamucil powder one teaspoon. 3. Colace 200 mg. 4. Folic acid one mg. 5. Lisinopril 10 mg 6. Thiamine 100 mg A review of the electronic Medication Administration Record (eMAR) dated January 26, 2013, revealed documentation indicating the resident was unable to tolerate medications even with applesauce. On June 3, 2014, at 4 p.m. during an interview with LVN 1, he stated that at 8:35 a.m. on January 26, 2013, he was with the RN 1, when she assessed Resident 1 with swallowing difficulties.LVN 1 also stated he was aware that the resident was having difficulty of swallowing that morning and was seen by the ST. However, he was not able to recall if the ST had informed him of her findings and recommendations.According to LVN 1, he documented in the MAR the resident was unable to tolerate the medications. When asked why he gave medications when the resident was having swallowing difficulties, he said he wasn't able to recall. On June 11, 2014, three attempts were made to contact the ST, however she was not available for interview. According to the director of rehabilitation, ST 1 was no longer employed by the facility.The Progress Note dated January 26, 2013, entered at 10:52 a.m., indicated at 8:35 a.m., approximately five minutes after the oral medications were documented as administered, the resident had a change of condition manifested by labored breathing. The resident's vital signs were: blood pressure of 110/68, temperature 97 degrees Fahrenheit (reference range 97- 98.6), respiratory rate of 32 breaths per minute (reference range 12-20), heart rate 130 beats per minute (reference range 60-100), and oxygen saturation (amount of oxygen in the blood) was at 45 percent by room air. Oxygen was administered and was increased to 15 liters per minute by non-rebreather mask (device used to deliver oxygen in an emergency), and the head of the bed was elevated.Oxygen saturation in a range of 96% to 100% is generally considered normal. Anything below 90% could quickly lead to life-threatening complications. The margin between "healthy" saturation levels (95-98%) and respiratory failure (usually 85-90%) is narrow. American Journal of Nursing (AJN), May 2005 - Volume 105 - Issue 5 - Page 72).The Progress Note dated January 26, 2013, entered at 10:52 a.m., indicated that at 8:38 a.m., the resident's oxygen saturation was 65 percent while receiving oxygen at 15 liters per minute by non-rebreather mask, the blood pressure was 112/65, and heart rate was 141 beats per minute. The note indicated 911 was called and to continue to monitor.The Progress Note then indicated that at 8:42 a.m., the resident's vital signs were: blood pressure 115/66, temperature of 97.4 Fahrenheit, respiratory rate of 35 breaths per minute, and heart rate of 145 beats per minute. The oxygen saturation fluctuated to 51 percent at while on oxygen at 15 liters per minute by non-rebreather mask. Documentation indicated Resident 1 was non-verbal and was responsive only to painful stimuli. At 8:47 a.m., the paramedics arrived at the facility and transferred the resident to the GACH.According to the Ambulance Services report dated January 26, 2013, at 8:47 a.m., the resident was found in bed with a chief complaint of shortness of breath after eating breakfast. The resident was found with agonal respirations (abnormal pattern of breathing characterized by gasping, labored breathing), and airway obstruction. The resident was intubated (tube put into the airway for administration of oxygen) and oxygen saturation improved. The resident remained unresponsive during treatment and transport, according to the report. A review of the GACH Emergency Department Admission (ER) reports dated January 26, 2013, indicated the resident had been intubated. The report indicated the paramedic informed the ER that when he was inserting the ET tube, there was a bolus (a rounded mass) of food stuck in the oropharynx (a section of the mouth and throat, located at the back of the mouth, when the mouth is opened wide), and trachea that looked like "applesauce" and the resident had a temperature of 101.2 Fahrenheit, pulse rate of 126 beats per minute, blood pressure of 122/56, respiratory rate of 48 breaths per minute, and oxygen saturation of 70 percent while she was being bagged by an ET tube. The resident was admitted to an intensive care unit (ICU) and had multiple physician consultations from January 26, 2013 to January 28, 2013. The GACH History and Physical Examination Record dated January 26, 2013 indicated the resident had a fever, recent choking on food possibly leading to acute respiratory failure, possibly due to dysphagia (difficulty swallowing) and oral medication. The pulmonologist Consultation Record dated January 26, 2013, indicated the impression was acute hypoxemia (inadequate oxygenation of the blood) respiratory failure, likely due to aspiration (entry of food material into the lungs) with acute central airway obstruction resulting in hypoxemia, after intubation. Pulmonary embolus (blood clot in the lungs) was much less likely. A review of the GACH Death Summary dated January 28, 2013, indicated discharge diagnoses that included sudden death, acute respiratory failure, possible chronic obstructive pulmonary disease from previous smoking history, and possible aspiration leading to acute respiratory failure. The time of death noted on the summary was January 28, 2013, at 12:52 a.m. A review of Resident 1's Death Certificate dated February 1, 2013, indicated the resident's cause of death was cardio-respiratory arrest, aspiration pneumonia, and chronic obstructive pulmonary disease. Therefore, the facility's licensed nursing staff failed to ensure that Resident 1, who was assessed as having difficulties in swallowing, was not given oral medication mixed in applesauce. This violation resulted in the resident choking on the medications in applesauce, her oxygen levels decreased, the paramedics were called and upon arrival they had to intubate the resident. Resident 1 was transferred to the GACH where she expired two days later as a result of aspiration pneumonia. The above violation presented either imminent danger that death or serious harm would result, or a substantial probability that death or serious harm would result, and was a direct proximate cause of the death of Resident 1. |
| 920000058 |
WINDSOR GARDENS HEALTHCARE CENTER OF THE VALLEY |
920012680 |
A |
28-Oct-16 |
GGSG11 |
8311 |
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 6/24/16, at 9 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 right upper arm fracture. Based on interview and record review, the facility failed to provide its residents the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being and failed to ensure that the resident environment remains as free of accident hazards as is possible to prevent fall and injuries, including: 1. Failure to ensure Resident 1, who was assessed as fall risk due to history of falls and decline in walking ability, received adequate supervision and assistance devices to prevent falls and minimize injuries. 2. Failure to review and revise Resident 1?s plan of care to include interventions addressing the resident?s non-compliance with safety, poor judgment, and believing he could walk independently. As a result, on 6/21/16, Resident 1 suffered a fall sustaining a fracture to the right shoulder and experiencing severe pain on the affected area. A review of the admission record indicated Resident 1 was admitted to the facility on 5/28/16, from a general acute care hospital (GACH) with diagnoses including kidney cancer, syncope (fainting or a sudden temporary loss of consciousness), and abnormalities of gait and mobility. According to the GACH psychiatric consultation dated 5/27/16, the resident had general knowledge and insight about his condition, but had poor cooperation, used poor judgment, and could not make good decisions for self-care. The resident continued to refuse physical therapy (PT), was unable to ambulate independently and was refusing to go to a nursing home for 24 hours care. The psychiatrist noted the resident needed a person with durable power of attorney (DPOA) to make decisions for him and would declare the resident incompetent to make decisions A review of the Fall Risk Assessment dated 5/28/16, indicated Resident 1 had one to two falls within the last six months, had a decrease in muscle coordination, and sometimes had memory/recall ability problems, resulting in a score of 11. The form indicated the resident had a moderate risk for falls which was in conflict with the facility's policy and procedure titled, "Fall Management Process," that indicated a score of 10 or above represented high risk for fall. A review of Resident 1's PT Initial Evaluation dated 5/28/16, indicated a new onset of decrease in functional mobility, decreased coordination, decreased strength, fall risk, increased need for assistance, and compromised physical exertion level during activity. The note also indicated the use of the assistance devices, wheelchair and walker, for transfer, walking, and locomotion. A review of the care plan developed on 5/30/16, for the Resident 1's risk for falls related to syncope, with gait and balance problems had a goal for the resident to be free of falls. The interventions included anticipating and meeting the resident?s needs, ensuring the call light was within reach as the resident required prompt response to all requests for assistance. The care plan did not indicate Resident 1's level of supervision needed due to poor judgement and decision-making deficit. The care plan did not address the level of assistance the resident required with transfers and walking and did not include the use of assistance devices to promote safety and prevent falls such as wheelchair, walker, and gait belt. A review of the Minimum Data Set (MDS - standardized assessment and care planning tool) dated 6/3/16, indicated Resident 1 was independent with his cognitive skills for daily decision-making, required extensive assistance with two person physical assist for toilet use, ambulation, and transfers. The cognitive assessment was in conflict with the psychiatrist?s assessment conducted seven days prior on 5/27/16. A review of the nursing notes and fall investigation form indicated that on 6/16/16, at 5:09 p.m., resident sustained an unwitnessed fall and was found in his room, by his bed. According to the resident he tried going to his wheelchair because he wanted to go to dinner by himself and he did not ask for help. The resident did not sustain injury. A care plan developed after the fall on 6/16/16, included in the interventions, anticipating needs, keeping the call light within reach, keeping the room assignment for close observation and monitoring. The care plan did not indicate Resident 1's non-compliance with safety instructions; supervision required as the resident believed he could walk without assistance and did not call for help; and use of assistance devices. According to the nursing notes and fall investigation form dated 6/21/16, timed at 9:30 a.m., (five day after the prior fall), resident sustained an unwitnessed fall and was found by his bed, lying on his left side on the floor. The resident was complaining of right shoulder pain rated at 10 out of 10 (in a pain scale from zero to ten and 10 being the worst possible pain). The resident stated he was getting up to go to his meeting and he fell down. He also stated he was able to do it (walk) on his own. The physician was notified and ordered transfer to the GACH for evaluation. A review of Resident 1's GACH Emergency Room x-ray results dated 6/21/16, indicated a mildly comminuted (broken in more than two fragments) proximal humeral head fracture (top of the upper arm bone). Resident 1 was given Norco (contains a narcotic pain reliever (hydrocodone) and a non-narcotic pain reliever (acetaminophen), used to control moderate to severe pain) and Resident 1 was admitted for further treatment and evaluation. On 6/24/16, at 1 p.m., during an interview, the director of nursing (DON) stated after the first fall on 6/16/16, there were no new individualized care plan interventions to meet the resident?s need and prevent further falls an injury. According to the facility's policy and procedure, dated July 2008, titled, "Fall Management Process," a fall risk score of 10 or above represents high risk for fall and required the development of a nursing care plan with appropriate interventions initiated and implemented designed to prevent falls. The policy indicated recent falls would be reviewed within one week by a designated facility fall team, to evaluate cause, determine additional strategies as needed to prevent recurrences and further revise the care plan if needed. The facility failed to provide its residents the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being and failed to ensure that the resident environment remains as free of accident hazards as is possible to prevent fall and injuries, including: 1. Failure to ensure Resident 1, who was assessed as fall risk due to history of falls and decline in walking ability, received adequate supervision and assistance devices to prevent falls and minimize injuries. 2. Failure to review and revise Resident 1?s plan of care to include interventions addressing the resident?s non-compliance with safety, poor judgment, and believing he could walk independently. As a result, on 6/21/16, Resident 1 suffered a fall sustaining a fracture to the right shoulder and experiencing severe pain on the affected area. The above violation presented either (1) imminent danger that death or serious harm to the resident of the Skilled Nursing Facility would result therefrom, or (2) substantial probability that death or serious physical harm to the resident of the Skilled Nursing Facility would result therefrom. |
| 920000058 |
WINDSOR GARDENS HEALTHCARE CENTER OF THE VALLEY |
920012785 |
B |
6-Dec-16 |
LOTA11 |
3861 |
F224 Code of Federal Regulations Section 483.13 ? 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 failed to implement its written policy on Abuse Prevention, Investigation and Reporting, when Employee 1 paid her telephone bills and cashed a check from Resident 1's account, for one out of one sampled resident (1). On July 8, 2015, at 10:30 a.m., an unannounced visit was made at the facility to investigate an entity reported incident regarding misappropriation of resident's monies. A review of the medical record revealed Resident 1 was an 83 year-old female who was admitted to the facility on xxxxxxx, with admitting diagnoses that included congestive heart failure. The resident was discharged to a lower level of care on May 31, 2015. According to the documentation sent to the Department of Public Health, Ombudsman and Police Department dated June 18, 2015, the following was documented: The power of attorneys (POA) of former resident, Resident 1, came to meet the administrator. The POAs stated that there was money taken out of Resident 1's account to pay a telephone bill twice in the name of Employee and provided print outs showing two telephone bills were paid electronically with the resident's account to Employee 1's account . The charges were $174.50 on May 15, 2015, and $195.42 on June 15, 2015. Employee 1 was interviewed by the facility's administrator and she denied arranging the transfer of money from Resident 1's account to pay her telephone bills, but she read her name on the print out from the telephone company. Employee 1 stated she had not received a bill from the telephone company for two months and called the telephone company about this in May 2015. Employee 1 was suspended pending investigation. A review of Employee 1's personnel record indicated that she was hired by the facility on April 9, 2007, as a receptionist and later worked as an admission coordinator. According to the Administrator, the facility was informed about the allegation on June 18, 2015, and dismissed Employee 1 on June 23, 2015. On July 8, 2015, at 10:45 a.m., during an interview with the Administrator, she confirmed what she wrote in the entity report and in addition, stated that there was also a check which was cashed out from Resident 1's account for $250. According to the Administrator, the check was made payable to cash and there was no endorsements from any financial institutions or bank, and no evidence of a financial stamp. According to the Administrator, they reimbursed the resident's POA $1000 dollars to cover the telephone bills, the cashed check and other expenses. On January 6, 2016, the Evaluator was informed by the Department of Justice Agent that Employee 1 was arrested and was charged for the following: _ Penal Code section 368(e)(2), THEFT FROM AN ELDER OR DEPENDENT ADULT BY CARETAKER. -Penal Code section 484(a), PETTY THEFT. -Penal Code section 484(g), UNAUTHORIZED USE OF AN ACCESS CARD. -Penal Code section 470(d), FORGERY. The facility's policy regarding Abuse Prevention, Investigation and Reporting, stipulates: abuse, neglect, abandonment, isolation, financial abuse, will not be tolerated in this facility any time. It is the policy of this facility to take every proactive measure to prevent the occurrence of alleged abuse to any resident. The facility failed to implement its written policy on Abuse Prevention, Investigation and Reporting, when Employee 1 paid her telephone bills and cashed a check from Resident 1's account, for one out of one sampled resident (1). The above violation had a direct relationship to the health, safety and security of Resident 1. |
| 920000048 |
Wellsprings Post-Acute Center |
920012982 |
A |
14-Mar-17 |
1JXC11 |
10301 |
42 CFR? 483.25 (h) ACCIDENTS
The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents.
The facility failed to prevent an injury from a fall for Resident 1 by failing to:
1. Monitor and provide close and frequent supervision to Resident 1 who had a history of falls and who was identified and assessed as being a high risk for falls.
2. Ensure that fall prevention measures ordered by the physician were implemented based on a plan of care with interventions that were known to all care givers.
3. Implement the physician order to apply a bed tab-alarm (medical device that sounds to alert staff when a resident attempts to get out of bed unassisted), and ensure the alarm was regularly checked to ensure it worked properly (sounded).
On December 7, 2016, Resident 1 had a traumatic fall resulting in a fracture to the left pelvis (the large bony structure near the base of the spine to which the legs are attached) and left hip including a hematoma (localized swelling that is filled with blood caused by broken blood vessels). Resident 1 was transferred to the general acute care hospital (GACH), hospitalized for five days and discharged back to the facility.
On December 13, 2016, the Department of Public Health received an Entity Reported Incident (CA00514253) reporting Resident 1 sustained a fall with fracture on December 7, 2016. An investigation was initiated on December 27, 2016.
A review of the admission record indicated Resident 1 was admitted to the skilled nursing facility (SNF) on XXXXXXX, 2016, with diagnoses that included dementia (decline in mental ability that interferes with daily life), major depressive disorder, anemia (lack of healthy red blood cells in the blood), age-related osteoporosis (a condition in which bones become weak and fragile), and stress incontinence (inability to control the urge to urinate).
The Minimum Data Set [MDS-a comprehensive assessment and care screening tool] dated November 22, 2016, indicated Resident 1 had moderately impaired cognitive skills (the act or process of knowing, perceiving), required extensive assistance with one-person physical assist with bed mobility, transfer, toilet use and bathing, and limited one-person assist with walking in room and in corridor. The MDS also indicated the Care Area Assessment (CAA) for fall was triggered indicating a problem that would need further assessment and a development of a care plan.
A review of the Fall Risk Assessment (as assessment tool used for screening fall risk) dated November 15, 2016, indicated Resident 1 had a score of 22. According to the fall risk assessment tool, a score of 10 or above represents a high risk for falls. However, the SNF did not develop a plan of care after the resident was identified at a high risk for fall.
According to a primary care physician's History and Physical (H&P) Examination record, dated November 15, 2016, Resident 1 had fluctuating capacity to make decisions. The resident was admitted to the skilled nursing facility for Physical Therapy and Occupational Therapy and ongoing medical management. The anticipated length of stay was for one to two weeks.
On November 15, 2016, Resident 1 had the following physician orders:
1. Bedside safety mat to the floor for safety, every shift.
2. Hi-Lo bed (a bed that can be raised and lowered to a desired height), for safety every shift.
3. Tab-alarm (device that has a pull-string that attaches magnetically to the alarm with a garment clip to the resident. When the resident attempts to rise out of their chair or bed the pull-string magnet is pulled away from the alarm which causes the alarm to sound to alert staff), while in bed for safety every shift.
4. Tab-alarm, while in wheelchair (W/C) for safety every shift.
A review of Resident 1's clinical records did not indicate a plan of care that included the above physician orders as part of fall prevention measures so that the resident's care givers would know and implement the interventions to prevent an injury from a fall.
A review of the facility's Policy and Procedure for Fall Management revised on July 2016, indicated a Fall Risk Assessment of score of 10 or above represents a high risk for falls and will require the development of a care plan with interventions designed to prevent falls.
A review of another facility Policy and Procedures for Care Planning/Comprehensive, with a revised date October 2016, indicated residents triggered problem areas identified during assessment require further evaluation using Care Area Assessments. Each CAA that triggered must be assessed to evaluate the resident's strengths, problems, and needs. These assessments provide the foundation upon which the Patient Centered Care Plan is formulated." However, the facility did not follow both policies and procedures that addressed the need for the development of care plan.
On January 9, 2017, at 3:15 p.m., during a phone interview, the Director of Nurses (DON) stated in accordance to the facility's policy and resident's assessment information, there should have been a care plan specific for falls initiated when the resident was identified as a high risk for falls.
According to the Licensed Nurses Progress note dated December 7, 2016, at 8:00 p.m. Licensed Vocational 1 (LVN 1) responded to a report from Certified Nursing Assistant 1 (CNA 1). When entering the resident's room, LVN 1 found Resident 1 lying on the floor.
During an interview on December 27, 2016, at approximately 12 p.m., Registered Nurse 2 (RN 2), who was the Fall Coordinator, stated she was asked to assess Resident 1. According to RN 2, when she checked the bed-alarm after the resident had the fall, the bed-alarm was not turned on.
During a phone interview on January 4, 2017 at 9:30 a.m., CNA 2 stated on the night the resident had a fall, she heard Resident 1 calling for help while she was providing care to another resident next to Resident 1's room. When CNA 2 entered Resident 1's room, she found the resident on the floor lying on her back and she reported to LVN 1. CNA 2 stated she did not hear a bed-alarm sound.
During a phone interview on January 6, 2017, at 11:45 a.m., LVN 1 stated when she found Resident 1 on the floor, the resident was complaining of pain to her left hip. LVN 1 stated she did not hear the bed alarm prior to finding the resident on the floor. When asked who was responsible for ensuring the bed alarm was in working order, LVN 1 stated all nursing staff members are responsible for checking the bed alarms.
A review of the Situation, Background, Assessment, Recommendation form [SBAR- a format used for communication between members of the health care team] dated December 7, 2016, at 8:00 p.m. indicated LVN 1 responded to a report by CNA 1 that Resident 1 had a fall. When LVN 1 entered the resident's room, Resident 1 was lying on her back on the floor. RN 4 was paged and came and assessed the resident. Resident 1 complained she could not move her lower extremities due to a pain rated at 8/10 (10 being the most severe pain) to the left hip. According to the pain assessment tool, a pain level rating of 8/10 meant severe pain. The physician was notified and orders were obtained to administer pain medication (Norco tablet 5-325 milligrams) and to transfer Resident 1 to the GACH emergency room for further evaluation.
A review of the Nursing Home to Hospital Transfer Form dated XXXXXXX, 2016, 8:12 p.m., indicated Resident 1 was transferred to the GACH due to an injury from a fall. The transfer form indicated Resident 1 had a pain rated at 10/10 (very severe pain).
A review of the History and Physical (H&P) examination record obtained from the GACH dated December 8, 2016, indicated on XXXXXXX, 2016, Resident 1 was admitted to the GACH Emergency Department, and was diagnosed with status post ground-level fall with trauma, left hip fracture revealed by a CT scan [CT-Scan or CAT Scan- is best suited for viewing bone injuries, diagnosing lung and chest problems]. According to the H&P, Resident 1 also had left hip hematoma due to internal bleeding caused by the injury. Resident 1 was admitted to the GACH on XXXXXXX, 2016, and was treated for severe pain with long acting morphine and Percocet (narcotic medication to treat moderate to severe pain), a blood transfusion with one unit of packed red blood cell to replace blood loss, and intravenous fluid therapy.
According to readmission face sheet, Resident 1 was hospitalized for a total of five days and discharged to the SNF on XXXXXXX, 2016.
On December 27, 2016, at approximately 11:00 a.m., during an interview, RN 1 was unable to provide a care plan that was developed for the prevention of falls, prior to Resident 1's fall.
On December 27, 2016, at approximately 11:30 a.m., in the presence of RN 3, Resident 1 was observed awake in bed. Resident 1 was not able to recall the details of the fall during the interview.
The facility failed to prevent an injury from a fall for Resident 1 by failing to:
1. Monitor and provide close and frequent supervision to Resident 1 who had a history of falls and who was identified and assessed as being a high risk for falls.
2. Ensure that fall prevention measures ordered by the physician were implemented based on a plan of care with interventions that were known to all care givers.
3. Implement the physician order to apply a bed tab-alarm, and ensure the alarm was regularly checked to ensure it worked properly.
On December 7, 2016, Resident 1 had a traumatic fall resulting in a fracture to the left pelvis (the large bony structure near the base of the spine to which the legs are attached) and left hip including a hematoma (localized swelling that is filled with blood caused by broken blood vessels). Resident 1 was transferred to the GACH, hospitalized for five days and discharged back to the facility.
The above violations presented either an imminent danger that death or serious physical harm would result or a substantial probability that death or serious physical harm would result. |
| 920000302 |
WINDSOR TERRACE HEALTHCARE CENTER |
920013281 |
A |
23-Jun-17 |
B1UY11 |
13912 |
?483.24 Quality of life
Quality of life is a fundamental principle that applies to all care and services provided to facility residents. Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident?s comprehensive assessment and plan of care.
?483.25
(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 December 12, 2016, at 7:15 a.m., an unannounced visit was conducted at the facility to investigate an entity reported incident regarding Resident 1?s self-inflicting injury.
Based on interview and record review, the facility failed to ensure Resident 1, who had a history of suicidal ideation (thinking about, considering, or planning suicide), received adequate supervision and failed to ensure Resident 1?s environment remained free from accident hazards as possible to prevent injuries, including:
1. Failure to increase level of supervision (1:1 supervision) and provide suicide precautions (continuous interventions aimed at providing a safe environment for a person who might be thinking about or wanting to commit suicide) when Resident 1 was noted with low mood (change of behavior) on November 24, 2016 at 7 a.m. to 3 p.m. as ordered by the physician on November 21, 2016.
2. Failure to notify the Director of Nursing Services and Administrator when Resident 1 was observed to have a "low mood" on November 24, 2016 during 7 a.m., to 3 p.m. shift to identify if the change of behavior was acute depression associated with suicidality and to provide immediate intervention, including 1:1 supervision and potential discharge to an acute setting.
3. Failure to conduct an entire room search by no less than two staff members to remove potentially dangerous objects as stipulated in the suicide prevention policy and procedure dated July 2008.
These deficient practices resulted in Resident 1 successfully eloped out of the facility, tried to jump in front of a car and inflicted the following self-injuries, (cutting himself):
1. Left wrist, one, six centimeter (cm) laceration (cut) that required eight stitches, and one, four cm laceration that required six stitches.
2. Right wrist - one, three cm laceration that required two stitches and six superficial lacerations that were closed with Dermabond (a tissue adhesive that can be used to close easily approximated skin edges of wounds).
A review of Resident 1's general acute care hospital (GACH) History and Physical (H&P) dated November 4, 2016 indicated Resident 1 presented to the emergency room with altered mental status. The H&P indicated Resident 1 stated he took his whole bottle of methadone (an opioid medication used to treat severe pain and narcotic drug addiction). The H&P indicated Resident 1 had decreased sleep, decreased interest in life, felt guilty, and had positive suicidal ideation and plan. Resident 1 was admitted to the GACH, and was discharged to home on XXXXXXX 2016.
A review of Resident 1's admission record (Face Sheet) indicated Resident 1 was admitted from home to the facility on November 14, 2016 with diagnoses that included toxic encephalopathy (brain injury that may be caused by overdose), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), opioid (powerful pain-reducing medication) dependence, and anxiety disorder (mental illness that results in fear and worry about current and future events).
The Minimum Data Set (MDS - a standardized comprehensive assessment and care-screening tool), dated November 21, 2016, indicated that Resident 1's cognitive skills for daily decision-making were intact. Resident 1 was assessed with behavioral symptoms, including having little interest or pleasure in doing things; feeling down, depressed or hopeless; and having problems with sleep for several days during the last two weeks. The MDS indicated Resident 1 required limited assistance from staff with bed mobility, transfer, walk in room and corridor and extensive assistance with toilet use, personal hygiene and bathing.
A review of Resident 1's care plan initiated on November 14, 2016 for psychosocial well-being problems related to anxiety, depression, and toxic encephalopathy due to methadone overdose. The interventions included increase level of supervision/observation; monitor hourly for signs and symptoms of suicide or change of behavior and notify the medical doctor if any noted; and provide plastic utensils during meals as safety precaution.
A review of Resident 1's physician order dated November 15, 2016, at 4:35 p.m., indicated to increase level of supervision and suicide precaution; monitor for signs of suicide every two hours. If noted, notify medical doctor (MD) immediately.
A review of Resident 1's Psychiatry Evaluation dated November 17, 2016 indicated that Resident 1 was depressed, emotional and tearful, had paranoid delusions (belief that one is being watched, spied on, followed, poisoned or drugged) and had auditory hallucinations (hearing and responding to voices that are not there in reality).
A review of Resident 1's physician order dated November 21, 2016, at 11:30 a.m., indicated increase level of supervision and suicide precaution; monitor for signs of suicide every hour. If noted, to notify MD immediately.
A review of Resident 1's Medication Administration Record (MAR) from November 15 to 24, 2016, at 8 p.m., indicated that Resident 1 was being monitored for signs and symptoms of suicide every one hour.
A review of Resident 1's physician progress notes dated November 24, 2016 untimed indicated that a registered nurse reported that Resident 1 had episodes of low mood. The progress notes indicated that the patient (resident) was participating in PT (physical therapy), has good appetite, earlier refused meds (medications) but later took his meds, alert and denies any suicide ideation.
A review of Resident 1's nurses progress notes dated November 24, 2016 at 10:00 p.m. indicated around 9:15 p.m., the emergency exit door alarm went off. The notes indicated Resident 1 ran out of the facility with bloody wrists and 911 (emergency number to summon paramedics) was immediately called. The progress notes indicated that Resident 1 ran into the middle of the street and was trying to jump in front of a car. Resident 1 was taken to GACH by paramedics.
A review of Resident 1's GACH - Emergency Room (ER) notes dated November 25, 2016 at 12:15 a.m., indicated Resident 1 was found couple of blocks away from the facility with cuts on both wrists and with altered mental status. The notes indicated Resident 1 stated that he was trying to kill himself.
The ER Admission Summary indicated that Resident 1 had multiple lacerations to his both wrists.
1. Left wrist - one, six cm laceration that required eight stitches, and one, four cm laceration with bleeding that required six stitches.
2. Right wrist - one, three cm laceration that required two stitches and six superficial lacerations that were closed with Dermabond.
During an interview on May 3, 2017 at 9:31 a.m., Licensed Vocational Nurse 1 (LVN 1) stated that Resident 1 was on suicide precautions. According to LVN 1, on November 24, 2016, she was working from 7 a.m. to 3 p.m., shift. LVN 1 stated Resident 1 did not take his medications in the morning but took them later during a third attempt. LVN 1 explained that she was monitoring Resident 1 more closely because Resident 1 was ?Acting differently that day and something was wrong.? LVN 1 stated "I informed everyone that something is up and they were worried about him." LVN 1 stated that she told the doctor but she did not document this in the resident's clinical record. LVN 1 stated she informed the nurses of the 3:00 p.m., to 11:00 p.m. shift but she does not remember who the nurse was.
LVN 2 who cared for Resident 1 on November 24, 2016 during the 3:00 p.m., to 11:00 p.m. shift did not return calls after multiple phone calls. According to the Director of Staff Development, LVN 2 no longer works in the facility.
During an interview and review of Resident 1?s clinical records on May 3, 2017 at 10:20 a.m., the Director of Nursing (DON) stated it was the LVNs' responsibility to monitor and supervise the resident on suicide precaution. The DON explained that monitoring and supervising Resident 1 involved "doing more frequent rounds, involving the resident in activities, know where the resident is at all times, and watch for any kind of behavior that is unusual.? During an interview the DON was asked if Resident 1 level of supervision from hourly was changed to more frequent supervision and/or if the 1:1 supervision was provided to Resident 1, and if the suicide precaution was increased on November 24, 2016 when LVN 1 from 7 a.m., to 3 p.m., shift noted the change of behavior, the DON stated that on November 24, 2016, she was not notified that Resident 1 had change of behavior or acting differently that day. The DON was unable to provide information that Resident 1?s level of supervision and/or suicide precaution was increased on November 24, 2016 for 3 p.m. to 11 p.m., shift. The DON was not able to provide information that Resident 1?s room was searched in its entirety, to remove potentially dangerous objects.
During an interview on May 4, 2017 at 12:07 p.m., Certified Nurse Assistant 1 (CNA 1) stated that she was the regular assigned CNA to Resident 1. CNA 1 stated that on November 24, 2016, she provided Resident 1 with evening snacks. Then around 9:00 p.m., she was attending to another resident when she heard the alarm of the emergency exit door. CNA 1 stated the razor blade found in Resident 1's bathroom was yellow and was different from the kind of razor blade used at the facility.
On May 19, 2017, at 8:45 a.m., during an interview with 3 p.m. to 11 p.m., RN supervisor (RNS 1) stated that she was not aware that Resident 1 was on suicide precaution. RNS 1 stated she became aware on the day (November 24, 2016) of the incident of Resident 1 history of suicide attempt when she looked in Resident 1's clinical records, when the police needed information about Resident 1.
On May 19, 2017 at 9:40 a.m., during an interview, CNA 1 stated no one was assigned to stay with Resident 1 as a 1 to 1 supervision. CNA1 stated during 3 p.m., to 11 p.m., shift she usually takes care of no more than 11 residents.
According to the facility's July 2008, policy and procedures titled "Suicide Prevention" stipulated the interdisciplinary team will continually monitor residents for indicators of acute depression associated with suicidality and provide immediate intervention, including:
1. Any resident with a history of suicidal ideation, behavioral attempts or any sign and/or symptoms of acute (new) depression will be monitored for the recurrence of such signs and symptoms.
2. At such time that signs and symptoms of onset of acute depression/suicidal ideation/behavior are exhibited, the resident is to be placed on formal monitoring until evaluation by attending physician or a mental health professional may be arranged. Should the resident express an active, realistic plan of self-harm, or act a way as to harm self they are to be placed on an immediate 1:1 supervision. The Director of Nursing Services and Administration should be informed and consultation arranged for potential discharge to an acute setting.
3. A room search will be conducted to remove potentially dangerous objects, such as sharps, glass, call light electrical cords, belts, shoelaces, ties, combs, portable mirrors, shaving cream, and food and beverage items may need to be removed or temporarily confiscated for the resident's safety. The room will be searched in its entirety. The room search should be conducted by no less than two staff members.
4. Circumstances leading to the assessment, the risk factors identified during the assessment, interventions implemented to ensure safety and the plan for managing the risk are to be documented in the nursing section of the resident's clinical record.
The facility failed to ensure Resident 1, who had a history of suicidal ideation, received adequate supervision and failed to ensure Resident 1?s environment remained free from accident hazards as possible to prevent injuries, including:
1. Failure to increase the level of supervision (1:1 supervision) and provide suicide precautions when Resident 1 was noted with low mood (change of behavior) on November 24, 2016 at 7 a.m. to 3 p.m. as ordered by the physician on November 21, 2016.
2. Failure to notify the Director of Nursing Services and Administrator when Resident 1 was observed to have a "low mood" on November 24, 2016 during 7 a.m., to 3 p.m. shift to identify if the change of behavior was acute depression associated with suicidality and to provide immediate intervention, including 1:1 supervision and potential discharge to an acute setting.
3. Failure to conduct an entire room search by no less than two staff members to remove potentially dangerous objects as stipulated in the suicide prevention policy and procedure dated July 2008.
These deficient practices resulted in Resident 1 purposely inflicted self-injuries by cutting his left and right wrists which bled and needed stiches, successfully eloped out of the facility and tried to jump in front of a car.
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. |
| 920000302 |
WINDSOR TERRACE HEALTHCARE CENTER |
920013337 |
B |
14-Jul-17 |
GEJG11 |
6982 |
CFR 483.25 Quality of Care
Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care.
CFR 483.25(h) Free of Accident Hazards / Supervision/ Devices
The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents.
On 12/27/16, an unannounced visit was made to the facility to investigate a complaint regarding Quality of Care.
Based on interview and record review, the facility failed to ensure its residents 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, 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 physical limitations, was assisted by two staff when transferring from wheelchair to a shower chair as indicated in the comprehensive assessment.
2. Failure to ensure CNA 1 implemented Resident 1?s plan of care to transfer with two-person assistance.
As a result, on 10/21/16, Resident 1 fell when Certified Nursing Assistant 1 (CNA 1) attempted to transfer the resident from the wheelchair, causing Resident 1 to scream out and cry in severe back pain, and have continued pain to the lower back.
A review of the clinical record indicated Resident 1 was admitted to the facility on XXXXXXX 16, with diagnoses including stroke, right dominant sided hemiparesis (weakness/lack of movement on one side of the body), and difficulty walking.
A review of the History and Physical (H&P) examination, dated 8/29/16, indicated Resident 1 was alert and oriented with the capacity to understand and make decisions.
A plan of care dated on admission, 8/28/16, developed for Resident 1?s risk for falls / injury related to new environment, difficulty walking, and impaired physical mobility, indicated the resident required two-person assistance with transfers / mobility. The plan of care interventions included to provide a safe, hazard-free environment and to follow facility fall protocol.
Another plan of care developed on admission for Resident 1?s deficit in performing daily living activities related to his diagnoses, included in the interventions having two staff participate with Resident 1?s transfers and toilet use.
According to the Minimum Data Set (MDS - a standardized assessment and care planning tool), dated 9/8/16, Resident 1 was alert and oriented requiring extensive assistance with two or more person assistance with transferring from bed to chair, and transferring on and off the toilet.
A Progress Note, dated 10/21/16, timed at 5:45 p.m., indicated Resident 1 was being transferred to the shower chair by CNA 1 and the resident slid onto the floor during transfer. The physician was notified and ordered x-rays and to administer Dilaudid Solution (narcotic pain medication) 2 milligrams (mg) injection intramuscularly (IM) one time for severe pain which was given after the fall.
According to the Pain Assessment form, at the time of Resident 1?s fall on 10/21/16, the pain intensity was rated 10/10, on a pain scale level from zero to 10, with 10 being worst pain possible.
A review of the Medication Administration Record (MAR) dated 10/22/16 ? 10/27/16, indicated Resident 1 had a pain level rated between 6 and 9. The MAR dated from 10/29/16 ? 10/31/16, indicated Resident 1 had a pain level rated between 7-9 on the pain scale and was given Norco (used to relieve moderate to severe pain).
A review of the clinical record indicated Resident 1 had a Physician?s Order, dated 11/7/16, to receive Lyrica 75 mg twice per day for neuropathic pain. On 11/16/16 the physician?s order indicated to increase the Lyrica to 75 mg three times per day for neuropathic pain.
On 12/27/16, at 12:30 p.m., during an interview, Resident 1 stated she was sitting in her wheelchair and CNA 1 was going to sit her in the shower chair. The wheelchair and the shower chair were facing each other. CNA 1 positioned himself in between both the shower chair and the wheelchair, stood her (Resident 1) up in a bear hug and turned the resident around but half way through, CNA 1 was unable to keep her up and dropped her on the floor. Resident 1 stated she hit the wheelchair, fell on her buttocks and left back side, and started hollering in pain. Resident 1 stated she was currently having pain in her lower back, both wrists and the right shoulder.
On 12/27/16, at 3:45 p.m., during an interview, Staff 1 (physical therapy assistant) stated one the day of the incident, she was in the hallway and heard Resident 1 fall and holler out in pain. According to Staff 1, she went to the resident's room and observed Resident 1 on the floor crying and complaining of back pain. The resident had a small abrasion on her back and complained of pain in her back and left ankle.
On 12/28/16, at 9:30 a.m., during an interview, Licensed Vocational Nurse 1 (LVN 1) stated Resident 1 complained of back pain rated at a level of 10/10, the resident was screaming and crying in a lot of pain, even after the injection of Dilaudid.
The facility failed to ensure its residents 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, 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 physical limitations, was assisted by two staff when transferring from wheelchair to a shower chair as indicated in the comprehensive assessment.
2. Failure to ensure CNA 1 implemented Resident 1?s plan of care to transfer with two-person assistance.
As a result, on 10/21/16, Resident 1 fell when Certified Nursing Assistant 1 (CNA 1) attempted to transfer the resident from the wheelchair, causing Resident 1 to scream out and cry in severe back pain, and have continued pain to the lower back.
The above violations presented either an imminent danger that death or serious harm would result to Resident 1 therefrom, or substantial probability that death or serious physical harm would result to Resident 1 therefrom. |
| 940000019 |
WHITTIER HILLS HEALTH CARE CENTER |
940009045 |
B |
27-Feb-12 |
E8NU11 |
6522 |
?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: (6) To be transferred or discharged only for medical reasons, or the patient's welfare or that of other patients or for nonpayment for his or her stay and to be given reasonable advance notice to ensure orderly transfer or discharge. Such actions shall be documented in the patient's health record. On 10/17/11, at 1:25 p.m., an unannounced visit was made to the facility to investigate a complaint regarding Patient 1?s sudden discharge without preparation and without family notification and approval. Based on interview and record review, the facility failed to ensure Patient 1 had the right to be transferred only for medical reasons and be given reasonable advance notice for an orderly transfer by failing to: 1. Notify in advance the patient and the patient?s representative (Family Member A) of a transfer to another skilled nursing facility. 2. Allow the patient and Family Member A time to make an informed decision regarding the patient?s transfer. Patient 1 was sent to another facility without prior notice, preparation and the approval from the patient and Family Member A.According to Family Member A, she was informed on 9/30/11, at approximately 4:50 p.m., Patient 1 was in the process of being transferred to another skilled nursing facility due to the patient?s insurance coverage. Family Member A went immediately to the facility and did not agree to the transfer. However, a pre-arranged transportation was already waiting to transfer the patient, no alternative options were given and Family Member A had to allow the transfer.On 10/17/11, a review of the closed clinical record revealed Patient 1 was an 86-year old female admitted to the facility on 9/7/11, with diagnoses including atrial fibrillation (irregular heartbeat), hypertension (high blood pressure) and a history of falls. The physician?s history and physical examination dated 9/9/11, indicated the patient had the capacity to understand and make decisions. The patient?s medication regimen included daily use of the psychotropic (affect the mind) medications Aricept for dementia, Remeron for depression and Ativan for anxiety.A Physician?s progress note dated 9/9/11, indicated the patient lived alone and the plan was to discharge the patient early next week. The physician ordered the case manager (from the patient?s insurance agency) to contact the social worker regarding providing a caregiver at home for discharge planning next week. The Case Manager Notes form documented on 9/13/11, that the case manager (from the facility) was to meet with the patient?s family for discharge plans but Family Member A did not respond. Another entry dated 9/26/11, indicated a skilled nursing facility was contacted and declined to admit the patient. Another entry by the case manager dated 9/30/11, documented another skilled nursing facility had been contacted and agreed to admit the patient.A physician?s order dated 9/30/11, indicated to transfer the resident to the accepting skilled nursing facility on that same day.The Social Service Progress Notes dated 9/21/11, indicated the patient declined to initiate advanced healthcare directive and wanted Family Member A?s assistance with it. A last entry dated 9/28/11, indicated the patient met with the ombudsman and Family Member A and completed an advanced health care directive. The social services note did not address a discharge planning. According to the Advanced Health Care Directive completed and signed on 9/28/11, Patient 1 appointed Family Member A as her health care agent giving her the authority to make health care decisions starting on that date. A Licensed Nurses Progress Note dated 9/30/11, timed at 6:45 a.m., documented Family Member A visited the resident but did not address discharge planning. Another nursing note entry dated 9/30/11, at 7 p.m., documented the case manger had obtained a physician?s order for discharge and the patient was discharged in good conditions and with the patient?s belongings. Prior to this nursing note, there was no documentation the nurses were working with the patient and Family Member A in a discharge plan.The facility?s policy and procedure on Discharge or Transfer, revised 5/2001, indicated the facility will provide a safe organized structured transfer from the facility; a planned transfer included to keep the patient/family involved with all discharge planning and to document the entire process in the nursing notes.Further record review revealed no documented evidence Patient 1 and Family Member A, were informed in advance of the transfer and given the opportunity to evaluate the facility were the patient would be residing, including the location and other pertinent information in order to make an informed decision. On 10/17/11, at 3:10 p.m., during an interview, the administrator stated it was difficult to find a facility that accepted the patient?s specific insurance and once the facility was found, on 9/30/11, the patient was asked and she agreed. The administrator further stated Family Member A came to the facility and did not agree with transferring the patient but was explained it was better to take advantage of the opportunity at that time because it would be hard to find another place, then Family Member A agreed to the transfer. The administrator stated the patient could have stayed in the facility if they wanted to.The facility failed to ensure Patient 1 had the right to be transferred only for medical reasons and be given reasonable advance notice for an orderly transfer by failing to: 1. Notify in advance the patient and the patient?s representative (Family Member A) of a transfer to another skilled nursing facility. 2. Allow the patient and Family Member A time to make an informed decision regarding the patient?s transfer. Patient 1 was sent to another facility without prior notice, preparation and approval from the patient and Family Member A. The above violation had direct or immediate relationship to the health, safety, or security of Patient 1. |
| 940000019 |
WHITTIER HILLS HEALTH CARE CENTER |
940009046 |
B |
27-Feb-12 |
E8NU11 |
11724 |
1289.4 Theft and loss program ?A theft and loss program shall be implemented by the long-term health care facilities within 90 days after January 1, 1988. The program shall include all of the following:(a) Establishment and posting of the facility's policy regarding theft and investigative procedures.(b) Orientation to the policies and procedures for all employees within 90 days of employment.(c) Documentation of lost and stolen patient property with a value of twenty-five dollars ($25) or more and, upon request, the documented theft and loss record for the past 12 months shall be made available to the State Department of Health Services, the county health department, or law enforcement agencies and to the office of the State Long-Term Care Ombudsman in response to a specific complaint. The documentation shall include, but not be limited to, the following:(1) A description of the article.(2) Its estimated value.(3) The date and time the theft or loss was discovered.(4) If determinable, the date and time the loss or theft occurred.(5) The action taken.(d) A written patient personal property inventory is established upon admission and retained during the resident's stay in the long-term health care facility. A copy of the written inventory shall be provided to the resident or the person acting on the resident's behalf. Subsequent items brought into or removed from the facility shall be added to or deleted from the personal property inventory by the facility at the written request of the resident, the resident's family, a responsible party, or a person acting on behalf of a resident. The facility shall not be liable for items which have not been requested to be included in the inventory or for items which have been deleted from the inventory. A copy of a current inventory shall be made available upon request to the resident, responsible party, or other authorized representative. The resident, resident's family, or a responsible party may list those items which are not subject to addition or deletion from the inventory, such as personal clothing or laundry, which are subject to frequent removal from the facility.(e) Inventory and surrender of the resident's personal effects and valuables upon discharge to the resident or authorized representative in exchange for a signed receipt.(f) Inventory and surrender of personal effects and valuables following the death of a resident to the authorized representative in exchange for a signed receipt. Immediate notice to the public administrator of the county upon the death of a resident without known next of kin as provided in Section 7600.5 of the Probate Code.(g) Documentation, at least semiannually, of the facility's efforts to control theft and loss, including the review of theft and loss documentation and investigative procedures and results of the investigation by the administrator and, when feasible, the resident council.(h) Establishment of a method of marking, to the extent feasible, personal property items for identification purposes upon admission and, as added to the property inventory list, including engraving of dentures and tagging of other prosthetic devices.(i) Reports to the local law enforcement agency within 36 hours when the administrator of the facility has reason to believe patient property with a then current value of one hundred dollars ($100) or more has been stolen. Copies of those reports for the preceding 12 months shall be made available to the State Department of Health Services and law enforcement agencies.(j) Maintenance of a secured area for patients' property which is available for safekeeping of patient property upon the request of the patient or the patient's responsible party. Provide a lock for the resident's bedside drawer or cabinet upon request of and at the expense of the resident, the resident's family, or authorized representative. The facility administrator shall have access to the locked areas upon request.(k) A copy of this section and Sections 1289.3 and 1289.5 is provided by a facility to all of the residents and their responsible parties, and, available upon request, to all of the facility's prospective residents and their responsible parties.(l) Notification to all current residents and all new residents, upon admission, of the facility's policies and procedures relating to the facility's theft and loss prevention program. On 10/17/11, at 1:25 p.m., an unannounced visit was made to the facility to investigate a complaint regarding the facility?s lack of investigating and reporting misappropriation of Resident 1?s property. Based on interview and record review, the facility failed to implement its theft and loss program by failing to: 1. Thoroughly investigate a report of a lost and stolen resident?s property. 2. Update the written inventory of personal property when a handbag with a wallet was brought into the facility. 3. Report within 36 hours to the local law enforcement agency, state agency and ombudsman, a loss of resident property with a value of over one hundred dollars ($100). Resident 1 lost her wallet with several credit cards, social security card and a check book, which resulted in fraudulent charges of over $3,000.00. According to the complaint, Resident 1?s handbag with a wallet containing several credit cards, a social security card and a check book was brought by a resident?s friend sometime after admission to the facility. Family Member A visited the resident on 9/15/11, and saw the blue handbag with its content and asked Certified Nursing Assistant 1 (CNA 1) and Registered Nurse 1 (RN 1) to include the items in the inventory list; however, this was not done. On 9/16/11, a Saturday, Family Member A returned to the facility to find the handbag and the wallet with its contents were missing. Family Member A immediately reported the missing items to several staff members and was told it was probably in the social service?s office. On 9/19/11, Monday, the handbag (a blue bag) was returned without the wallet. The facility did not investigate the lost/stolen wallet and did not make a report to the police. Between 9/15/11 and 9/22/11, (when the accounts were closed) Resident 1 had charges in at least 10 credit cards, a new credit card was opened using her name and at least one check was written and cashed, for total charges of over $3,000.00. Family Member A made a police report on 9/29/11. On 10/17/11, a review of the closed clinical record revealed Resident 1 was an 86-year old female admitted to the facility on 9/7/11, with diagnoses that included atrial fibrillation (irregular heartbeat), hypertension (high blood pressure) and a history of falls. The physician?s history and physical examination dated 9/9/11, indicated the resident had the capacity to understand and make decisions. The medication regimen included daily use of the psychotropic (affect the mind) medications Aricept for dementia, Remeron for depression and Ativan for anxiety.The facility?s Theft and Loss policy and procedure, revised 11/2007, indicated the purpose was to provide a theft and loss program which protects and conserves residents, facility, visitors and employee property. A loss or theft of a property worth more than $25.00 will be documented and submitted to the administrator for investigation, police reporting or other appropriate action. A written resident personal property inventory must be recorded on appropriate form upon the resident?s admission and maintained current by noting all items being added or deleted by the written request of the resident or the person acting upon the resident?s behalf. If we (the facility) have the reason to believe that resident property more than $100.00 has been stolen, we (the facility) must report the theft to local law enforcement within 36 hours of discovery. According to the facility?s policy on Investigating Misappropriation of Resident Property, revised 10/2007, noted reports of misappropriation of resident property shall be promptly and thoroughly investigated. The procedures included when an incident of misappropriation of resident property is reported, the administrator will appoint a staff member to investigate the incident. The investigation consists of interviews with person(s) reporting the missing items, with witnesses, with the resident, with the employee(s) accused, with staff members from all shifts having contact with the resident, with the roommate, family and visitors. The results of the investigation will be reported to the administrator within five working days of the reported incident. Should the investigation reveal the suspected or actual misappropriation of property occurred, the administrator will report such findings to the resident?s representative, the local police department, the ombudsman, and the state licensing agency.The facility?s policy on Inventory of Personal Effects, revised 5/2007, indicated the policy was to take reasonable steps to protect the personal property of the residents. The procedures included when any personal item is brought into the facility after admission, the item shall be recorded, dated, and signed by the staff member on the Inventory of Personal Effects form. The Inventory of Resident?s Belongings form dated on admission 9/7/11, did not include the handbag and wallet brought to the facility on 9/15/11. The form had an entry dated 9/19/11, documenting a blue bag containing keys and a phone book was returned to Family Member A. A Theft and Loss Report form, documented Family Member A reported the missing items on 9/19/11, at 10 a.m., and Family Member A had last seen the items on 9/15/11. The report had an entry dated 9/22/11, indicating social services followed up with laundry and no items were found. The report also indicated the items were searched for in the resident?s room and the CNA and supervisor were notified.There was no documented evidence a thorough investigation was conducted, and there was no evidence staff members or any witnesses were interviewed.There was no documented evidence the theft/loss of the resident?s valuables were reported to the local police department, the ombudsman, or the state licensing agency.On 10/26/11, at 11:15 a.m., during a telephone interview, CNA 1stated on 9/15/11, she observed Family Member A going through the blue handbag and did not know if there was a wallet inside the bag. CNA 1 further indicated she was not aware what was listed in the resident?s inventory list. On 10/26/11, at 11:27 a.m., during a telephone interview, RN 1 stated she remembered the resident wanted to keep the wallet with her. RN 1 stated that Family Member A showed her and a CNA the contents of the bag; however, she did not remember if Family Member A asked her to include the wallet in the inventory list. RN 1 further stated she was never asked by the administrator or other staff member about the wallet.The facility failed to implement its theft and loss program by failing to: 1. Thoroughly investigate a report of a lost and stolen resident?s property. 2. Update the written inventory of personal property when a handbag with a wallet was brought into the facility. 3. Report within 36 hours to the local law enforcement agency, state agency and ombudsman, a loss of patient property with a value of over $100. Resident 1 lost her wallet with several credit cards, social security card and a check book, which resulted in fraudulent charges of over $3,000.00. The above violation had direct or immediate relationship to the health, safety, or security of Resident 1. |
| 940000111 |
WINDSOR PALMS CARE CENTER of ARTESIA |
940009064 |
B |
06-Mar-12 |
MOG811 |
7642 |
? 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: (5) To receive all information that is material to an individual patient's decision concerning whether to accept or refuse any proposed treatment or procedure. The disclosure of material information for administration of psychotherapeutic drugs or physical restraints or the prolonged use of a device that may lead to the inability to regain use of a normal bodily function shall include the disclosure of information listed in Section 72528(b). ? 72319. Nursing Service-Restraints and Postural Supports. (b) Restraints shall only be used with a written order of a physician or other person lawfully authorized to prescribe care. The order must specify the duration and circumstances under which the restraints are to be used. Orders must be specific to individual patients. In accordance with Section 72317, there shall be no standing orders and in accordance with Section 72319(i)(2)(A), there shall be no P.R.N. orders for physical restraints.On 12/6/11, at 1:25 p.m., an unannounced visit was made to the facility to investigate an entity report regarding Patient 1?s unexplained injuries. Based on observation, interview and record review, the facility failed to ensure Patient 1 had the right to be free from any physical restraint without a physician?s order by failing to: 1. Implement policies and procedures on physical restraint in assessing the patient?s needs and medical symptoms warranting the use of a soft waist belt restraint while asleep in bed. 2. Implement policies and procedures on physical restraints in obtaining a signed informed consent with documented justification and an explanation of potential benefits and risks. 3. Obtain a physician?s order for the use of the soft waist belt restraint. Patient 1 sustained red marks across the waist and both hips.A review the clinical record revealed Patient 1 was a 70 year-old male admitted to the facility on 11/2/11, with diagnoses including dementia (a deterioration of memory, language, perception, and judgment) and paranoid schizophrenia (a chronic mental illness in which a person losses touch with reality). The admission face sheet indicated the patient was self-responsible and had no contact person listed. The admission Minimum Data Set (MDS - standardized assessment and care planning tool) dated 11/9/11, indicated the patient was severely impaired in cognitive skills for daily decision-making, had unclear speech and rarely or never understood. The patient did not walk, required extensive assistance in bed mobility, transfer, eating and personal hygiene; and was totally dependent on staff for dressing, toilet use and bathing. The physician?s orders dated 11/3/11, included the use of a wheelchair and a bed alarm to alert staff, fall precautions and two oral routine antipsychotic medications (Depakene and Haldol) for psychosis manifested by sudden angry outburst, resistive to care, combative and striking out and physical restlessness. There was no physician?s order for the use of physical restraints (soft waist belt). According to a change of condition form, on 11/26/11, at 8 a.m., Certified Nursing Assistant 1 (CNA 1) reported the patient was found with bumps and bruises on the right cheekbone, the right eyebrow and the right knee. The patient also had red marks on both hips and across the waist. The patient was confused and had no discomfort/pain. At 1:30 p.m., the patient was transferred to an acute hospital via paramedics due to altered level of consciousness. The patient returned to the facility on 11/30/11. According to the facility?s investigation report, CNA 3 and CNA 4, who worked the 11 p.m. to 7 a.m. shift, stated on 11/25/11, the patient was wearing a soft waist restraint when they first took care of the patient and they removed the restraint before the end of the shift at 5:30 a.m. CNA 3 and CNA 4 denied seeing any redness or bumps on the patient. CNA 2, who worked the evening shift, 3 p.m. to 11 p.m., on 11/25/11, denied placing a soft waist restraint on the patient and stated she only applied the bed alarm. The investigation report indicated a soft waist belt was applied by someone before the 11 p.m. to 7 a.m. shift without a physician?s order and the CNAs continued to keep the soft waist belt during the night until 5:30 a.m. The report indicated the redness area to the lower abdominal area and hips may have been caused by the soft waist belt. On 12/6/11, at 2 p.m., during an interview, CNA 1 stated she observed red marks similar to belt straps on the patient?s hips during the first incontinent brief change on the morning of 11/26/11. CNA 1 also stated the patient only had a tab alarm to alert staff whenever the patient tried to get out of the bed or the wheelchair and did not wear a soft waist belt restraint. On 12/6/11, at 1:30 p.m., Patient 1 was observed in bed with slight discoloration (fading purplish color) to the right temple area and right cheek. The patient was unable to participate in an interview.On 12/6/11, at 3:50 p.m., during an interview, CNA 2 denied applying a restraint to the patient. On 12/7/11, at 8:55 a.m., during an interview, CNA 3 stated together with CNA 4, they entered the resident?s room around 11:05 p.m. to 11:10 p.m., on 11/25/11, to perform their first round at the beginning of their shift. CNA 3 further stated when they uncovered the resident he was wearing a brown soft waist belt restraint tied underneath the bed frame and it was not removed until 5:30 a.m. on 11/26/11. According to the facility?s policy and procedure titled, ?Physical Restraint,? dated 11/23/06, prior to the use of any restraint, the Interdisciplinary Team (IDT) will assess the resident to properly identify the patient?s needs and medical symptom warranting restraint use. The facility?s policy and procedure also indicated when a restraint is used, a physician?s order must contain the following elements: type of restraint ? waist, limb, geri-chair, side rail; medical reason/symptom that indicate the restraint use; circumstances in which restraint is to be used; and release exercise statement with time frames. Also, a Physical Restraint Informed Consent must be completed. However, record review revealed no documented assessment by the IDT for the patient?s need of a soft waist belt restraint and there was no informed consent obtained from the patient/responsible party to apply the soft waist belt restraint. The facility failed to ensure Patient 1 had the right to be free from any physical restraint without a physician?s order by failing to: 1. Implement policies and procedures on physical restraint in assessing the patient?s needs and medical symptoms warranting the use of a soft waist belt restraint while asleep in bed. 2. Implement policies and procedures on physical restraints in obtaining a signed informed consent with documented justification and an explanation of potential benefits and risks. 3. Obtain a physician?s order for the use of the soft waist belt restraint. Patient 1 sustained red marks across the waist and both hips.The above violation had direct or immediate relationship to the health, safety, or security of Patient 1. |
| 940000112 |
WOODRUFF CONVALESCENT CENTER |
940009383 |
B |
02-Jul-12 |
X8UW11 |
7256 |
F-323 CFR 483.25 (h) AccidentsThe 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. On 5/11/12, at 12:45 p.m., an unannounced visit was made to the facility to investigate an entity reported incident regarding Resident 1's fall with injury during a transferring procedure. On 5/8/12, Resident 1 sustained a posterior head laceration that required transfer to an emergency room where four staples were applied.Based on observation, interview and record review, the facility failed to ensure Resident 1 received adequate supervision and assistance devices to prevent accidents and injuries by failing to: Train in the safe operating use of a mobility device the staff members assisting the resident with transferring. Resident 1 fell on the floor when the harness (applied to the upper body to keep the resident safely in position) became loose and went over the resident's head. The resident sustained a laceration to be back of the head that required four staples. On 5/11/12, at 12:45 p.m., an unannounced visit was made to the facility to investigate a self-reported incident regarding Resident 1's fall with injury during a transferring procedure. On 5/8/12, Resident 1 sustained a posterior head laceration that required transfer to an emergency room where four staples were applied. The resident returned back to the facility on the same day. A review of the clinical record revealed the resident was readmitted to the facility on 9/20/11, with diagnoses that included diabetes mellitus, morbid obesity (excessive overweight), hypertension, dizziness and weakness. The quarterly Minimum Data Set (MDS - standardized assessment and care planning tool) dated 10/2/11, indicated the resident was oriented, had some memory recall deficit, was able to communicate her needs, required extensive assistance with two or more persons physical assist with transfer and walking and extensive assistance with one person physical assist with bed mobility, locomotion dressing, toilet use and personal hygiene.The resident was assessed as having unsteady balance when moving from seated to standing position, turning around, moving on and off the toilet and when transferring from surface to surface. According to the Weight Record form, on 4/7/12, the resident weighed 312 pounds. A plan of care developed on 10/2/11, for the resident's impaired physical mobility and risk for fall/injury, had a goal for the resident to be free from falls and injuries. The interventions included to utilize an assistive device during care, a mechanical device for transfers. A Discharge Body Check form dated 5/8/12, indicated the resident sustained a head laceration measuring 3 centimeters (cm) by 0.7 cm. The resident returned with the laceration closed with four staples. According to the facility's investigation report dated 5/9/12, on 5/8/12 at 6:30 p.m., after the resident used the toilet, two certified nursing assistants (CNAs 1 and 2) assisted the resident going out of the bathroom using the EZ Stand (a device designed to assist with transfers and ambulation). A harness is applied around the resident's upper body with harness loops attached to the stand and the resident holds onto the stand handles. The EZ Stand requires the resident to follow directions and have upper body strength. The investigation report further documented the resident was lifted up with the EZ Stand to transfer her back to the wheelchair but the resident's hands slipped from the handles, resulting in the resident losing her balance and hitting her head on the floor. The resident sustained a laceration on the back of the head and was sent to an emergency room for evaluation and treatment. She returned back to the facility on the same day at 11 p.m. The investigation report did not explain why the resident fell, did not address the application of a harness, if the technique used by the staff was adequate or if there was a device malfunction. According to the EZ Way Smart Stand Operator's Instructions Manual, the stand has padded handles for the resident to hold on to during the standing procedure and the feet are placed on the adjustable foot plate. A harness is applied around the upper body so the sides of the harness are between the resident's torso, resting two to three inches below the underarms. The harness has a safety strap with a buckle to be securely fastened around the torso. The harness has loops on each side that are attached to two hooks at each side the stand. The manufacturer's recommended for safe operation of the EZ Way Smart Stand, operators should watch a training video, read through the manual, complete the competency checklist and practice on fellow staff members before use with patients. On 5/11/12, at 1 p.m., during an interview, Register Nurse 1 (RN 1) could not explain the resident's fall if the harness was secured and proper technique had been implemented. RN 1 could not provide evidence CNAs 1 and 2 had received training in the use of the lift. The personnel files of CNAs 1 and 2 lacked documentation of training related to the use of the lift.On 5/11/12, at 2:10 p.m., during observation of the lift and an interview, the resident stated the CNA (CNA 1) positioned her in the lift, with her feet on the base (foot plate) with the harness around her waist and she was holding the handles. The resident explained when she reached the standing position, CNA 1 moved the lift out of the restroom and before sitting in the wheelchair, the resident's hands slipped off the handles, the harness traveled up her back and over her head and then she fell on the floor hitting her head. On 5/18/11, at 11:40 a.m., during a telephone interview, CNA 1 confirmed she positioned the resident on the lift and was operating it while CNA 2 was outside the restroom holding the wheelchair. CNA 1 stated she had done the procedure multiple times with the resident and other residents and could not explain what went wrong. CNA 1 indicated the harness did not break and the buckle was not damaged. CNA 1 could not ascertain she buckled the harness. Furthermore, CNA 1 stated she did not receive training from the facility in operating the EZ Stand lift but had learned how to use it in another facility.On 5/30/12, at 3:10 p.m., during a telephone interview, CNA 2 stated she did not see how CNA 1 secured the harness. CNA 2 also indicated that prior to the incident she had not received instructions on the use of the lift. The facility failed to ensure Resident 1 received adequate supervision and assistance devices to prevent accidents and injuries by failing to: Train in the safe operating use of a mobility device the staff members assisting the resident with transferring. Resident 1 fell on the floor when the harness (applied to the upper body to keep the resident safely in position) became loose and went over the resident's head. The resident sustained a laceration to be back of the head that required four staples.The above violation had a direct or immediate relationship to the health, safety or security of Resident 1. |
| 940000019 |
WHITTIER HILLS HEALTH CARE CENTER |
940009481 |
A |
11-Sep-12 |
1O8611 |
13396 |
Based on a resident's comprehensive assessment, the facility must ensure that a resident - (1) Maintains acceptable parameters of nutritional status, such as body weight and protein levels, unless the resident's clinical condition demonstrates that this is not possible; and (2) Receives a therapeutic diet when there is a nutritional problem. Based on interview, closed record review, and the acute hospital record review, the facility failed to ensure Resident 1 maintained his body weight, by not: 1. Addressing the resident's weight loss and revising the plan of care. Resident 1, who had dementia (a decline in reasoning, memory, and other mental abilities), required total assistance with all activities of daily living (ADLs), including eating.These failures of not revising a plan of care to address the resident's weight loss and providing adequate nutrients resulted in Resident 1 losing 35 pounds (lbs.) in 32 days and compromised Resident 1's nutritional status, while in the skilled nursing facility (SNF). On May 14, 2012, a review of Resident 1's Admission Record (face sheet) indicated the resident was an 86 year-old male admitted to the facility on February 25, 2012. Resident 1, who had a diagnoses of Alzheimer's disease (a form of dementia that gradually gets worse over time, affecting memory, thinking, and behavior), history of falls, congestive heart failure ([CHF], a buildup of excess fluid around the heart and in the lungs), and after care for a healing traumatic fractured hip.A review of a care plan dated February 25, 2012, titled, "Altered Nutrition and Hydration Status" related to the resident's diagnosis of dementia, decreased feeding skills, reported intake of 75%, and poor appetite, indicated the resident's goal was to achieve adequate nutritional intake at least 75% each meal and without any significant weight changes of 5% or more per month. The staff 's approaches included allowing sufficient time for the resident to chew, notify physician of weight loss, and the registered dietitian (RD) to assess the resident 's nutritional status. On May 14, 2012, a review of a Minimum Data Set (MDS), a standardized assessment and care screening tool, dated March 27, 2012, indicated the resident was confused with poor memory and required total assistance from the staff with all activities of daily living (ADLs). According to the MDS, the resident's admission weight was 157 lbs. The resident's Monthly Weight Record indicated the resident weighed 157 lbs. on February 27, 2012 and March 1, 2012. The facility's RD initial assessment note, dated February 27, 2012 indicated the resident weighed 157 lbs. and had a height of 65 inches upon admission. The assessment indicated the resident was confused and non-expressive. The resident was initially started on a no added salt (NAS), low fat/cholesterol diet. Then on March 1, 2012, per the RD recommendation, the resident's diet was changed to fortified NAS and with 2 Cal/HN 90 ml by mouth to be given three times a day during the medication pass. Another RD entry, dated March 1, 2012, indicated Resident 1's caloric requirement was estimated to be 1700 calories per day, 70-90 grams of protein per day, and approximately 2000 milliliter (ml) of fluid per day. The RD made a recommendation to add 90 ml. (three ounces) of 2 CAL HN (a dietary supplement), three times a day by mouth. The physician ordered the dietary supplement for the resident on March 1, 2012. Another RD note, dated March 7, 2012, indicated the resident weighed 147 lbs., a weight loss of 10 lbs. in 12 days. The RD recommended and the physician ordered the resident to receive a Magic Cup, (a frozen liquid supplement that provides 290 calories and 9 grams of protein) twice a day with lunch and dinner.A review of a history and physical (H/P), dated March 8, 2012, indicated the physician documented Resident 1 was confused with advanced dementia. The physician documented under WT: "As per chart." There was no further documentation of the resident weight on the H/P. On May 14, 2012, a review of another physician's note (Ortho), dated March 13, 2012, indicated the resident was two weeks post-op surgery and doing well. However, the resident had lost 12 lbs. in the last 17 days since admission and there was no mention of the resident's weight loss. According to the clinical record, on March 13, 2012, the RD assessed the resident again and documented that the resident continued to lose weight, weighing 145 lbs. and the RD recommended to continue with the current interventions. According to the "Weight Monitoring Record" Resident 1 was last weighed on March 19, 2012, weighing only 135 lbs. There were no further weights recorded prior to the resident being transferred to a board and care facility (B/C), on March 27, 2012. According to Resident 1's Weight Record the following was indicated: On February 27, 2012, the resident weighed 157 lbs. On March 7, 2012, the resident weighed 147 lbs. (10 lbs. and 6.4% weight loss over 9 days). On March 13, 2012, the resident weighed 145 lbs. (12 lbs. and 7.6% weight loss over 15 days). On March 28, 2012, the resident weighed 122 lbs. (according to the general acute record), which was 35 lbs. and 22% weight loss over 32 days. According to the State Operations Manual, a severe weight loss is considered to be greater than 5% in one month. The RD's note, dated March 20, 2012, indicated the resident weighed 135 lbs. with a total weight loss of 22 lbs. since admission and a 10 lb. weight loss in the past week. The RD documented the resident had a very poor intake and was unable to state food preferences. The RD recommended a complete metabolic panel ([CMP], lab work that is an indicator of health and nutritional status).According to the CMP drawn on March 21, 2012, the residents' blood-urea-nitrogen level (BUN) was 76 mg/dl. (normal reference range of 8 mg/dl-26 mg/dl), creatinine level of 2.5 mg/dl (normal reference range of 0.70 mg /dl-1.20 mg/dl), sodium level of 167 mg/dl (normal reference range of 135 mg/dl-145 mg/dl), and a chloride level of 130 mg/dl (normal reference range of 101 mg/dl-111 mg/dl). However, a review of the general acute care hospitals' (GACH) Admission History and Physical, dated February 21, 2012 (four days prior to the resident's admission to the SNF), indicated the resident's laboratory data was within a normal range as following: sodium was 141, potassium 3.8, chloride 109, BUN 28, and with a creatinine of 1. According to GLOBALRPh, the Clinician's Ultimate Guide, elevated BUN and creatinine levels are indicative of someone in renal failure (). There was no documented evidence any other interventions were recommended and/or ordered for the resident's poor nutritional intake and weight loss. On May 14, 2012, a review of a nurses' note, dated March 21, 2012, indicated the resident had a 10 lb. weight loss and the resident's physician was notified without any new orders. There was no further documentation related to the resident's weight loss or new interventions. A review of a Change of Condition Report, dated March 25, 2012, indicated Resident 1 continued to refuse to eat breakfast and lunch, with a food intake of 25% in the last 24 hours, the report indicated the resident does take fluids. On the report, under Objective/underlying illness/Dx: Weight Variance was one of the choices, but was not checked, indicating the facility failed to place the resident on a weight variance although he was losing so much weight. The record indicated the nurse explained to the resident the risks and benefits of not eating. The report indicated both the resident's physician and responsible party were notified of the resident's refusal to eat. However, the resident's weight loss was not documented on the report. A review of Resident 1's Breakfast/Lunch/Dinner Record, during the months of February and March 2012, indicated the resident had eaten 45% of offered breakfasts, 32% of offered lunches, and 31% of offered dinners. From March 23, 2012 to March 27, 2012 the resident had refused four of the five breakfasts, three of the four lunches, and two of the four dinners. The feeding record indicated the resident refused breakfast five of seven times during the last seven days he was in the facility and ate only 30 % of his offered breakfast meals the other two days. He refused lunch four of the last seven days he was in the facility and ate only 20% of his offered lunch the other three days. The last seven days Resident 1 was in the facility, he refused to eat dinner for two days and ate an average of 35% of his dinner the other five days, prior to being discharged to a board and care facility. On May 15, 2012, at 8:30 a.m., during a telephone interview, the resident's family member stated the resident did not eat or drink well while in the facility.On May 16, 2012, at 9:40 a.m., during an interview, the director of nurse (DON) stated she was not aware the resident was not eating and had a significant weight loss with abnormal labs.On May 18, 2012, at 8:10 a.m., while she read her March 20, 2012 note, the RD stated the family was difficult to work with. She stated multiple diets and snacks were tried. The RD stated the certified nursing assistant (CNAs) were directed to encourage and assist the resident to eat. The RD stated she ordered lab work on March 20, 2012, to assess the resident's nutritional status after the resident had loss so much weight in one week (10 lbs.) and considered a possible intervention of a feeding tube placement. The RD documented under her plan to clarify the resident/family's desires regarding enteral feeding (being fed by a feeding tube). However, there was no further follow-up regarding the enteral feedings. The RD was questioned about this and stated, "I thought the nurses would follow-up with the family about a placement of a G-tube, I don't know what happened." There was no further documentation in the resident's clinical record about the resident's significant weight loss. An interview on May 18, 2012, at 10:05 a.m., a licensed vocational nurse (LVN 1) stated the resident did not eat well, but took fluids. LVN 1 stated she explained the risks and benefits of not eating to the resident. When she was asked how she communicate that information to the resident she stated, "I know he does not understand, was non-verbal, and did not communicate." LVN 1 stated she did speak to the resident's family and the physician about the risks of the resident not eating. However, there was no documented evidence LVN 1 had spoken to the resident's family or the physician and there was no follow-up. According to a "Licensed Nurses Discharge Progress Note," dated March 27, 2012, at 11:30 a.m., Resident 1 was discharged to a board and care facility. On May 18, 2012, a review of a paramedic run sheet, dated March 27, 2012, and timed at 7:30 p.m., indicated the resident was observed at the board and care with an altered level of consciousness (ALOC). According to the paramedic run sheet, the paramedics were told the resident had not eaten or drank anything since Friday, March 23, 2102, a period of four days. According to the GACHs' record, dated March 28, 2012, at 12:45 a.m., Resident 1's admission weight was 55.5 kg (122 lbs.) which was an additional weight loss of 13 lbs. (from the last time the resident was weighed in the SNF on March 19, 2012) for a total weight loss of 35 lbs. in 33 days.According to GACH discharge summary, dated April 18, 2012, the resident's admitting diagnosis was dehydration (inadequate fluid in the body), renal failure (the kidneys are not functioning), and hypernatremia (high levels of sodium in the blood). The resident was fed in the GACH with enteral feedings with a nasogastric tube (NGT/ the insertion of a plastic tube placed through the nose, past the throat, and down into the stomach). A review of the facility's policy and procedure, titled, Care and Treatment/ Nutrition, revised May 5, 2012, indicated the facility would ensure all residents will maintain acceptable parameters of nutritional status, such as body weight and protein levels. It also indicated that significant weight loss (5% in one month) should be addressed in the care plan. Under Clinical Evaluation, it indicated any resident with a weight that varies from the previous period by 5% in 30 days will be evaluated by the inter-disciplinary team to determine the cause of the weight loss and interventions required. However, a review of the resident's two IDT meetings, conducted on March 9, 2012 and March 16, 2012, did not contain documentation regarding the resident's significant weight loss.The above violation presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would and did result to Resident 1. The facility failed by not: 1. Addressing the resident's weight loss and revising the plan of care. Resident 1, who had dementia (a decline in reasoning, memory, and other mental abilities), required total assistance with all activities of daily living (ADLs), including eating.The above violation presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would and did result to Resident 1. |
| 940000019 |
WHITTIER HILLS HEALTH CARE CENTER |
940009482 |
B |
11-Sep-12 |
1O8611 |
14167 |
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 Department received a complaint on May 4, 2012, alleging a resident (Resident 1) was discharged in a very poor condition with renal failure and severe dehydration. The complainant also alleged the resident was transferred to a general acute care hospital (GACH) ?within six hours? after discharge from the skilled nursing facility (SNF). A complaint investigation was conducted on May 14, 2012. Based on interviews, a closed record review, and review of the GACH?s clinical record, the facility failed to ensure: Resident 1?s transfer and discharge was appropriate and the residents? health had improved and no longer needed the services provided by the facility.These failures resulted in Resident 1 being transferred to a board and care (B/C) and within eight hours of being transferred the resident had an altered level of consciousness (ALOC) and was transferred to a general acute care hospital (GACH), placed in the intensive care unit (ICU) and required many dialysis treatments (mechanical filtering of the blood).On May 14, 2012, a review of Resident 1?s SNF medical record indicated the resident was an 86 year-old male who was admitted to the facility on February 25, 2012. The residents' diagnoses included a history of a fall with a traumatic right hip fracture, status post (S/P) open reduction and internal fixation (ORIF/ surgically opening the hip, and using metal plates, screws and/or rods to repair the fracture), Alzheimer's disease (a form of dementia that gradually gets worse over time, affecting memory, thinking, and behavior), and congestive heart failure ([CHF], a buildup of excess fluid around the heart and in the lungs). On May 14, 2012, a review of a care plan titled, "ADL/Self-care Deficit" dated February 25, 2012, indicated the resident required a two-person assist for all activities of daily living (ADLs).According to a history and physical (H/P), dated March 3, 2012, the resident was described as confused, weak, and non-ambulatory. The H/P indicated the resident did not have the ability to understand or make decisions. On May 14, 2012, a review of another care plan titled, "Alzheimer's or Dementia," dated March 8, 2012, indicated the resident had altered thought processes, memory loss, and confusion. The care plan also indicated the resident was at risk for injury due to altered judgment and self-care deficit. On May 14, 2012, a review of a Minimum Data Set (MDS), a standardized assessment and care screening tool, dated March 27, 2012, indicated the resident was confused with poor memory and required total assistance from the staff for all ADLs. The MDS indicated the resident required a two-person assist for bed mobility, transferring, dressing, and personal hygiene. According to a registered dietitians (RD) note, dated March 20, 2012, she recommended a complete metabolic panel ([CMP] lab work that is an indicator of a resident's health and nutritional status), due to the resident's significant weight loss. The lab work was drawn on March 21, 2012, with the following results: blood-urea- nitrogen level (BUN) of 76 milligram per deciliter (mg/dl) with a normal reference range of 8 mg/dl-26 mg/dl), creatinine level of 2.5 mg/dl with a normal reference range of 0.70 mg /dl-1.20 mg/dl, sodium level of 167 mg/dl with a normal reference range of 135 mg/dl-145 mg/dl, and a chloride level of 130 mg/dl with a normal reference range of 101 mg/dl-111 mg/dl. According to GLOBALRPh: the Clinician's Ultimate Guide, an elevated BUN and creatinine levels are indicative of renal failure (). According to Brenner & Rector's, "The Kidney," 8th edition (2008), Chapter 21;Page 692, significant hypernatremia (high sodium levels) can be lethal in some cases with mortality (death) as high as 46% to 70%. Acute increases in serum sodium concentrations more than 160mEq/l is associated with a 75% mortality rate. A review of the general acute care hospitals' (GACH) Admission History and Physical, dated February 21, 2012 (four days prior to the resident's admission to the SNF), indicated the resident's laboratory data was within normal range as following: sodium was 141, potassium 3.8 (normal reference range is 3.5-5.0), chloride 109, BUN 28, and a creatinine of 1. On May 14, 2012, a review of a nurse's note, dated March 21, 2012, and timed at 3:30 p.m., indicated the resident's physician was notified of the abnormal lab values and ordered a repeat CMP in one week (March 28, 2012). According to a telephone physician?s order, dated March 26, 2012, the resident had an order to be transferred to a board and care facility. However, there was no documented evidence in the resident?s clinical record that the physician was notified that the pending lab ordered a week prior (due to being abnormal), to be done on March 28, 2012, was not done prior to the resident?s discharge on March 27, 2012. On May 14, 2012 at 3:15 p.m., while in the facility, Resident 1?s physician was called and a message was left for him to please return the call regarding the resident?s discharge. The physician?s call was not returned. During an interview on May 14, 2012, at 3:20 p.m., the facility's social worker ([MSW] masters in social work) stated it was not appropriate to transfer or discharge a resident to a board and care facility that required two or more areas of maximum assist in care, such as eating, drinking, toileting, and personal hygiene. After reviewing the resident's records, the MSW stated the facility's case manager handled Resident 1's discharge. She stated if the case manager had concerns or problems she could have assisted her if she had asked, especially since there was an issue of verbal abuse against the resident's family toward the resident. The MSW stated she had to report and refer the case to adult protective services (APS). In an interview with the case manager, on May 14, 2012 at 3:36 p.m., in the presence of the MSW, the case manager stated she thought it was okay for Resident 1 to transfer to the board and care. Both the case manager and the MSW indicated the resident's family initially wanted to keep the resident at the facility or transfer to another SNF, but there were financial concerns. The MSW stated she would not have recommended a board and care for this resident and if the family insisted she would have called an inter-disciplinary team (IDT) meeting. The case manager stated the last time an IDT meeting was conducted regarding Resident 1 was on March 9, 2012, almost three weeks prior to the resident's discharge. According to CMS/Medicare, " a Board and Care Facility is defined as group living arrangement that provides help with activities of daily living such as eating, bathing, and using the bathroom for people who cannot live on their own, but do not need nursing home services." During a telephone interview, on May 15, 2012 at 8:30 a.m., the complainant stated the resident had fallen in 2011 and again in 2012 and the second fall resulted in a fractured hip and the resident was admitted to the facility for rehabilitation. She stated the resident had difficulties, and would try to get up from his wheelchair and was not eating or drinking well. The complainant stated after the resident was transferred to a B/C, the resident was then transferred to a GACH, and almost died, requiring dialysis treatments. On May 16, 2012, during a review of the GACH medical records, the paramedic run sheet, dated March 27, 2012 and timed at 7:30 p.m., indicated the resident was observed at the B/C with an ALOC. According to the run sheet, the resident's Glasgow Coma Scale (GCS/a neurological scale of the eye, verbal, and motor activity, a score of three being the lowest and 15 the highest). Resident 1's score was three.According to the paramedic run sheet, "the resident was last known well on March 23, 2012, after not eating or drinking in days." The resident's vital signs were as follows: blood pressure, 104/62 (normal blood pressure is 120/80, National Health Library, ), pulse 100, respirations 16, and an oxygen saturation of 96%. The record indicated the paramedics were told by the B/C staff the resident had not eaten or drank anything since Friday, March 23, 2102. An intravenous line (a small tube or catheter is inserted into a vein for access to give medication or fluids) was started and the patient was transported to the GACH.The Admission Summary from the GACH indicated the resident was admitted to the ICU. Lab work done upon admission indicated the following: BUN of 198 mg/dl (normal range 8 mg/dl-26 mg/dl), sodium of 187 (normal range 135 mg/dl-145 mg/dl), and a creatinine level of 7.10 (normal range (0.70 mg/dl- 1.20 mg/dl). Resident 1's admitting diagnoses were severe dehydration (inadequate fluid), renal failure (inability of the kidneys to remove waste and concentrate urine), and hypernatremia (high levels of sodium in the blood), which 187 mg/dl is a critical level, and a hip fracture, S/P ORIF. The resident had a Quinton Catheter (a large bore venous access catheter) inserted in the right internal jugular vein and received dialysis treatments (mechanical filtration of the blood) on March 28, 2012, March 29, 2012, March 30, 2012 and April 2, 2012. The resident was stabilized and after seven days, was transferred to another GACH on April 3, 2012, due to insurance reasons. During an interview, on May 16, 2012, at 9:40 a.m., the facility's director of nurses (DON) stated Resident 1's family wanted to transfer the resident to another SNF, but the cost made them decide on a B/C. The DON stated she was not aware the resident was not eating, had a significant weight loss (35 pounds in 32 days) and had abnormal labs with an order to repeat the lab work on March 28, 2012 (the following day after the resident was discharged). The DON stated if she had known she would have spoken to the resident's physician about the resident's change of condition. She stated she would have at least encouraged the physician and or family to wait to repeat the abnormal labs. The DON stated if the labs remained abnormal, the family would then have to sign the resident out against medical advice (AMA) with a follow-up with adult protective services (APS).The DON stated it was the facility's responsibility to ensure a resident's transfer or discharge was safe and the resident was in a stable condition. She stated it was not just the case managers' responsibility, but the whole facility as a whole to look at the residents' needs and level of care prior to discharge. The DON stated if she had known all the information regarding this resident she would have intervened to prevent the discharge. She stated the facility should have waited for the repeat labs ordered March 28, 2012, prior to letting the resident leave and to ensure the results were normal, because the resident had lost weight and was not eating, the resident did not meet the criteria for a lower level of care. An interview on May 16, 2012, at 3 p.m., RN 1 stated Resident 1 was confused, non-ambulatory and required total assistance in all care. RN 1 stated the resident was not a good transfer candidate.On May 18, 2012 at 8:55 a.m., while in the facility, the resident?s physician was called again regarding the resident?s discharge and another message was left. The DON stated she would assist and she also placed a call to the physician requesting if he could return the call. Resident 1?s physician did not return the call. In a written declaration, dated May 18, 2012, written by the case manager, who was not a nurse, indicated she was not aware the resident's condition was deteriorating with weight loss, not eating, and had life threatening abnormal labs. The declaration also indicated the nurses had not informed the case manager about the resident's condition. An interview on May 18, 2012, at 10:05 a.m., a licensed vocational nurse (LVN 1) stated the resident did not eat well, but took fluids.On May 18, 2012, a review of the resident?s Breakfast/Lunch/Dinner Record indicated the resident during the previous month had eaten only 45% of offered breakfasts, 32% of offered lunches, and 31% of offered dinners. From May 23, 2012 to May 27, 2012, the resident had refused four of five breakfasts, three of four lunches and two of four dinners. A review of the facility's policy and procedures, revised March 2007, for resident discharge planning indicated, under Section 1, the social service designee with the interdisciplinary team shall complete an assessment and develop a planned program for a resident discharge to a lower level of care. Under Section 3, the policy indicated the planning included health status, and the current level of care needed for the resident to be transferred. Under Section 5, the policy indicated the discharge plan was to be reviewed and reevaluated when there was a change in the resident's condition.The facility failed by not ensuring: Resident 1?s transfer and discharge was appropriate and the residents? health had improved and no longer needed the services provided by the facility.The above violation had a direct relationship to the health, safety, and security of Resident 1. |
| 940000019 |
WHITTIER HILLS HEALTH CARE CENTER |
940010090 |
B |
07-Aug-13 |
GFZJ11 |
6499 |
F223 -483.13 (b) Abuse. The resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment, and involuntary seclusion. On 6/4/13 at 1 p.m., an unannounced complaint investigation was conducted at the facility regarding an incident of alleged staff to resident verbal abuse.Based on interview and record review, the facility failed to ensure that residents were free from verbal abuse by failing to: 1. Ensure that Resident 2, who was intellectually disabled, was not verbally abused by a license vocational nurse (LVN 1). 2. Ensure that Resident 1, who witnessed and reported the verbal abuse incident, felt safe and secure. On 6/4/13 at 1:20 p.m., during an interview, Resident 2 was unable to answer questions. The resident repeatedly said, "What do you want to ask? What do you want to ask?"A review of Resident 2's nursing progress notes, dated 6/11/13, indicated that the resident was re-admitted to the facility on 1/20/13 with diagnoses including unspecified intellectual disabilities (someone who has an IQ score under 70 and has other social and learning problem) and depressive disorder (feelings of sadness, loss, anger, or frustration that interfere with everyday life).On 6/4/13 at 2:15 p.m., during the entrance conference, the facility's administrator stated that he was aware of a verbal abuse incident by a staff member (LVN 1) to Resident 2. He stated the facility had investigated the incident and was unable to substantiate the complaint. The administrator further stated, even though the facility was unable to substantiate the complaint, LVN 1 was ?let go from his duty.?On 6/4/13 at 2:30 p.m., a review of the Resident Abuse Investigation Report Form revealed that Resident 1 reported on 5/18/13 at around 6:15 a.m., that she overheard a man dressed in scrubs (staff member) say, "Shut the F*** up" to another resident (Resident 2). Resident 1 initially stated she did not know who the staff member was. However, during a follow-up conversation between the administrator and Resident 1, she stated that the individual who made the objectionable comments was LVN 1.According to the investigation report, Resident 1 was re-interviewed via telephone on 6/3/13 because Resident 1 had been discharged from the facility. During that conversation, the resident reiterated that she was on her way out to smoke around 6:15 am, when she heard someone say, "Shut the F*** Up". She looked toward where she heard the comment coming from and saw a male resident (Resident 2) wheeling himself down the hallway. She also heard the resident respond by saying, "What do you mean, shut the F*** up??The only other person in the hallway with Resident 2 at the time was a male staff member (LVN 1). A review of the investigation report conclusion revealed that the facility was unable to reach a conclusion on the issue of whether LVN 1 committed an act of verbal abuse on 5/18/13. The report indicated that Resident 1's account of the event was clear and consistent over the two times she was interviewed. There was a delay in her identification of the staff member she claimed to have been involved (LVN 1) in the incident. In addition, she did not actually see LVN 1 make or direct the comment to Resident 2. She only heard the comment being made, and assumed it came from LVN 1 since she saw him in the hallway. There were no other witnesses to the incident. The report also indicated that LVN 1's employment with the facility would be terminated effective 6/4/13, even though the facility was not able to conclude one way or the other; if the incident of abuse occurred, as alleged.On 6/4/13 at 3 p.m., during an interview, the certified nursing assistant (CNA 1) stated on 5/18/13 at around 3 p.m., that Resident 1 came and told her that she was absolutely horrified that morning because she saw a male staff (dark skin, short hair wearing scrub, standing near the medication cart appeared to be charting) yelling at a resident in a wheelchair to shut the F*** Up. Resident 1 continued to tell CNA 1 that she used to work in the medical field, and to have a staff yelling at the resident, in that manner, was horrible. CNA 1 immediately reported the incident to the administrator. A review of Resident 1's medical record indicated that the resident was a 59 year old female, admitted to the facility on 5/13/13 and discharged on 5/27/13 with diagnoses including muscle weakness, difficulty in walking and right pelvic fracture (broken bone). The Minimum Data Set (MDS, a standardized assessment and care planning tool) dated 5/20/13, indicated the resident had no memory problem or behavioral issues, She used a walker and wheelchair for ambulation and required one person assist for all activities of daily living. On 6/4/13 at 4:23 p.m., during a telephone interview with Resident 1, she stated that on 5/8/13 at around 6 a.m., she saw a man in a wheelchair who was mentally challenged and repeatedly said, "It's a Saturday morning. It's a Saturday morning...." So she looked towards Resident 1?s direction and noticed a guy (LVN 1), 5 rooms down from the entrance who yelled, "Why don't you shut the F*** up". Resident 1 further stated that the staff member made the remark while he was looking at the resident. She further stated the staff member was not aware of her presence. She further stated the resident in the wheelchair was a simple resident; he did not know what he was saying or what was being said to him. She stated she was horrified and shocked that a staff member could speak like that to a resident. She stated at the time of the incident, she did not know much about the staff member until the next day when he attended to her because of her swollen feet. It was then that she noticed that LVN 1 was the same staff member who verbally abused the resident the previous day. She stated, "He (LVN 1) was so sweet. He was just a doll." She further stated she could not understand how someone can be so nice one day and so horrible another day. The facility failed to ensure residents were free from verbal abuse by failing to: 1. Ensure that Resident 2, who was intellectually disabled, was not verbally abused by a license vocational nurse (LVN 1). 2. Ensure that Resident 1, who witnessed and reported the verbal abuse incident, felt safe and secure. The above violation had direct or immediate relationship to the health, safety, or security of Residents 1 and 2. |
| 940000111 |
WINDSOR PALMS CARE CENTER of ARTESIA |
940010691 |
A |
23-Sep-14 |
0FZ511 |
12221 |
F-223 CFR 483.13(b) ? Abuse The resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment, and involuntary seclusion. On 10/17/13, at 11:30 a.m., an unannounced visit was made to the facility to investigate a report of Resident A's allegation of verbal and physical abuse perpetrated by Resident B. Based on observation, interview and record review, the facility failed to ensure the resident had the right to be free from verbal and physical abuse by failing to:Ensure Resident A was not verbally and physically abused by Resident B, who approached Resident A, called her ?Bitch? and violently beat and hit her in the face with closed fists because the resident called and requested the CNA (certified nurse assistant) to turn her radio on in the middle of the night at around 3:00 a.m. As a result, Resident A sustained multiple bruises on the face and a left orbital fracture.On 10/17/13, at 12:30 p.m., a review of the clinical record indicated that Resident A was a 41 year old female, initially admitted to the facility on 1/8/03, with diagnoses that included Blindness, Spastic Quadriplegia, and Contractures of upper and lower extremities, Chronic Poly-Articular Juvenile Rheumatoid Arthritis, Osteoporosis and Depressive Disorder.The annual Minimum Data Set (MDS - a standardized assessment and care plan tool), dated 9/21/13, indicated that Resident A had no long/short-term memory problems, was independent in cognitive skills for daily decision-making, was able to make herself understood and able to understand others. The resident was bed bound, required extensive assistance with bed mobility and totally dependent on facility staff for transfers, dressing, eating, toilet use, personal hygiene and bathing. A review of Resident B?s clinical record indicated she was a 59 year old female, initially admitted to the facility on 11/1/11, with diagnoses that included Paranoid Schizophrenia, Psychosis and Obesity.The annual Minimum Data Set (MDS - a standardized assessment and care plan tool), dated 7/4/13, indicated Resident B had a long/short-term memory problems, moderately impaired cognitive skills for daily decision-making, usually made herself understood, and usually able to understand others. Resident B was also identified with other behavioral symptoms such as: threatening, screaming, cursing others, hitting or scratching herself, pacing, rummaging, throwing or smearing food or body wastes, making disruptive sound, was easily distracted and had disorganized thinking. These symptoms put others at a significant risk for physical injury. However, the resident required limited assistance with dressing, extensive assistance with personal hygiene and bathing, supervision with bed mobility, transfers, locomotion, eating and toilet use. According to the licensed progress notes dated 9/30/13, LVN 1 indicated that at 3:33 a.m., CNA 1 went to Resident A?s room to turn her radio on as per resident?s requested. As soon as CNA 1 left the room she heard the resident yelling for help and immediately went back to the room. Upon arrival to the room CNA 1 witnessed Resident B leaving Resident A?s bedside with closed fist and angry face and also attempted to hit the staff. CNA 1 shouted for help and other staff members responded. Resident B was removed and taken to Palm Grove Unit. Upon assessment, Resident A sustained bruises on the face, eye and mouth. Both Resident A and B were roommates and they were in the room with four other residents. The doctor was notified, order was given to transfer the resident to the acute hospital. Resident A was picked up by the Ambulance and the Sheriff?s Department was notified. A review of the Med Reach Ambulance service form dated 9/30/13 indicated Resident A was transferred to Norwalk Community Hospital emergency room for treatment.A review of the acute hospital emergency department patient care record and the emergency department physician record indicated that Resident A sustained a left orbital fracture of the eye, as a result of the assault she suffered from her roommate at the nursing facility. The review of acute hospital?s history and physical evaluation and Resident A?s CT-Scan (CAT scan computed tomography) indicated that Resident A sustained a left orbital fracture and was intubated on mechanical ventilation.A review of the acute hospital wound assessment data sheet revealed pictures showing swelling and multiple bruises on the resident?s eyes, mouth and face. In an interview, on 10/22/13, at 10:24 a.m., Resident D stated that Resident B yelled at her and other roommates lots of times when she was in the same room with them. (See declaration from LVN-2 and the review of progress note dated 5/22/12.)According to CNA 1 and CNA 2?s written declaration statements, both staff turned on Resident A?s radio in the middle of the night when all residents, including the resident?s roommates were sleeping. (The radio was turned on whenever Resident A requested staff to do so, during the day or at night.) On 10/30/13, at 2:45 p.m., during an interview Resident A was discharged from the acute hospital, she stated that when she was listening to her radio at night, she heard the footsteps and voice of Resident B as she walked towards her radio and turned it off. She said she immediately called CNA 1 and told her to turn her radio back on because Resident B just turned it off. When CNA 1 left her room, Resident B again walked towards the radio turned it off, and then came to her bed and started to hit her all over her face and head multiple times. The resident stated she could not stop Resident B because she is visually impaired due to blindness and unable to use her hands to cover her face in defense. Resident A stated she could feel that Resident B was a big strong woman and should not have been placed in her room. The resident stated the beating was so bad that she immediately blackout, but later yelled, and CNA 2 came in to stop Resident B. The resident stated she thought she was going to die during the beating. She said she thought her face was ?melting away? because she could feel blood running on her face and called her a "Bitch" and left.On 10/17/13, at 1:30 p.m., Resident C stated during an interview that Resident B was not happy when Resident A?s radio was turned on at night. Resident C stated she heard Resident A?s voice which sounded as though she was in pain and saw that her face was badly bruised after she was beaten by Resident B. (The facility staff did not admit awareness.) In an interview on the same date (10/17/13) at 2:00 p.m., DAD (director of activity department) stated she was not aware that Resident A?s radio was being turned on at night when everyone was sleeping. The DAD stated the night staff should have requested for a head phone for Resident A in order that noise from her radio would not disturb or prevent Resident B and other residents from sleeping at night. On 10/17/13, at 3:05 p.m., the SSD (Soc. Serv. Designee) stated during an interview that Resident B exhibited verbal and physical aggressive behavior such as scratching staff member when providing care and yelling at her peers. The SSD stated that on 9/30/13, at approximately 8:30 a.m., she interviewed Resident B right after the incident had occurred and the resident told her that she beat Resident A because the light was on, the radio was too loud and she could not sleep. A review of Resident B?s care plans dated, 6/28/12 and 8/5/12, indicated the resident had behavioral problem that included psychosis and paranoid schizophrenia manifested by episodes of yelling, threatening, assaulting and striking out at staff and other residents. Resident B also exhibited short attention span and refuses activity invitation. The care plan goal indicated the resident will have no injuries caused to self and others weekly and would be able to participate in activities that suit her mood/behavior concerns. The intervention required facility staff members such as CNAs, Activities, Social Service and Licensed Nursing Staff were to monitor her whereabouts, provide positive interaction with peers, remove the resident from any source of agitation and also monitor for change in mood and behavior activities. A further review of Resident B?s intervention description indicated that the facility did not provide the frequency as to how often assigned staff members were to monitor the resident in order to prevent or remove her from any and all sources of agitation. Also there was no written intervention showing how frequently the facility assigned staff members were to monitor Resident B for change in mood and behavior during all shifts. A review of Resident A?s plan of care dated 1/20/11, 6/2/12 and 4/1/13, indicated the resident was at risk for impaired visual functioning related to blindness. The resident has high risk for bleeding, bruising and skin discoloration relative to anticoagulant therapy. The intervention required nursing staff members provide a safe environment and protect the resident from injury.On 11/6/13, at 1:20 p.m., during an interview, LVN 2 stated that in the past, he had witnessed Resident B suddenly got into physical altercation with Resident E and started to pull her shirt without provocation. Resident B yelled at Resident E alleging that she stole her dress. LVN 2 stated that he and another staff member immediately intervened and separated the residents. The voluntary written declaration statement on the incident between Resident B and E provided to the evaluator indicated that the incident occurred on 5/22/12. A review of the facility?s progress note dated 5/22/12, indicated that at 15:30 (3:30 p.m.), Resident B (#5346) was noted assaulting Resident E (#5223) in the hallway. LVN 2 (#1515) immediately intervened, separated the two residents. Resident B was observed with increased delusions stating that Resident E stole her dress. In an interview, on 11/8/13, at 1:20 p.m., the RN (registered nurse) supervisor stated Resident B was admitted with behavioral problem and was placed in Palm Grove Unit because this was where residents with aggressive behavior were housed. However, the resident was later transferred to Palm Court Unit (a unit that houses the less aggressive residents), with Resident A. in order to make room for a new aggressive resident in Palm Grove Unit. On 11/8/13, at 2:40 p.m., the DON (director of nursing), stated that Resident B had a history of aggressive behavior and striking out at other residents, however the facility was doing all it could to control and prevent the abuse incident. The review of the facility?s MAR (medication administration record) revealed that the Resident B exhibited behavior of irritability episodes up to three times daily, during the day shift, between 8/1/13 and 8/25/13. The facility policy and procedure indicated that ?Abuse? of Residents will not be tolerated in the facility at any time. It is the policy of this facility to take every proactive measure to prevent the occurrence of alleged abuse to any resident. Each resident has the right to be free from Verbal, Physical and Mental Abuse. Resident must not be subjected to abuse by anyone including but not limited to other Residents, Facility Staff, Consultants, Staff of other agencies serving resident, Legal Guardians, friends or other individuals. The facility failed to ensure that Resident A had the right to be free from verbal and physical abuse by failing to: Ensure Resident A was not verbally and physically abused by Resident B, who approached Resident A, called her a ?Bitch? and violently beat and hit her in the face with closed fists because the resident called and requested the CNA to turn her radio on in the middle of the night at around 3:00 a.m. As a result, Resident A sustained a left orbital fracture along with multiple bruises to the face.The above violation presented either an imminent danger that death or serious harm to the facility residents or that substantial probability that death or serious physical harm to would result therefrom to Resident A. |
| 940000112 |
WOODRUFF CONVALESCENT CENTER |
940011147 |
A |
10-Dec-14 |
I4F611 |
11536 |
CFR 483.20(d) (A facility must?) use the results of the assessment to develop, review and revise the resident?s comprehensive plan of care. CFR 483.20(k) Comprehensive Care Plans. (1) The facility must develop a comprehensive care plan for each resident that includes measureable 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 CFR 483.25; and(ii) Any services that would otherwise be required under CFR 483.25 but are not provided due to the resident?s exercise of rights under CFR 483.10, including the right to refuse treatment under CFR 483.10(b)(4).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 received an entity reported incident (ERI) on January 6, 2014, indicating a resident (Resident 1) had fallen, fractured the left shoulder and pelvis. According to the report received to the department, the facility was unaware of the incident. Based on record review and interviews, the facility?s nursing staff failed to ensure Resident A who had a history of falls, attained the highest practical, physical, and psychosocial well-being by not: 1. Providing adequate supervision 2. Revising the care plan after the falls to prevent further falls.These failures, of not providing adequate supervision to Resident A, who had a history of several falls and revising the care plan to prevent further falls resulted in the resident sustaining a fractured right scapula (shoulder blade) and pelvic bones (a ring of bones that protects the abdominopelvic cavity). During an unannounced investigation of an ERI on January 14, 2014 and October 20, 2014, Resident A?s admission record was reviewed, which indicated the resident was a 64 year- old female who was admitted to the facility on July 8, 2013. The resident?s diagnoses included altered mental status, anxiety, and end stage renal disease and receiving dialysis (is the artificial process of eliminating waste (diffusion) and unwanted water (ultrafiltration) from the blood), three times a week, and difficulty walking with lower extremity muscle weakness. A review of a Minimum Data Set (MDS), a standardized assessment and care screening tool, dated July 21, 2013, indicated the resident was alert with no cognitive problems. According to MDS, the patient?s activities of daily living self-performance required extensive assistance with transferring with a one- person physically assist.A review of the ?Occupational Therapy Treatment Record?, dated July 9, 2013, indicated the resident had a decline in toileting, balance, gait, transfer, safety, and postural alignment, related to a decreased in functional mobility, activity, and upper extremity strength and coordination. The resident needed stand by assistance with these concern due being at risk for falls. A review of the ?Physical Therapy Treatment Record?, dated July 9, 2013, identified Resident A as having a decline in range of motion, bed mobility, transfer, gait and balance. The written goal for the physical therapy treatment was to provide gait training, therapeutic exercise, neuro muscular re-education and wheelchair mobility. A Licensed Nurses Note, dated July 15, 2013, and timed at 7:45 p.m., indicated the resident was found in the room, lying on floor next to the bed. The resident had confusion without injury or pain. A review of a plan of care July 15, 2013, and titled, ?Actual fall? due to unsteady gait and general weakness, the resident was found lying on the floor on her abdomen with no injury, indicated the plan for the resident was to provide a low bed and to place an alarm on the bed. The plan further indicated the staff would encourage patient to use call light to keep the call light within reach and to use a low bed pad alarm on bed. A review of the Licensed Nurses Note, dated July 23, 2013, and timed at 7:45 p.m., indicated the resident was found on the floor, lying next to her bed, according to the resident?s roommate, the resident removed the bed alarm, stood up unassisted and slid onto the floor. The resident was assessed by a licensed nurse to have a bump on the right side of the upper back with bruising. The resident complained of pain at a level of 5/10 on a scale of 0-10, 10 being the worse. The resident was medicated for pain. The physician was notified, an x-ray was taken of both spine and scapula (back bone). The x-ray results showed no visible fractures. A review of another care plan dated, July 23, 2013 and titled, ?Actual Fall? due to the resident?s removal of personal alarm in bed, got up and fell. The facility?s goal was to minimize injury from falls by the use of a low bed pad alarm on the bed. The facility?s nursing interventions were listed as following; to encourage the resident to use a call light, keep the call light within reach, answer the call light promptly, provide a safe environment, and report and document the resident?s unsteady gait and poor balance. A review of a physician?s order dated, July 24, 2013, and timed at 5 p.m., indicated to discontinue the mattress on the floor and the resident?s personal bed alarm. The physician?s order indicated to provide a low bed with a bedside safety mat and to place a pad alarm onto the resident?s bed.A review of the Licensed Nurses Note, dated August 14, 2013 and timed at 3:10 p.m., indicated at 7:20 a.m., that morning, a certified nurse assistant (CNA) was transferring the resident from the wheelchair to the toilet. The resident was not able to transfer all the way onto the toilet, so the CNA slowly placed the resident in a sitting positon on the floor, and then yelled for help. The Licensed Nurses Note further indicated, the resident had no complaints of pain and no injury. A review of a care plan, dated August 14, 2013, titled, ?Actual Fall? due to an assisted transfer from the toilet to the floor by staff?. The facility?s goal for the resident was not to have any injury from falls. However, there was no further revision of the care plan to prevent further falls. A review of the Licensed Nurses Note, dated November 30, 2013, and timed at 4:45 p.m., indicated the resident was found lying on the floor on her abdomen. The resident was able to move both upper and lower extremities and there was no visual injury noted. The skin was intact, but the resident complained of pain at a level of 8/10 on a scale of 0-10, 10 being the worse, in the groin area (The crease or hollow at the junction of the inner part of each thigh with the trunk). The note further indicated the resident had removed the safety alarm from the bed. The physician was informed and ordered an x-ray of the pelvis, hip, and upper thigh. The facility?s x-ray results, dated November 30, 2013, and timed at 8:30 p.m., indicated no fractures, dislocations, degenerative changes, or bony destructive lesions were present. A review of another care plan, dated November 30, 2013, titled ?Actual Fall? due to poor safety awareness indicated the staff?s approaches included keeping the call light within reach and answering promptly, reporting and documenting unsteady gait and poor balance, and to provide a safe environment for the resident. A review of another Licensed Nurse Note, dated December 2, 2013, and time at 9:30 a.m., indicated the resident was up in the wheel chair leaving for her dialysis treatment and had no complaints of pain. At 3 p.m., the resident returned from dialysis with no complaint of pain. At 3:25 p.m., the dialysis nurse called the skilled nursing facility and stated the resident had complained of left arm and chest pains while at the dialysis center. According to note, the dialysis nurse informed the facility that the resident?s primary physician was informed regarding the resident?s complaint of left arm and chest pains. The note further read, the primary physician indicated to transfer the resident to the General Acute Care hospital (GACH). A review of the GACH records, dated December 3, 2013, indicated an x-ray was taken of the resident?s left shoulder due to a post fall with shoulder pain. The result of the x-ray indicated the resident?s shoulder had a left humeral head (upper arm bone) fracture. Another GACH record, dated December 4, 2013, indicated an x-ray was taken of the resident?s bilateral hips including the pelvis area (front and back). The x-ray report indicated the bones were demineralized with mild degenerative changes and right medial pubic ramus fractures (a group of bones that make up a portion of the pelvic bone).On October 20, 2014, at 11:10 a.m., during an interview, the director of nurses (DON) stated on July 23, 2013, at 7:45 p.m., the resident?s roommate informed a certified nurse assistant (CNA) the resident removed the low bed alarm which was clipped to the resident?s gown. According to the DON, the roommate stated, the resident was standing next to the bed and then slid onto the floor. Further investigation of the resident?s body (according to the DON), the resident sustained a 3 by 3 centimeter size bump on the right upper back of her body with some bruising (discoloration). An x-ray was taken and there was no fracture. On October 20, 2014, at 11:12 a.m, the DON stated, on November 30, 2013, the resident?s safety magnet alarm which was usually pinned to the resident?s gown, to alert the staff whenever the resident attempted to get out of bed by herself, was found on the resident?s bed, because the resident had removed it. The resident complained of left groin pain rating of 7 on a scale of 0 to 10 (10 being the worse). The resident was medicated for the pain with Norco 5/325 milligram, one tablet by mouth. The physician was informed and an x-ray was done. During an interview, the DON stated on December 2, 2013, the evening shift licensed nurse wrote a note indicating the resident returned from the dialysis treatment center due to the resident complaining of left arm and chest pain. When the DON was questioned as to how the facility staff was monitoring the resident to prevent any future falls from occurring she stated, the nursing staff was visually monitoring the resident every hour or two. When the DON was asked to provide documentation to show how often the resident was being monitored, there was no records available. According to the DON, a system for monitoring the residents, who were at high risk for falls, was not developed / created until the first of the year (2014).On October 20, 2014, at 2:20 p.m., during an interview, the administrator was presented with and reviewed two of Resident A?s care plans after falls. The administrator stated, ?The care plans were basically the same?.The facility failed by not: 1. Revising the plan of care after the falls to prevent further falls. 2. Providing adequate supervision and monitoringThe above violations either jointly, separately, or in any combination presented either an imminent danger that death or serious physical harm would result or a substantial probability that death or serious physical harm would result. |
| 940000111 |
WINDSOR PALMS CARE CENTER of ARTESIA |
940011430 |
B |
01-May-15 |
0D5P11 |
6546 |
F225 - 42 CFR 483.13(c)(1)(2). Reporting/Response: The facility must ensure that all alleged violations involving mistreatment, neglect, 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). F225 - 42 CFR 483.13(c)(1)(4). Reporting/Response: 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. Based on observation, interview, and record review, the facility failed to implement it's abuse policy and procedure by failing to: 1. Report a resident to resident altercation within 24 hours to the Department (the State licensing and certification agency), 2. Report the results of the facility's investigation to the Department within 5 days of the incident.Resident B hit Resident A in his left eye area resulting in the discoloration of the area. The administrator did not report the incident to the Department and did not submit a written report of the results of the facility's investigation within 5 days of the incident to the Department. On 11/12/13, at 2:00 p.m., an unannounced visit was made to the facility to conduct an investigation regarding an incident of resident to resident physical abuse between Resident A and B on 10/7/13. According to the complaint, Resident A was observed to have two black eyes and a bloodshot eye on 10/16/13 and the facility staffs were informed not to report the incident between Resident A and B to the Department. A review of Resident A's clinical record indicated he was re-admitted to the facility on 4/9/13, with diagnosis which included Alzheimer's disease (a progressive brain disease that slowly destroys memory and thinking skills, and eventually even the ability to carry out the simplest tasks), anxiety disorder, psychosis (a mental disorder involving loss of contact with reality), depressive disorder, and schizoaffective disorder (a mental disorder characterized by abnormal thought processes and deregulated emotions).The annual assessment Minimum Data Set (MDS, a standardized assessment and care plan tool), dated 9/19/13, indicated Resident A was confused but able to verbalize his name. The resident had short and long term memory problems and was severely impaired in cognitive skills for daily decision-making. The resident required supervision in walking and during locomotion on and off the unit. A review of Resident B's clinical record indicated he was admitted to the facility on 5/3/04 and was re-admitted to the facility on 10/14/13, with diagnosis which included paranoid schizophrenia (a mental illness that involves false beliefs of being persecuted or plotted against), drug abuse, anxiety disorder, and psychosis.The annual assessment MDS, dated 5/17/13, indicated Resident B was confused but sometimes was able to make his needs known. The resident had short and long term memory problems and was moderately impaired in cognitive skills for daily decision-making. The resident required supervision in walking and during locomotion on and off the unit. A review of the nurse's progress note, dated 10/7/13 and timed at 4 p.m., indicated Resident A was hit in the left eye area by Resident B. The progress note indicated the doctor was notified and an order was received to place Resident A on 72 hours neurologic assessment/check monitoring. A review of another nurse's progress note, dated 10/7/13 and timed at 4 p.m., indicated Resident B's psychiatrist was notified that Resident B hit Resident A on the left eye area and an order was received to transfer Resident B to an acute care hospital for behavioral management. On 11/12/13, at 2:20 p.m., Resident A was observed in his room confused, but he was able to verbalize his name. There were dark discolorations below his eyes that were fading.On 11/12/13, at 2:25 p.m., during an interview, Resident A stated Resident B hit him in the face because he (Resident A) shoved him (Resident B). During an observation, on 11/14/13, at 3:20 p.m., Resident B was walking in the hallway. Resident B stated, during an interview, that Resident A bumped into him and hit him in the face. Resident B stated he then hit Resident A back and Employee 2 separated them from fighting. During an interview, on 11/12/13, at 3:30 p.m., Employee 1 stated Resident B admitted that he struck Resident A because Resident A hit him first and he had to defend himself. On 11/14/13, at 2:45 p.m., Employee 2 stated that on the day of the incident, she heard the voice of Resident B yelling a profane word at Resident A. Employee 2 stated she quickly ran and separated the two residents, and she observed that Resident A had purplish discoloration on his lower left eye and a reddish discoloration on top of his left eyelid area. Employee 2 stated she reported the incident to Employee 3.On 11/14/13 at 3:50 p.m., in an interview with Employee 3 (a licensed vocational nurse), he stated that during the assessment of Resident A's face, he observed a swollen cut on the resident's left eye lid. On 11/14/13, at 4:25 p.m., during an interview, the administrator stated the facility was not aware that the incident was a reportable incident. A review of the facility's policy and procedure titled "Abuse Prevention, Investigation, and Reporting," revised 3/2013, indicated that all mandated reporters are required by law to report incidents of known or suspected abuse by telephone immediately or as soon as practically possible (within 24 Hours) to the Department of Public Health and to the local Ombudsman or the local law enforcement agency. The administrator shall report the results of the investigation to the Department within 5 days of the incident. Therefore, the facility failed to implement it's abuse policy and procedure by failing to: 1. Report a resident to resident altercation within 24 hours to the Department (the State licensing and certification agency), 2. Report the results of the facility's investigation to the Department within 5 days of the incident.The above violations had a direct or immediate relationship to the health, safety, or security of patients. |
| 940000111 |
WINDSOR PALMS CARE CENTER of ARTESIA |
940011447 |
B |
06-May-15 |
JKC311 |
7263 |
F-223 CFR 483.13(b) - Abuse The resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment, and involuntary seclusion. On 1/24/14, at 3:40 p.m., an unannounced visit was made to the facility to investigate a report of Resident A's allegation of physical abuse perpetrated by Certified Nursing Assistant 1 (CNA 1). Based on interview and record review, the facility failed to ensure the resident had the right to be free from physical abuse by failing to: Ensure Resident A was not verbally and physically abused by CNA 1, who while repeatedly told Resident A to put on his shirt, kicked Resident A in the stomach that caused the resident to fall to the ground because the resident refused, got agitated and threw his soda drink on the CNA. The physical abuse incident was witnessed by Employee 1 (State?s Ombudsman Care-Manager) during her visit to the facility on 12/30/13. The above violation had direct or immediate relationship to the health, safety, or security of Resident A.On 1/24/14, a review of the clinical record indicated Resident A was a 55 year old male who re-admitted to the facility on 8/23/13, with diagnoses that included Schizophrenia, bipolar disorder, psychosis, manic disorder, end stage renal disease, epilepsy and depressive disorder. The Minimum Data Set (MDS - a standardized assessment and care plan tool), dated 1/17/13, indicated Resident A had long/short-term memory problems, moderately impaired cognitive skills for daily decision-making, was delusional and had signs and symptoms of disorganized thinking. The resident required supervision when walking in corridor, limited assistance with dressing and when using the toilet and extensive assistance with personal hygiene and bathing.On 1/24/14, at 3:55 p.m., during an interview in the presence of Employee 2 Resident A was unable to respond due to confusion.On the same date (1/24/14) at 4:15 p.m., Employee 1 was observed in the facility visiting. During an interview Employee 1 stated she observed CNA 1 arguing with Resident A about putting on his shirt. Resident A became agitated and threw soda drink from the cup he was holding on CNA 1. The CNA moved towards Resident A, kicked him in the stomach and the resident fell to the ground. Employee 1 stated the resident got up and ran towards CNA 1 and they both grabbed each other?s arms. Employee 1 said she left at that point to get a nurse supervisor who approached and separated both CNA 1 and Resident A.On 1/29/14, at 1:50 p.m., LVN 1 stated during an interview that CNA 1 was not supposed to respond to Resident A?s agitation by kicking the resident?s stomach in retaliation.In an interview on the same date (1/29/14), at 2:30 p.m., CNA 2 stated that, whenever Resident A, exhibits anger outburst or throw any object at him, he would calm him down and discourage any form of confrontation with the resident. On 1/29/14, at 3:10 p.m., during an interview, Resident B stated that he saw CNA 1 was very upset at Resident A. Resident B said he observed CNA 1 fought with the Resident A when Resident A threw soda drink at him. At 3:40 p.m., on the same date (1/29/14), Resident C stated he too saw CNA 1 kicked Resident A in the stomach when the resident threw soda drink at him. Resident B and Resident C were observed in Palm Grove Unit. They were both alert oriented and able to make their needs known. According to the medical record, Resident B was a 54 year old male, readmitted to the facility on 9/24/09 and Resident C was 36 years old male, initially admitted to the facility on 2/15/12. Both residents had diagnoses that included depressive and schizoaffective disorder. The Minimum Data Set (MDS - a standardized assessment and care plan tool), for Resident B and C dated 12/2/13 and 11/21/13, consecutively, indicated that both residents had no memory problems and were independent in cognitive skills for daily decision-making. According to the facility?s investigation, during an interview on 12/30/14, at 4:40 p.m., CNA 1 denied he kicked Resident A in the stomach. CNA 1 blamed the physical abuse incident on another resident. A review of Employee 1's ?written declaration? dated 3/24/14, on the abuse incident, the declaration statements indicated that on 12/30/13, at approximately 2:30 p.m., when Employee 1 was talking to one of the facility residents in the outside patio of Palm Grove Unit, she observed Resident A walking around without his shirt on. CNA 1 approached the resident and told him to put his shirt on, but the resident ignored the CNA. When CNA 1 approached the resident again and said to the resident, ?You have to put a shirt on.? Resident A threw his soda drink on the CNA. Employee 1 said she then observed CNA 1 kicked Resident A in the stomach and the resident fell to the ground. A review of Employee 3 declaration statement dated 1/29/14 indicated that Employee 1, Resident B and Resident C all stated during an interview, that they observed and witnessed CNA 1 kicked Resident A in the stomach when the resident threw his soda drink at the CNA.A review of Resident A?s plan of care on behavioral problem, dated 8/13/13 indicated that the resident is resistive to care relative to anxiety, adjustment to nursing home, combative and irritability. The care plan intervention indicated that CNAs must: Give clear explanation of all care activities prior, as they occur during each contact; Negotiate a time for ADLs (activity of daily living) so that the resident participates in the decision making process; If the resident resists ADLs, the care giver must reassure the resident, leave and return 5-10 minutes later and the try again. The care giver must first identify themselves to the resident and must gently handle the resident in a calm manner during activity of daily living (ADL).According to the summary of investigation letter sent to the Department of Public Health, dated, 1/3/14, the facility determined that CNA 1 was e responsible for kicking Resident A.The facility's policy and procedure on Abuse Prevention, Investigation and Reporting, dated, March 2013, indicated that abuse, neglect and abandonment of facility residents will not be tolerated at any time. Each resident has the right to be free from physical, verbal, sexual and mental abuse, corporal punishment and involuntary seclusion. Residents must not be subject to abuse by anyone, including but not limited to, facility staff, other residents, consultant or volunteers, staff of other agencies serving the resident, family members and legal guardians, friends and other individuals.The facility failed to ensure Resident A had the right to be free from physical abuse by failing to: Ensure Resident A was not physically abused by CNA 1, who while repeatedly told Resident A to put on his shirt, kicked Resident A in the stomach that caused the resident to fall to the ground because the resident refused, got agitated and threw his soda drink on the CNA. The physical abuse incident was witnessed by Employee 1 (State?s Ombudsman Care-Manager) during her visit to the facility on 12/30/13. The above violation had direct or immediate relationship to the health, safety, or security of Resident A. |
| 940000111 |
WINDSOR PALMS CARE CENTER of ARTESIA |
940012227 |
B |
26-May-16 |
59C811 |
6009 |
F223 483.13 (b) Abuse The resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion.The facility must not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion. The Department received an entity reported incident (ERI) on 3/21/16, alleging that the facility?s housekeeper staff observed a certified nurse assistant (CNA 5) push and hit a resident (Resident 84). CNA 5 was suspended initially during the investigation and later terminated on 3/29/16. The facility failed to ensure residents had the right to be free from abuse, including but not limited to: 1. Failure to follow its policy regarding abuse. 2. Failure to ensure Resident 84 was safe and free from abuse. These failures resulted in Resident 84, who had psychiatric disorders and memory problems, being physical abuse by CNA 5, and put Resident 84 at risk to feel unsafe, insecure, and had the potential for emotional distress and psychological trauma.On 3/29/16 at 8 a.m., during an unannounced recertification survey, the ERI was conducted regarding Resident 84 being struck by CNA 5.A review of Resident 84's Admission Face Sheet indicated Resident 84 was a 75 year-old female who was last admitted to the facility on 8/19/13. Resident 84's diagnoses included paranoid schizophrenia (a brain disorder in which people interpret reality abnormally), depressive disorder (a mood disorder causing a persistent feeling of sadness and loss of interest), epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing seizures [jerk and have extreme muscle spasms]) and diabetes mellitus (a chronic condition in which the pancreas produces little or no insulin resulting in increased blood sugars). A review of Resident 84's Minimum Data Sheet (MDS), a standardized assessment and care screening tool, dated 8/28/15, under Section C, indicated Resident 84's brief interview for mental status (BIMS) was a 10, which indicated Resident 84 was moderately cognitively impaired. According to the MDS, Resident 84 had difficulty in recalling, had inattentiveness and disorganized thinking. The MDS, under Sections D and E, indicated Resident 84 had a depressive mood disorder resulting in the resident feeling down and hopeless. According to the MDS, Resident 84 had the ability to transfer and walk with supervision; required limited to extensive assistance with a one-person physical assist for dressing, eating, toileting, hygiene and bathing.A review of a nurse's progress note, dated 3/20/16, and timed at 1:16 p.m., indicated that a housekeeper (HK 1) had been cleaning Resident 84's bathroom, when she witnessed, on the same day, between the time of 12:30 p.m. and 1 p.m., a certified nurse assistant (CNA 5) push and hit Resident 84. The same nurse's progress note indicated Resident 84 was assessed without injuries, denied pain or discomfort, but was monitored for 72 hours.On 3/30/16 at 2:50 p.m., during an interview regarding the abuse incident, Resident 84 stated, "No one hit me." There were no bruises observed on Resident 84's face. When asked if she was fearful of being at the facility, Resident 84 stated, "No." During a concurrent interview, CNA 25 stated he was on duty the day of the incident, but was out on the patio, and did not witness the incident. When CNA 25 was asked about Resident 84's behavior, CNA 25 stated he had no problem with Resident 84, but stated she was always asking for money. On 3/30/16 at approximately 3:30 p.m., during an interview, the administrator (ADM) and the director of nurses (DON) both stated CNA 5 had been terminated due to the substantiated allegation of physically abusing Resident 84. During a telephone interview conducted on 4/5/16 at 12:20 p.m., HK 1 stated she was cleaning Resident 84's bathroom, when she heard a slap and Resident 84 cry out," She's bothering me!"HK 1 stated she ran out of the bathroom and witnessed CNA 5 push Resident 84 and hit her twice in the mouth. HK 1 stated, ?I told the CNA to stop, but she did not care that I was there. I asked the resident (Resident 84) if she was okay and she stated she was. I reported it right away to the registered nurse supervisor (RN 3)." A review of CNA 5's employee file, a form titled, "Employee Corrective Action Notice," dated 3/29/16, indicated CNA 5 was terminated because of being observed pushing and hitting Resident 84. A review of the facility's investigation of CNA 5's abuse of Resident 84, dated from 3/20/16 through 3/23/16, indicated two residents (Residents 90 and 91) witnessed CNA 5 hitting Resident 84 on the head prior to the 3/20/16 incidents. When Residents 90 and 91 were asked why they did not report the incident, Resident 90 stated he did not know and Resident 91 stated she thought it would be a problem. The report indicated Residents 90 and 91 were asked if they were afraid, they initially answered, ?Maybe, and kind of," respectively. A review of the Resident's MDS, dated 3/5/16 for Resident 91 and 3/10/16 for Resident 90, indicated both resident?s cognition and memory were intact. A review of the facility's policy and procedures, dated 3/2013, and titled, "Abuse Prevention, Investigation and Reporting,? indicated the facility would ensure that all residents have the right to be free from sexual, physical, and mental abuse, corporal punishment from staff and anyone entering the facility. The facility failed to ensure residents were free from abuse, including but not limited to: 1. Failure to follow its policy regarding abuse. 2. Failure to ensure Resident 84 was safe and free from abuse. This deficient practice resulted in Resident 84 not being free of physical abuse, and put Resident 84 at risk to feel unsafe, insecure, and had the potential for emotional distress and psychological trauma.The above violation had the direct relationship to the health, safety, or security of Resident 84. |
| 940000111 |
WINDSOR PALMS CARE CENTER of ARTESIA |
940012231 |
A |
26-May-16 |
59C811 |
13221 |
F 323 ? ?483.25 (h) Accidents The facility must ensure that ? (1) The resident environment remains as free from accident hazards as is possible: and (2) Each resident receives adequate supervision and assistance devices to prevent accidents. The Department received an entity reported incident (ERI) on 8/11/15, alleging that a resident (Resident 11) accidently slid from the side of his bed, while being positioned, during a transfer with a standing lift by a CNA. Resident 11 sustained a left humerus (arm) fracture and was transferred to the hospital. The facility failed to ensure the residents environment remains as free from accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents, including but not limited to: 1. Failure to follow its policy and procedure. 2. Failure to provide a two-person physical assist for transferring Resident 11 with a mechanical lift. 3. Failure to follow the manufacturer?s guidelines in using a mechanical lift. These failures resulted in Resident 11, who had a high risk for falls and required a two-person physical assist in using a mechanically lift, per the facility's policy, the staff used a one-person assist, which resulted in Resident 11 falling, left arm being caught in the lift's sling, resulting in a left arm fracture (humerus). Resident 11 required a transfer to the general acute care hospital (GACH), received strong narcotic pain medications of Dilaudid .5 mg and Norco 10/325 milligram (mg) to control the pain. A surgical intervention was the plan per the orthopedic surgeon, but due to the resident?s existing conditions, surgery was not done per the resident?s family request. Resident 11 required a special sling, Sarmeinto humeral arm cuff (a pre-fabricated foam-lined orthosis designed for the management of a mid-shaft and distal third humeral fractures) for left arm alignment post-accident. During the facility's tour (in the Palm Court Unit), on 3/29/16, at 9 a.m., a licensed vocational nurse (LVN 10) stated a resident (Resident 11) had a history of falls that resulted in a fracture. A review of Resident 11's Admission Face Sheet indicated the resident was a 52 year-old male who was admitted to the facility on XXXXXXX and re-admitted on XXXXXXX. Resident 11's diagnoses included essential primary hypertension (a medical condition in which the blood pressure in the arteries was persistently elevated), history of falling, fracture of the shaft of the humerus (broken bone of the arm), cerebrovascular disease (also known as stroke, poor blood flow to the brain can results in cell death), diabetes mellitus (long term metabolic disorder, characterized by high blood sugar, insulin resistance) and schizophrenia (a mental disorder resulting in faulty perception, inappropriate actions and feelings). A review of Resident 11's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 7/11/15, indicated Resident 11 had a short and long-term memory problems with severely impaired cognitive skills (ability to think and reason) impairment. According to the MDS, Resident 11 required an extensive assistance (resident involved in activity with one staff providing support) with bed mobility, transferring, hygiene, and dressing. Resident 11 was totally dependent in walking, toilet use and personal hygiene and was always incontinent (lack of control) of bowel and bladder, but was not on a bowel program. A review of a "Fall Risk Assessments," documented initially on 6/11/10, and last recorded on 7/13/15, indicated Resident 11 was identified as a high risk for falls. According to the assessments, Resident 11's total score was 16 and the assessment indicated a score of 10 or above represented a high risk for fall. During an observation on 3/30/16, at 8:30 a.m., Resident 11 was being transferred to a shower chair by two certified nursing assistants (CNAs 7 and 12) and one occupational therapist (OT). CNA 12 and the OT were assisting Resident 11 to sit-up, while CNA 7 was maneuvering the standing lift. When Resident 11 was in a sitting position, with the feet dangling on the floor, the OT applied the brace on the resident's left arm. Then CNA 12 applied the sling on both arms and the belt to the back. When everything was secured, CNA 12 started to lift Resident 11 to the shower chair, while the OT was standing to the right of Resident 11. CNA 7 was standing and holding onto the back of the shower chair waiting for Resident 11 to place in a sitting position on the shower chair. On 3/30/16 at 10:20 a.m., during an interview, LVN 10 stated that on 8/10/15, CNA 20 called him and stated that Resident 11 was on the floor. LVN 10 stated he immediately went to Resident 11's room and saw the resident on the floor and holding his left arm. LVN 10 stated he assessed Resident 11, immobilized and applied an ice compress to Resident 11's left arm. LVN 10 stated he asked Resident 11 if he was in pain, but Resident 11 did not respond verbally. LVN 10 stated Resident 11 responded by nodding when he tried to touch Resident 11's left arm, indicating he was in pain. LVN 10 stated that CNA 20 was assisting Resident 11 and cannot remember the other CNA that was in the room. On 3/30/16, at 3:30 p.m., during a subsequent interview, LVN 10 stated there were two CNAs in the room at the time of Resident 11's fall incident, but LVN 10 could not remember the name of CNA 13. LVN 10 stated CNA 13 was helping another resident in the room, while CNA 20 was transferring Resident 11. LVN 10 stated that every time we are using a standing lift a two-person assist was required. On 3/31/16 at 9:10 a.m., during an interview, CNA 20 stated that on the morning of 8/10/15, she and another CNA was transferring Resident 11 to a shower chair using a standing lift. CNA 20 stated she could not remember the other female CNA's name that helped her the day Resident 11 fell, because she was not always assigned in that area. CNA 20 stated when she got Resident 11 in a sitting position, she put the sling on while putting the belt on the back and Resident 11 slid off the bed resting on the floor, positioned on the right side of his body. CNA 20 stated Resident 11's left arm was still hanging on the sling (thus resulting in the left arm fracture). CNA 20 stated that while she was applying the belt to secure Resident 11, CNA 13 turned her back away from Resident 11 to answer a question of another resident in the room. CNA 20 stated she did not wait for CNA 13, because Resident 11 was just sitting down and she had just applied the belt. CNA 20 stated she did not think she needed help at that point. CNA 20 stated after Resident 11 fell, CNA 13 went out to call the charge nurse for help. On 3/31/16 at 9:20 a.m., during an interview, CNA 20 stated that every time the staff used the standing lift, they must always have two people to assist. Which meant a two-person assist from the start to the finish, until the resident was secure and safe. At 10 a.m., on 3/31/16, during an interview, CNA 13 stated that she was just passing by Resident 11's room and entered to assist another resident in the room and helped CNA 20. CNA 13 stated she had her backed turned, while CNA 20 was applying the belt on Resident 11. On 3/31/16 at 10:45 a.m., during an interview, the director of staff and development (DSD) stated that upon being hired all CNAs are in-serviced and trained regarding the standing lift. The DSD stated all CNAs are given the policy titled, ?Safe Patient Lifting and Repositioning" to read and sign, and to do a return demonstration. The DSD stated during the return demonstration she emphasized that every time a standing lift was used a two-person assist or more was required. During a review of the facility's employees files regarding in-service and training of the standing lift. There was no documented evidence, CNA 20 who was hired on 12/16/14, and re-hired on 11/17/15, was given an in-service and training in the years of 2014, 2015, and 2016, of the proper use of the standing lift. At 4/1/16 at 1:30 p.m., during an interview, CNA 20 stated she was given an in-service and training by the rehabilitation staff and the DSD regarding how to transfer a resident using a standing lift, but could not remember when. CNA 20 stated," I think before the incident happened with Resident 11." On 4/1/16 at 1:40 p.m., during an interview, the DSD stated before the staff start to transfer a resident using the standing lift, they should always ask for help. The DSD stated there must be at least two or more to assist. The DSD further stated that there was no point in time when a staff starts transferring a resident, using the standing lift, that the staff should leave or lose focus to prevent accident. On 4/4/16 at 2:35 p.m., during an interview, the physical therapist (PT) stated that he does not provide in-service or training regarding the use of the standing lift. The PT stated it was the DSD who provided the training, because it was more of a nursing skill, but stated, "We do teach staff regarding safe transfer." A review of Resident 11's clinical record indicated an incident note, dated 8/10/15, and timed at 4:30 p.m., indicated LVN 10 was notified that Resident 11 was on the floor in his room. LVN 10 immediately went to the scene and noted that Resident 11 was lying on his right side and holding his left arm and shoulder area. LVN 10 assisted Resident 11 back to bed using a full body lift, with a two-person assistance. LVN 10, did a further skin assessment and observed yellowish discoloration to Resident 11's left shoulder, with a raised bump on the left arm without any opened area or bleeding noted. The note indicated the left arm was immediately immobilized shoulder and ice compresses were applied. Resident 11 was medicated with Tylenol 650 milligram (mg) given for facial grimacing and shoulder pain. The physician was notified and ordered a "stat (immediately)" x-ray order, but instead Resident 11 was transferred to the GACH for an evaluation and treatment. A review of the clinical record for Resident 11 GACH's records, dated 8/10/15, and timed at 4:16 p.m., indicated the x-ray results revealed Resident 11 had a comminuted (break or splinter of the bone into more than two fragments) mid-humerus fracture with mild angulation (rotation and loss of alignment). The emergency room's note further indicated that Resident 11 required a surgery to place a rod in the arm and therefore should be admitted for surgery. A review of Resident 11's GACH record (medication administration record) indicated that Resident 11 was given Dilaudid (injection into the deep muscle to treat moderate to severe pain) and Norco (pain medication) for the following dates: -8/10/15 at 4:52 p.m., Dilaudid 0.5 mg intramuscular IM, right deltoid (muscle forming the rounded contour of the shoulder). -8/11/15 at 8:33 p.m., Norco 10-325 mg one tablet, given orally. -8/12/15 at 8:54 a.m., Norco 10-325 mg one tablet, given orally. -8/13/15 at 5:37 a.m., Norco 10-325 mg one tablet, given orally. -8/13/15 at 5:11 p.m., Norco 10-325 mg one tablet, given orally. A review of an orthopedic surgeon (educated and trained in the diagnosis and treatment of diseases and injuries of the musculoskeletal system) progress note, dated 8/11/15, and timed at 7:15 p.m., indicated since Resident 11 had a history of diabetes mellitus the situation was discussed with Resident 11's family members. The note indicated the family chose a closed and conservative treatment with an arm sling and splint (a rigid or flexible appliance for fixation of displaced or movable parts). The note indicated the patient may benefit with the use of a Sarmeinto humeral arm cuff (a pre-fabricated foam-lined orthosis designed for the management of a mid-shaft and distal third humeral fractures) and then also the sling. A review of the facility's policy and procedure titled, "Lifting Machine By Mechanical Device," dated 11/2012, indicated the facility's staff are to follow the manufacturer's instructions for the use of the lifting machines with a minimum of two staff members used to reduce the risk of staff and residents injury. The policy also stipulated the DSD or (designee ) will provide training regarding the safe and correct use of mechanical lifts (per manufacturer?s instructions) to nursing staff during the orientation process, and periodically as the need arises, such as new or different equipment acquired. The facility failed to ensure the residents environment remains as free from accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents, including but not limited to: 1. Failure to follow its policy and procedure. 2. Failure to provide a two-person physical assist for transferring Resident 11 with a mechanical lift. 3. Failure to follow the manufacturer?s guidelines in using a mechanical lift. 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. |
| 940000111 |
WINDSOR PALMS CARE CENTER of ARTESIA |
940012232 |
B |
26-May-16 |
59C811 |
30441 |
F441 ?483.65(a)(b) The facility must establish and maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection.(a) Infection Control Program The facility must establish an Infection Control Program under which it - (1) Investigates, controls, and prevents infections in the facility; (2) Decides what procedures, such as isolation, should be applied to an individual resident; and (3) Maintains a record of incidents and corrective actions related to infections.(b) Preventing Spread of Infection (1) When the Infection Control Program determines that a resident needs isolation to prevent the spread of infection, the facility must isolate the resident. (2) The facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease. (3) The facility must require staff to wash their hands after each direct resident contact for which hand washing is indicated by accepted professional practice.(c) Linens Personnel must handle, store, process and transport linens so as to prevent the spread of infection.The facility failed to implement an infection control program that tracks, provide surveillance and prevents the spread of infection ([scabies] a contagious skin infestation by the mite Sarcoptes scabiei resulting in severe itchiness) for six of 30 sampled residents (Residents 5, 10, 12, 14, 19, and 24) and 37 of 72 randomly selected residents (RSR 31-35; 37-41; 43-45; 47-50; 52-56; 58-71, and 78) for a total of 40 residents since 1/2015, including but not limited: 1. Failure to follow its policy and procedure and Public Health Department's (DPH) recommendations for infection control. 2. Failure to treated roommates of residents who were treated for scabies and provide contact isolation. 3. Failure to report a scabies outbreak to the DPH, as stipulated in the policy. As a result of the facility?s failures of not following the policies to control scabies, since 1/2015, 40 documented residents contracted rashes with itching and some were treated multiple times with Elimite and Ivermectin (both anti-parasitic). The facility did not provide prophylaxis (to prevent something from occurring) treatment to residents in the same room simultaneously (at the same time) or isolation precautions as stipulated in the policy to control and eradicate the highly contagious skin infection. This resulted in residents complaining of rashes with constant itching and scratching and resulted in the spread of the infection and had the potential to affect more residents, staff, and visitors.Residents 5, 10, 12, 14 and 36 RSRs for a total of 40 residents, who were symptomatic with rashes and itching, were treated with Elimite, without a diagnosis; isolation; or the facility following its policy and/or the (PHD) policy regarding treatment and prevention of scabies to prevent the spread of the infection.1. On 3/29/15 at 7:50 a.m., during the facility's initial tour, Resident 5 was observed standing in front of the nursing station complaining of a body rash with itching. Resident 5 was observed asking a licensed vocational nurse (LVN 3) for a skin treatment. In a concurrent interview, LVN 3 stated, "She (Resident 5) wants a skin treatment." LVN 3 escorted Resident 5 to her room, which Resident 5 shared with three other residents, to observe Resident 5?s skin condition. When LVN 3 was asked if any of Resident 5's roommates had rashes he stated, "Yes, one of the roommates (Resident 10), has rashes too." During an observation of Resident 5's rash, there were multiple scattered small pink raised rashes on the back, chest, abdomen and abdominal folds, both inner thighs, and inguinal (groin) area. In a concurrent interview, Resident 5 stated she had the rash for a long time for more than a month and it was not getting better. Resident 5 stated, "I get ointments, but it does not get better."According to Resident 5's Admission Face Sheet, Resident 5 was admitted to the facility on 4/15/15 and readmitted on 5/18/15. Resident 5's diagnoses included paranoid schizophrenia (a mental disorder resulting in faulty perception, inappropriate actions and feelings that other people are trying to hurt them).A review of Resident 5's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 1/19/16, indicated Resident 5 had no cognitive (ability to think and reason) impairment and was able to make needs known and understand others. The MDS indicated Resident 5 required limited assistance (resident highly involve in activity) with a one-person assist with personal hygiene.According to a facility's document titled, "Interact Change of Condition Evaluation,? dated 12/13/15, Resident 5 was assessed with scant (limited number) rashes to the abdomen and lower back and the resident complained of pruritus (irritating skin itchiness). On 1/15/16, the report indicated the recurrent scant papular (small, solid, inflamed raised bumps) rash had progressed to the resident ' s generalized body and Resident 5 continued to complain of occasional pruritus. On 3/30/16 at 11:15 a.m., during a concurrent interview and record review, conducted with the assistant director of nursing (ADON), Resident 5's Medication Administration Record (MAR) and the physician's orders, indicated Resident 5 was assessed and treated for an ongoing skin rash with various creams and ointments. Resident 5 had a rash on the abdomen and the lower back and received skin treatment from 12/13/15 to 2/26/16. Then for another 20 days from 3/9/16 to 3/29/16, the documentation indicated Resident 5?s rash had spread and became a general body rash.On 2/18/16, Resident 5 was treated with Elimite Cream 5 % applied to all skin surfaces from the head to the soles of the feet; between the toes and fingers and left on overnight for 8-14 hours. There was no documented evidence Resident 5 was placed in isolation or that the other three roommates were treated simultaneously (at the same time), as stipulated in the DPH and the facility?s policy (as confirmed by the infection control nurse [LVN 1]).During a concurrent interview, on the same date and time (3/30/16 at 11:15 a.m.), the ADON stated, "The resident (Resident 5) had rashes since December last year (2015), but she was receiving skin treatments." When asked if Resident 5 was seen by a dermatologist (a physician who specialized in skin disease) for evaluation and treatment, since the rashes had not been resolve for four months after multiple treatments, the ADON replied, "No, she (Resident 5) did not have a skin scraping (a skin test for mites, eggs, or mite fecal matter and look under a microscope.) and was not seen by the dermatologist. Her (Resident 5) primary physician is not a dermatologist, but he is the one that diagnosed her skin problem and ordered the skin treatments. We cannot do anything if that's what the primary doctor ordered."A review of Resident 5's primary physician's progress notes, dated from December 2015 to April 2016, there was no documented evidence that indicated the reason for repeated treatment of Nystatin-Triamcinolone Cream 1% for Resident 5's general body rashes when the treatment was ineffective, because Resident 5 continued to itch and scratch. There was also no documentation in Resident 5's clinical record that Resident 5 was seen by a dermatologist and or skin scrapings were ordered and done prior to the application of the Elimite cream to ensure Resident 5 received the medication for the treatment of scabies. There was no contact precaution signage posted in on Resident 5's room to alert staff and visitors to wear personal protective equipment ([PPE], refers to protective items, such as gloves, and head caps, long sleeve gown, worn to protect the body from contact with infectious/hazardous agents).2. On 3/29/16 at 2:15 p.m., during a skin observation of Resident 10's skin with a licensed vocational nurse (LVN 11). Resident 10, who was Resident 5's roommate, had multiple dry, dark brown color scaly, and pinkish pimple-like rash on the chest, back, and upper/lower extremities.A review of Resident 10's Admission Face Sheet indicated the resident was originally admitted to the facility on 5/29/14 and re-admitted on 8/26/15. Resident 10's diagnoses included chronic kidney disease ([CKD] loss of kidney function), diabetes mellitus (a long term metabolic disorder that is characterized by high blood sugar, insulin resistance, and relative lack of insulin), major depressive disorder (a mental disorder characterized by a pervasive and persistent low mood that is accompanied by low self-esteem) and anxiety disorder (mental disorder characterized by feelings of anxiety and fear). A review of Resident 10's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 1/7/16, indicated Resident 10 was independent in cognitive skills for daily decision-making, and had no short or long-term memory problems. On 3/30/16, at 2:30 p.m., during an interview, a treatment nurse (LVN 3), stated Resident 10 had develop a generalized body rash on 8/27/15 (over 7 months prior) based on a documented skin monitoring and assessment. LVN 3 stated Resident 10 was seen and examined by Resident 10?s primary physician on 8/27/15 at 2:15 p.m., and the primary physician gave an order for hydrocortisone (used to treat skin inflammation and itching) to be applied to Resident 10?s generalized body rash twice a day for 14 days. The physician also ordered a dermatologist consult. On 3/31/16, at 7:25 a.m., during a concurrent interview and observation in the dining area, Resident 10 stated she was transferred to another room and was now in a room by herself. During an interview, LVN 3 stated Resident 10 was seen by the dermatologist on 3/30/16 in the afternoon and a skin scraping (test for scabies) was ordered for Resident 10. LVN 3 stated Resident 10 was placed in isolation.On 3/31/16, at 8 a.m., during a telephone interview, Resident 10's primary physician stated he suspected the resident may have scabies so he referred Resident 10 to be seen by the dermatologist back on 8/27/15 and 11/13/15.At 2:50 p.m., on 3/31/16, during Resident 10's clinical record review with the ADON, the progress notes and skin monitoring assessment indicated Resident 10 was seen and examined by a dermatologist with an order for Elimite cream 5% and fluocinonide cream 0.05% (anti-inflammatory agent relieves itching, redness, dryness, crusting, scaling). The dermatologist ordered the following: -On 8/27/15, Isolation and Elimite cream 5% twice, once a week, Zyrtec (use to treat itching and swelling) 10 mg by mouth once a day times four weeks and lidex (use to treat skin rashes) cream 0.05 % twice a day for four weeks. -On 9/2/15, Elimite cream 5%, Fluocinonide cream 0.05% twice a day. -On 9/10/15, Fluocinonide cream 0.05% twice a day for two weeks. - On 9/16/15, Fluocinonide cream 0.05% twice a day for two weeks. -On 10/7/15, continue Fluocinonide cream 0.05% twice a day for rash on the lower back and abdomen, on and off; Benadryl by mouth (use to treat itching) 25 mg once a day for three weeks for pruritus. A review Resident 10's primary physician's progress note and skin monitoring assessment, dated 11/13/15, indicated the primary physician ordered Celestone Soluspan Suspension (treatment for atopic dermatitis and contact dermatitis) 6 mg IM (injection to the muscle) on 11/13/15, 11/16/15, and 11/19/15. Resident 10?s primary physician ordered another dermatologist consult. A further review of Resident 10?s skin monitoring assessment, indicated Resident 10 had a general erythematous (abnormal redness of the skin due to local congestion, as in inflammation) papular body rash with scattered opened areas, lesions with yellow patches of skin surrounding the erythema. On 3/31/16, at 3:15 p.m., during an interview and record review, the ADON stated Resident 10 was not seen by the dermatologist on 11/13/15, as prescribed by the resident?s primary physician. The ADON stated sometimes the consultant would refused to see the residents because of the lack of insurance coverage, then the ADON stated, ?I think the dermatologist was on vacation, I do not know why Resident 10 was not seen on 11/13/15. " The ADON stated, ?The resident (Resident 10) was not isolated, on 8/27/15, as ordered by the dermatologist, because Resident 10 was not diagnosed with scabies.? On 4/1/16, a review of Resident 10's diagnostic laboratories results of a skin scraping performed on 3/30/16, after being treated with Elimite cream several times, indicated the skin scraping was negative for scabies.3. On 3/31/16 at 2:43 p.m., during an observation, Resident 14 was observed with multiple red spot rashes on both hands, including the fingers, while sitting in a wheelchair in front of the nurses' station. A review of Resident 14's Face Sheet (record of admission) indicated the resident was initially admitted to the facility on 2/20/15 and re-admitted on 3/21/16. Resident 14 diagnoses included bacteremia (infection in the blood stream), recent hip fracture, and chronic kidney disease (progressive loss of kidney function).A review of Resident 14's Minimum Data Set (MDS), a standardized care screening and assessment tool, dated 2/25/16, indicated the resident was oriented to year only. According to the MDS, Resident 14 required an extensive assistance of a one-person assist with personal hygiene and dressing. A review of a dermatologist progress note, dated 11/4/15, indicated an evaluation of a generalized body rash for Resident 14 that was described as "papules excoriated" and Resident 14 placed on contact isolation. A review of Resident 14 physician's orders, dated 10/31/15, indicated for an Elimite treatment on 11/1/15 and 11/8/15, and place the resident (Resident 14) in contact isolation for three days post each Elimite treatment.A review of Resident 14 physician's order, dated 12/21/15, indicated to give Ivermectin tablet (oral medication used for parasitic infections) 15 milligram by mouth one time daily only for generalized body rash on 1/2/16, 1/9/16 and 1/16/16. There was no order to place Resident 14 in contact isolation.A review of Resident 14 physician's order, dated 12/30/15, indicated Permethrin (Elimite) Cream 5% (medication for scabies) apply to generalized body daily one time daily every seven days for rash until 1/8/16, but there was no order for contact isolation. A review of Resident 14's general acute care hospital (GACH) physician's order indicated Resident 14 was complaining of itching and was prescribed and receiving Benadryl (medication for itching), while in the hospital for a hip fracture status-post a fall. The physician's order indicated a medication order for Benadyl 25 milligram (mg) every eight hours as needed started on 1/27/16 to 1/29/16 intravenously (into the vein), and Benadryl 25 mg one tablet every 6 hours as needed for itching from 1/24/16 to 2/23/16, during Resident 14's hospital stay. The facility failed to inform the GACH regarding Resident 14's potential risk for having scabies and receiving multiple treatments (four) with Elimite, prior to being hospitilized. A review of Resident 14's physician's order, dated 3/30/16, indicated to apply Elimite Cream 5% onto all skin surfaces from Resident 14's head to the soles of the feet and between toes/fingers and leave on overnight for 8-14 hours and showered off in the a.m.. A review of Resident 14's physician's order, dated 3/30/16, and timed at 7:10 p.m., indicated to place Resident 14 on contact isolation, indefinitely pending results of the skin scraping. A review of Resident 14's diagnostic laboratory result of the skin scraping for scabies that was collected on 3/31/16 at 3:35 p.m. The skin scraping results, dated 4/1/16, and timed at 12:16 p.m., indicated "scabies present." On 4/1/16 at 1:21 p.m., during an observation, Resident 14 was placed on contact isolation, with an isolation cart outside the door, but remained in the room with the three other roommates (Residents 3, 13 and 59), who were not treated. There was no documented evidence the three other residents in the room had been treated for scabies, after Resident 14 was diagnosed to have scabies. On 4/1/16 at 1:30 p.m., during a concurrent interview and record review, LVN 3 stated Resident 14's generalized rashes were first observed and documented on 10/31/15. LVN 3 stated Resident 14 received an Elimite treatment on 11/1/15, without a physician's order to perform a skin scraping. During a concurrent observation, Resident 14's skin rashes, on the bilateral hands, right forearm, abdomen, and back, had "red papules" (red skin lesion) all over. LVN 3 stated the rash the resident has now, looked the same and was in the same areas as it was back in 11/2015 (four months prior). On 4/4/16 at 3:40 p.m., during an interview, a treatment nurse (LVN 3) stated he had 106 residents in his unit (Terrance East and West). LVN 3 stated many residents had rashes and received Elimite treatment; some residents received the treatment many times. LVN 3 stated Resident 14's skin scraping was positive for scabies on 3/30/16, after the survey team questioned the staff about why so many residents had rashes. LVN 3 stated, after being questioned by the survey team, they called the dermatologist to come to evaluate the residents. LVN 3 stated Resident 14 was placed in isolation after the positive scabies diagnosis. LVN 3 was asked if Resident 14's three roommates were treated prophylactically for scabies, LVN 3 stated, ?No, the residents have to agree to receive the Elimite." LVN 3 was asked if the residents were asked and informed about the risk of contracting scabies and he stated, ?No, the residents were not asked or informed." LVN 3 stated they are monitoring the residents to see if they will develop a rash and then they will provide treatment. LVN 3 stated in the past, they would call the resident?s primary physicians and describe the resident?s rash and the physicians would sometime order Elimite to be applied. On 4/5/16 at 7:25 a.m., Resident 14 was observed in a private isolation room, after donning PPEs, Resident 14's rash was observed. The rash was reddish in color with papules on Resident 14's back and chest. Resident 14 stated, "It itches, but I have nothing else to do, but scratch." At 10:30 a.m., on 4/5/16, during an interview, a registered nurse (RN) supervisor, (RN 1) stated they called the PHD, and spoke to the PHN nurse supervisor on 4/1/16, after Resident 14 was positive for scabies. She stated some of the Elimite orders were prescribed by the residents' primary physicians and the others were prescribed by the dermatologist when she would make visits. RN 1 stated some of the residents were prescribed Ivermectin (Oral ivermectin is an effective and cost-comparable alternative to topical agents in the treatment of scabies infection) in addition to the Elimite. She stated once they contacted the PHD for direction in treating Resident 14 for scabies, they were told it was not reportable since it was only one resident. 4. A review of Resident 12's Admission Face Sheet indicated Resident 12 was admitted to the facility on 9/10/14. Resident 12's diagnoses included schizoaffective disorder (a psychological condition that consist of loss of contact with reality and mania [hyperactivity] or depression), cirrhosis of the liver (a condition in which the liver does not function properly due to long-term damage), and Parkinson?s disease (a neurological disorder that targets brain cells that control movement). A review of Resident 12's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 9/16/15, indicated Resident 12's decision-making and memory was moderately impaired, but Resident 12 only required limited assistance for activities of daily living. On 3/30/16 at 9:30 a.m., during a concurrent record review and interview, LVN 3 stated that Resident 12 had a "generalized body rash? and was treated with wescort ointment 0.2% (medication used to treat inflammation of the skin caused by a number of conditions such as allergic reactions, inflammation of the skin, or psoriasis-red, [itchy, and scaly patches of abnormal skin]) for four weeks to treat the psoriasis. Resident 12 was treated with Elimite (a topical medication for the treatment of scabies [1/16/16 and 1/24/16]) as preventive treatment along with Zyrtec (used to treat cold or allergy symptoms such as sneezing, itching, watery eyes, or runny nose, also itching and swelling caused by chronic hives [swollen, pale red bumps or welts]) 10 mg for three weeks. LVN 3 stated Resident 12's rash ?was due to the resident's liver condition." A review of Resident 12's Order Summary Report (a recapitulation of the physician's orders) for the month of January 2016, indicated an order, dated 1/16/16, for contact precautions for the diagnosis of generalized body rash.A review of the physician's orders, dated 1/16/16, and timed at 9:53 p.m., indicated an order for Elimite treatment one time only until 1/17/16. A second order, dated 1/16/16 at 9:57 pm., indicated another order for Elimite cream ordered for one time application until 1/24/16.A review of Resident 12's Wound Weekly Monitoring/Assessment, dated 1/11/16, indicated an assessment of a general body rash with circular/oval shape and normal surrounding tissue. The wound care treatment notes specified the current treatment of westcort ointment 09.2% twice daily. Resident 12's Wound Weekly Monitoring/Assessments, dated 1/25/16, 2/2/16, 2/8/16, 2/15/16, 2/22/16, 3/1/16, 3/8/16, and 3/17/16, indicated that Resident 12 had a generalized body rash, described as circular/oval in shape and with edges even, no depth noted. The wound care treatment notes specified the current treatment of Westcort ointment 09.2% twice daily and Elimite cream 5% applied on 1/17/16 and on 1/24/16. The record also indicated that Resident 12 denied any pain, discomfort nor pruritus during time of the assessments.A review of an online article, by Medline Plus, titled, Permethrin Topical, indicated Elimite use can cause numbness or tingling of the skin; rash; and some side effects can be serious, such as, trouble breathing; continued irritation of the skin or scalp area; infected or pus filled areas of the skin or scalp area at https://www.nlm.nih.gov/medlineplus/druginfo/meds/a698037.html On 4/5/16 at 8:25 a.m., during an interview, the facility's infection control nurse (LVN 1) stated since Resident 14's roommates did not have a rash they were not required to treat them. LVN 1 stated although Resident 14 was positive for scabies and had to be isolated, it was not necessary to treat the roommates. LVN 1, who initially was not providing information when she was asked for tracking and surveillance of skin rashes, stated after the survey team questioned the staff about so many residents with rashes on 3/30/16, the dermatologist was called and came performed skin scrapings (test for scabies mites) on five residents (Residents 14, 31, 33, 46, and 69), all were negative, except for Resident 14. LVN 1 stated they treated a lot of residents last year with Elimite for rashes with itching, but stated neither she nor anyone else at the facility reported all the rashes to the PHD. LVN 1 also stated three of the facility?s staff member requested to receive Elimite, because they were itching. However, as of that day, the three employees (included laundry staff, housekeeper, and one rehab staff) had not received the Elimite.On 4/5/16 at 11:25 a.m., during a telephone interview, a public health nurse (PHN) supervisor, from the communicable disease control program, stated the facility's staff called her on 4/1/16, and stated they only had one case of scabies and asked her if it was required to be reported. She (PHN) stated she informed them if it was only one case, it was not required to report. After the PHN was informed of all of the findings and multiple treatments with Elimite, she stated she was not informed about all the other residents with rashes, itching, and receiving Elimite treatment for over a year. She was asked if she had been informed, would her response to the facility have been different. The PHN stated,? Yes, I would have told them if they had two or more suspected cases it should be reported immediately. ?The PHN further stated it was a major problem and concern that they did not treat Resident 14's roommates once he was identified positive for scabies. The PHN supervisor stated, as she had informed the facility, if they apply Elimite on a resident with a rash with itching, then they are treating scabies and it should be reported. The PHN stated it is only considered prophylaxis when there are no signs/symptoms of scabies. The PHN stated all of Resident 14's roommates and care givers should have been treated prophylactically. She stated since the case seemed serious and the facility was not following the guidelines she had provided them she will open a case and personally come to the facility the next day (4/6/16). The PHN supervisor stated, after looking in the computer, the facility had not reported anything to them since 2011. According to the physician's orders and a list provided by the infection control nurse (LVN 1) the following residents received Elimite applications on the following dates: ResidentsElimite TX5 2/18/16 10 8/27/15, 9/2/15, 3/25/16, 3/31/16 12 1/16/16, 1/24/16 14 11/1/15, 11/8/15, 12/30/15,1/8/16, 3/30/16 31 1/22/16, 3/31/16 32 9/2015, 3/23/1633 1/16/16, 3/30/16 34 4/13/15, 7/14/15,7/21/15,9/17/15,9/24/15,11/6/15, 11/13/15 35 4/15/15 37 2/19/15, 2/26/15, 11/201538 4/2015 39 3/24/16 40 2/201541 9/201543 4/3/15, 4/9/15, 10/8/15, 10/15/15,44 4/23/15, 4/29/15 45 4/17/15, 5/6/15, 9/15/15 47 10/4/15, 10/11/15 48 11/14/15, 11/21/15 49 11/201550 12/14/15 52 4/11/16 53 5/201554 1/21/15, 1/29/15 55 3/30/15 56 9/201558 12/2015 60 1/22/16, 4/11/16 611/26/16 62 1/27/16, 2/3/16 63 3/31/16 65 1/13/16 66 1/27/16, 2/3/16 67 2/25/16 68 1/22/16 69 3/30/16 70 3/30/16 71 1/7/16 According to the Public Health Department a Guideline titled, "Management of Scabies Outbreaks in California Health Care Facilities," dated March 2008, indicated Scabies was a mite transmitted by direct contact with the person's skin. The sign and symptoms can include papules (red raised bumps) on the hand, wrist, elbows, and fold of armpits, female breast or male genitalia. The guidelines indicated in the long term care facility, the lesions may be found on the back and buttocks of the residents. As the infestation progresses, the rash may mimic other dermatological conditions. The guidelines indicated, usually the first indication that a scabies infestation was evolving was complaints of itching and new onset of rash by one or more residents within a period of 5-12 days. Skin scrapping was recommended on at least one symptomatic case. The guideline stipulated the absence of mites, eggs, or fecal pellets on microscopic examination, does not mean the resident does not have scabies. However, a positive skin scrapping should assist the physicians in the development of appropriate therapeutic and prophylactic treatment plans. The guideline also indicated an outbreak was either one confirmed (positive scraping) or at least two clinically suspected cases (residents, staff, volunteers etc.) during a two week period. A review of a letter, dated 4/8/16, addressed to the facility from the PHD/communicable diseases division and signed by a physician titled, ?Rash/Scabies Outbreak Notification," indicated an outbreak had been identified with specific guidelines provided of how to handle the scabies outbreak to prevent further infections, which stipulated no discharges or admissions until completed. A review of the facility's policy titled, "Infection Prevention and Control, dated March 2009, indicated when scabies were suspected, an immediate search for additional cases should be initiated. The policy also stipulated a scabies control program should be developed and approved by the infection control committee and the program should designate a physician, such as the medical director. The policy also indicated the infection control practitioner was responsible for the following: 1. Identification of contacts of symptomatic cases. 2. Prevention of transmission. 3. Treatment of symptomatic cases. 4. Treatment of contacts. 5. Post treatment assessment. 6. Assessment failures. On 4/15/16, at 1:30 p.m., during an extended survey, the facility's medical director stated the facility had scabies and he stated he thought the gait belt (a device used to transfer residents from one position to another, or while ambulating residents) used by the staff applied to many residents was a possible mode of transmission of the scabies. The facility failed to implement an infection control program that tracks, provide surveillance and prevents the spread of infection for six of 30 sampled residents (Residents 5, 10, 12, 14, 19, and 24) and 37 of 72 randomly selected residents (RSR 31-35; 37-41; 43-45; 47-50; 52-56; 58-71, and 78) for a total of 40 residents since 1/2015, including but not limited: 1. Failure to follow its policy and procedure and Public Health Department's (DPH) recommendations for infection control. 2. Failure to treated roommates of residents who were treated for scabies and provide contact isolation. 3. Failure to report a scabies outbreak to the DPH, as stipulated in the policy. The above violation had a direct or immediate relationship to the health, safety, or security of the residents. |
| 940000111 |
WINDSOR PALMS CARE CENTER of ARTESIA |
940012233 |
A |
26-May-16 |
59C811 |
10082 |
F 323 ? ?483.25 (h) Accidents The facility must ensure that ? (1) The resident environment remains as free from accident hazards as is possible: and (2) Each resident receives adequate supervision and assistance devices to prevent accidents. The Department received an entity reported incident (ERI) on 1/25/16, alleging that a resident (Resident 14) was reported to have pain in his left hip on 1/23/16. X-rays were ordered and taken with an acute femoral fracture identified, requiring a transfer to a general acute care hospital (GACH).The facility failed to ensure residents received adequate supervision to prevent accidents, including but not limited to: 1. Failure to follow its policy and procedure regarding supervision. 2. Failure to provide supervision of Resident 14. 3. Failure to identify a plan of care to provide supervision of Resident 14, who had a high risk for falls and had five recent falls. 4. Failure to investigate each fall, as a plan for fall prevention.These failures resulted in Resident 14, who was at risk for falls, and had a history of many falls, having two falls on the same day. The last fall, on 1/18/16, resultedin a fracture (broken bone) of Resident 14?s left hip, requiring a transfer to a GACH. Resident 14 was admitted for seven days and underwent surgical intervention to repair the left hip fracture and required a strong narcotic medication (Dilaudid) for pain control. During a recertification survey of a locked facility on 4/1/16 at 10:27 a.m., Resident 14 was observed sitting in a wheelchair inside his room.A review of Resident 14's Admission Face Sheet indicated Resident 14 was a 79 year-old male who was admitted to the facility on 2/20/15 and readmitted from the GACH on 3/21/16. According to the Admission Face Sheet and a Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 2/25/16, Resident 14's diagnoses included dementia (a decline in mental ability), Parkinson's disease (a disorder that affects movement), repeated falls, and a left hip fracture.A review of Resident 14's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 11/27/15, indicated Resident 14 had moderate cognitive impairment. Per the MDS, Resident 14 required non-weight bearing assistance during ambulation to and from any distant areas on the floor. The MDS, dated 1/1/16, indicated Resident 14 required guided maneuvering during transfers between surfaces (to and from the chair and standing position).Resident 14's nursing care plans did not have specific staff approaches as to how Resident 14 will be supervised when walking. The care plans only focused on the resident's decline in mobility, transfers, and decreased balance and safety awareness, but was documented as ?Resolved? on 1/5/16.A review of the facility's interventions, developed during the interdisciplinary team (IDT) meetings, after each of Resident 14's fall incidents (except 10/2/15), dated 10/20/15, 11/9/15, 11/12/15, and 1/19/16, lacked documentation of an evaluation of prior interventions to address Resident 14's unsteadiness and weakness.On 4/6/16 at 10:40 a.m., during an interview, a registered nurse (RN 2) indicated that the IDT meetings were conducted on residents after each fall incident. RN 2 stated, "We do analysis and we do what we could do." RN 2 indicated that they did not conduct an IDT meeting after Resident 14's fall incident on 10/2/15, which was Resident 14's first fall. RN 2 stated, ?I have no idea why we don't have an IDT for that fall."On 4/6/16 at 11:15 a.m., during an interview, a licensed vocational nurse (LVN 8) indicated that she regularly took care of Resident 14 as a charge nurse. LVN 8 stated that Resident 14 was very confused, required help with showers, was able to walk, but was assessed to be a fall risk with repeated incidents of actual falls. According to LVN 8, ?His (Resident 14?s) legs were weak and balance was unstable." LVN 8 stated that in November 2015, there was an incident when Resident 14 had fallen twice in one day, LVN 8 stated the first fall incident happened ?around 5:30 a.m., " on 11/12 /15, before she started her shift at 7 a.m. LVN 8 stated Resident 14 had the second fall on her shift, " after breakfast " on the same day, on 11/12/15. LVN 8 was asked whether she implemented additional interventions to prevent Resident 14 from falling the second time on the same day (11/12/15). LVN 8 stated she had instructed Resident 14's certified nursing assistant (CNA) to watch the resident. LVN 8 stated, "I told the CNA (CNA 27) that we cannot leave him (Resident 14) by himself.? LVN 8 stated, ?The problem was we didn't have an extra CNA to watch the resident and the CNA (CNA 27) had to help other residents.?During an interview on 4/6/16 at 3:45 p.m., a physical therapist (PT 1) indicated that she initially provided rehabilitation (rehab) services for Resident 14 in the month of November 2015, after the fall. PT 1 indicated that due to Resident 14 having dementia, he had difficulty in following instructions and staying on task. PT 1 indicated that Resident 14 had an unsafe gait pattern and required contact guard assist (help with balance by use of hands). PT 1 stated that Resident 14 stopped receiving rehab services on 1/5/16. PT 1 stated that upon Resident 14's discharge from rehab on 1/5/16 he demonstrated independence in ambulation, but still required visual or verbal cues for safety recognition.On 4/7/16 at 9:18 a.m., during a telephone interview, CNA 28 stated Resident 14 had fallen during her shift in January 2016 (1/18/16). According to CNA 28, she was not aware that Resident 14 had gone out to the smoking patio because she was assisting another resident. CNA 28 stated, "I have other residents who are total care." CNA 28 stated the charge nurse had informed her that Resident 14 had fallen in the smoking patio and they had done an incident report that time. CNA 28 stated, "I was surprised that he (Resident 14) went to the smoking area, because he always just stayed in the dining room.?A review of Resident 14's nursing progress notes documented from 10/2/15 through 1/23/16 indicated Resident 14 had fallen five times within three months in the facility as follows: ?An entry, dated 10/2/15, and timed at 7:19 p.m., indicated the staff found the resident on the bathroom floor. The resident was found to have an abrasion (an area damaged by scraping or wearing away) on the left knee. -An entry, dated 11/8/15, and timed at 9 p.m., indicated the staff found the resident on the floor outside the bathroom. The resident sustained a skin tear (partial or complete separation of the outer skin layers from the inner tissue) on the right forearm. -An entry, dated 11/12/15, and timed at 8:27 a.m., indicated at 5:30 a.m., that day, the resident tried to walk without assistance and fell. The resident sustained an abrasion on the left knee. -An entry, dated 11/12/15, and timed at 9:37 a.m., indicated at 8:50 a.m., that day, the resident tried to walk without assistance and fell. The resident sustained a laceration (a deep cut or tear in skin or flesh) on the right eyebrow. -An entry, dated 1/18/16, and timed at 3:20 p.m., indicated at 9:30 a.m., the staff found the resident on the floor by the smoking patio. The resident sustained a bump on the right cheek and abrasions on the left knee.A review of a nursing progress note, dated 1/23/16, and timed at 11:31 a.m., indicated Resident 14 complained of pain on the left hip. A subsequent nursing note, dated 1/23/16, and timed at 7:20 p.m., indicated Resident 14 was sent to the GACH, after an x-ray (left hip) indicated Resident 14 had a fractured (broken bone) left hip.A review of Resident 14's admission note, dated 1/23/16, from the GACH's emergency room, indicated that the primary complaint was a fall and Resident 14 presented with a left hip fracture.A review of Resident 14's history and physical (H&P) report, from the GACH, dated 1/24/16, indicated Resident 14 was admitted to the GACH with a left femoral neck (the shaft of the femur; hip) fracture after suffering a fall at the nursing home.A review of the GACH's operative report, dated 1/28/16, indicated Resident 14 underwent a hemiarthroplasty (a surgical procedure for repair of an injured or diseased hip joint involving replacing the head of the femur [long thigh bone] with a prosthesis [an artificial device to replace a missing or impaired part of the body] procedure of the left hip on 1/27/16. The indication for the surgical procedure was documented as, "Mechanical fall, pain in the left hip, inability to walk and x-rays showing a displaced left femoral neck fracture."Resident 14 was readmitted o the facility on 1/30/16, after a seven-day stay at the GACH.A review of the facility's policy and procedure titled, "Accidents and Incidents- Investigating and Reporting,? dated November 2012, stipulated that accidents or incidents occurring on facility's premises must be investigated. The procedures indicated that the results of the investigation and pertinent information will be included in the resident's medical record.On 4/7/16 at 12:10 p.m., the administrator and the director of nursing (DON) were unable to provide documentation of the outcome of the facility's investigation regarding Resident 14's fall that resulted in a fractured hip. The facility failed to ensure residents received adequate supervision to prevent accidents, including but not limited to: 1. Failure to follow its policy and procedure regarding supervision. 2. Failure to provide supervision of Resident 14. 3. Failure to identify a plan of care to provide supervision of Resident 14, who had a high risk for falls and had five recent falls. 4. Failure to investigate each fall, as a plan for fall prevention.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. |
| 940000111 |
WINDSOR PALMS CARE CENTER of ARTESIA |
940012234 |
A |
26-May-16 |
59C811 |
9660 |
F 323 ? ?483.25 (h) Accidents The facility must ensure that ? (1) The resident environment remains as free from accident hazards as is possible: and (2) Each resident receives adequate supervision and assistance devices to prevent accidents. The Department received an entity reported incident (ERI) on 4/4/16, alleging that a resident (Resident 79) became agitated and struck another resident (Resident 80) with a chair on the back of the head. Resident 80 sustained a 3.5 by .4 centimeter (cm) bleeding laceration to the back of the head requiring a transfer to a general acute care hospital (GACH). The facility failed to ensure the residents environment remains as free from accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents, including but not limited to: 1. Failure to follow its policy and procedure. 2. Failure to provide supervision in the residents? dining room. These failures resulted in Resident 80 being struck with a chair, by Resident 79, who had a history of unpredictable behavior warranting close supervision, as per the physician, but was not supervised. Resident 80 sustained blunt head trauma (BHT) and a laceration (a deep cut or tear in skin or flesh) requiring a transfer to a GACH and receiving five staples (used in closing large skin wounds) and pain medications. a.A review of Resident 80's admission Face Sheet indicated the Resident 80 was a 62 year-old male who was admitted to the facility on XXXXXXX Resident 80's diagnoses included dementia with behavioral disturbance (a mental illness characterized by radical changes in personality and distorted sense of reality), schizoaffective disorder (a mental disorder resulting in faulty perception, inappropriate actions and feelings that affects mood and behavior), schizophrenia, (a mental disorder that affects mood, behavior and perception of reality), bipolar disorder (a mental disorder that affects the mood and behavior), and hypertension (elevated blood pressure). A review of Resident 80's quarterly Minimum Data Set (MDS), a standardized assessment and screening tool, dated 2/29/16, indicated Resident 80 had memory problems. According to the MDS, Resident 80 required limited assistance from staff with transferring, personal hygiene, and toilet use. On 4/7/16 at 10:30 a.m., Resident 80 was observed awake sitting in a chair with a stapled (five staples) laceration (a deep cut or tear in skin or flesh) at the back of the head. During an interview, as interpreted by a certified nurse assistant (CNA 26), Resident 80 stated that on 4/4/16 at approximately 12 p.m., he was propelling himself in a wheelchair towards the dining room to get ready for lunch. Resident 80 stated Resident 79 suddenly grabbed a chair and hit him at the back of his head for no reason at all. Resident 80 stated that there were no staff present in the dining room at the time of the incident. A review of another physician's order, dated 4/4/16, indicated to transfer Resident 80 to a general acute care hospital (GACH) for evaluation and treatment of the laceration to Resident's head. A review of the GACH's records (emergency room [ER] note), dated 4/4/16, indicated Resident 80 was transported to the GACH via ambulance after being assaulted by another resident in a facility. The ER note indicated Resident 80 sustained a three centimeter (cm) scalp laceration to the occipito-parietal (part of skull positioned above the occipital lobe and behind the frontal lobe) area with the resident complaining of constant aching non-radiating pain to back of his head. The wound was cleaned and staples were applied. Resident 80 was transferred back to the facility on XXXXXXX, at 4:46 p.m. A review of Resident 80's untitled plan of care, dated 4/4/16, indicated the resident was physically struck by another resident (Resident 79) at the back of the head with a chair and sustained a laceration on the back of the head. The resident's goal was to have no more episodes of being hit by another resident, and be able to cope with the incident. The staff's interventions included to allow the resident to express feelings and concerns, monitor for episodes of isolation: and to provide safety and monitor the resident's whereabouts. A review of Resident 80's untitled another plan of care, dated 4/4/16, indicated the resident had a laceration on the back of the head, with the goal of Resident 80 being free from signs and symptoms of infections. A review of the physician's order, dated 4/2/16 [sic], indicated to cleanse the laceration with staples at the back of the Resident 80's head wound with normal saline, pat dry, and leave open to air. b. A review of Resident 79's Admission Face sheet indicated, Resident 79 was a 45 year-old male who was admitted to the facility on XXXXXXX, and readmitted last on XXXXXXX. Resident's diagnoses included schizoaffective disorder (a mental disorder resulting in faulty perception, inappropriate actions and feelings that affects mood and behavior), schizophrenia, (a mental disorder that affects mood, behavior and perception of reality), and hypertension (elevated blood pressure). A review of Resident 79's annual Minimum Data Set (MDS), a standardized assessment and screening tool, dated 1/21/16, indicated Resident 79 had both long and short-term memory problems, was moderately impaired (decisions poor; cues/supervision required) in cognitive skills for daily decision-making. According to the MDS, Resident 79 required supervision from staff with transferring, mobility and ambulation, but required only limited assistance from staff with personal hygiene and toilet use. A review of Resident 79's untitled plan of care, dated 3/14/16, indicated the resident had behavioral problems of hitting another resident. The resident's goal was to have no behavior problem of hitting another resident. The staff's interventions included to encourage the resident express feelings appropriately and listen attentively, give medications as ordered, and notify the physician of any significant changes. A review of the physician's order, dated 3/30/16, indicated to monitor Resident 79 for behavioral episodes of aggressiveness; responding to internal stimuli; striking out, and for behavioral episodes of unpredictable volatile behavior every shift. A review of another physician's order, dated XXXXXXX, indicated to transfer Resident 79 to the GACH for behavioral management and treatment. A review of a "Nursing Home to Hospital Transfer Form," dated XXXXXXX, indicated Resident 79 was transferred to a GACH for behavioral symptoms of agitation and psychosis. A review of Resident 79's plan of care, dated 4/4/16, indicated the resident had an actual physical behavior of throwing chairs related to poor impulse control, with a history of harm to others. The goal was for the resident to demonstrate effective coping skills, to not harm self or others, and for the resident to seek out staff/caregiver when agitation occurs. The staff's interventions included analyzing key times, places, circumstances, triggers, and what de-escalates the resident?s behavior. On 4/7/16 at 11 a.m., during an interview, CNA 4 stated that on 4/4/16, between the hours of 12 to 12:30 p.m., while residents were waiting for their lunch in the Grove's dining room, he was coming from the hallway (Grove lobby) to check on the residents. CNA 4 stated he saw Resident 79 sitting on a chair, then suddenly grabbed his chair and hit Resident 80 at the back of his head with the chair. CNA 4 further stated that there was no staff present in the dining room during the time of the incident. CNA 4 stated he ran to the dining room to intervene and separated the residents. CNA 4 stated both residents were transferred to the GACH, Resident 79 for the management of his behavior and Resident 80 for the treatment of the head laceration. On 4/7/16 at 12 p.m., during an interview, a licensed vocational nurse (LVN 15) stated that when she heard of the two residents altercation (Resident 79 and Resident 80), she immediately ran to the dining room. LVN 15 stated she observed that there was no staff present and supervising the residents in the dining room during the time of the altercation. LVN 15 stated the other staff was probably busy preparing the other residents for lunch. At 12:30 p.m., on 4/7/16, during an interview, a registered nurse (RN 1) stated, based on her investigation regarding the incident between Resident 79 and Resident 80, there was no staff present supervising the residents in the dining room during the time of the altercation. A review of the facility's policy and procedure, revised in 7/2015, and titled, "Abuse Prevention, Investigation and Reporting," indicated to ensure the resident's rights are protected by providing a method for the prevention of any type of resident abuse. The policy further stipulated each resident had the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion, and misappropriation of property. The facility failed to ensure the residents environment remains as free from accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents, including but not limited to: 1. Failure to follow its policy and procedure. 2. Failure to provide supervision in the residents? dining room. 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. |
| 940000111 |
WINDSOR PALMS CARE CENTER of ARTESIA |
940012367 |
A |
13-Jul-16 |
VSL511 |
8946 |
F 323 ? ?483.25 (h) Accidents The facility must ensure that ? (1) The resident environment remains as free from accident hazards as is possible: and (2) Each resident receives adequate supervision and assistance devices to prevent accidents. The Department received an entity reported incident (ERI) on 6/1/16, alleging a resident (Resident 1) had noted skin discoloration and edema of the bilateral lower extremities (both legs, ankles, and feet) and stat x-rays were ordered. The facility failed to ensure the residents environment remained as free from accident hazards as was possible; and each resident received adequate supervision and assistance devices to prevent accidents, including but not limited to: 1. Failure to follow its policy and procedure regarding transfers with mechanical lifts. 2. Failure to ensure CNA 1 used a two-person assist while transferring Resident 1. 3. Failure to follow Resident 1?s assessment (Minimum Data Set [MDS; a standardized assessment and care planning tool]) that indicated the resident required a two-person physical assist in transferring. 4. Failure to timely report Resident 1?s fall accident, as per the facility?s policy. These failures resulted in Resident 1 falling during transfer, sustaining pain and bruises of both lower legs (tibula [inner and larger bone] /fibula [the outer and narrower bone], and a two day delay in diagnosis and treatment at a general acute care hospital (GACH) for lower leg fractures requiring the application of splints (a splint is a device used for support or immobilization of a limb or the spine) of both legs. On 6/13/16, at 2:07 p.m., during an unannounced visit to the facility, Resident 1 was observed with splints intact to the bilateral lower extremities (BLE). Resident 1 was awake, well groomed, and dressed appropriately. Resident 1 stated she did not remember how she fractured her lower legs. A review of Resident 1?s Admission Face sheet indicated Resident 1 was a 69 year-old female who was admitted to the facility on 9/5/13. Resident 1?s diagnoses included blindness of eyes, generalized muscle weakness, osteoarthritis (joint disease that results from breakdown of joint cartilage and underlying bone), osteoporosis (bones become porous/brittle), and aphasia (loss or impairment of the ability to use or comprehend words). A review of Resident 1?s MDS, dated 3/8/16, indicated Resident 1 had memory problems, unclear speech, severely impaired vision, was unable to walk, and was totally dependent on staff for care. Resident 1 required a two-person physical assist for transferring (moving between surfaces including to or from: bed, chair, wheelchair, standing position). According to the MDS, Resident 1 required a one-person physical assist for eating, dressing, toilet use and personal hygiene. Resident 1 had no functional limitation in the range of motion of the upper and lower extremities and used a wheelchair as a mobility device. A review of a plan of care, dated 3/24/14, titled ?ADL (activity of daily living) self-performance deficit? indicated Resident 1 had deficits in activities of daily living. The staff interventions included to assist Resident 1 with transfers using a mechanical aid of a Hoyer lift with a two-person assist. According to the facility?s interdisciplinary progress notes, on 6/7/16, at 11:49 a.m., when Resident 1 was being transferred by CNA 1 from the bed to the shower chair, Resident 1 slid down the sling and CNA 1 assisted Resident 1 to the floor. Resident 1 sustained BLE fractures (breaks) of both bones of the lower leg, tibia/ fibula requiring an application of a BLE cast. According to a nursing note, dated 5/29/16, and timed at 2:51 p.m., two days after Resident 1?s fall, written by a licensed vocational nurse (LVN 1), Resident 1 had purple discolorations to the right anterior (nearer the front of the body) lower leg measuring 1.0 centimeters (cm) by 0.5 cm with surrounding light blue discoloration measuring 4.0 cm by 5.0 cm. Resident 1 had BLE pitting edema (the formation of a depression or indentation in living tissue that is produced by pressure with a finger or blunt instrument and disappears only slowly following release of the pressure in some forms of edema) +3 edema (6mm deep and10-12 seconds to rebound [bounce back]). The note indicated Resident 1?s pain was 2 on a scale of 0-10 (10 being the worse). Another nurse?s note indicated a message was left with Resident 1?s physician. The physician called back at 7:04 p.m., with an order to monitor Resident 1. A review of the facility?s undated investigation report included a written statement by CNA 1 indicating on 5/27/16, he was transferring Resident 1 from the bed to a shower chair when Resident 1 slid down the standing lift and he assisted her to the floor by putting his two arms on her back. The report indicated that CNA 1 and another CNA 2 did not report Resident 1?s fall incident to the charge nurse. A review of Resident 1?s nursing note, dated 5/31/16, and timed at 11:40 a.m., indicated physician?s orders for BLE and ankles x-ray (digital image of a part of the body), and a venous Doppler (a non-invasive technique that evaluates blood as it flows through a blood vessel) to BLEs. A nurses? note, dated 5/31/16, and timed at 4 p.m., indicated Resident 1 was transferred to a (GACH), four days after falling. A review of the GACH?s report, dated 6/1/16, at 7:05 p.m., indicated Resident 1 had swelling of the BLEs with tenderness to touch. The GACH?s x-rays of the bilateral tibula and fibula bones showed slightly displaced fractures of the bilateral tibiofibular bones with soft tissue swelling. On 6/20/16, at 10:28 a.m., during a telephone interview, CNA 1 stated on 5/27/16, he transferred Resident 1 from the bed to the shower chair by himself. CNA1 stated he assisted the resident to the floor when he noticed she was sliding down the standing Hoyer lift. CNA 1 stated another (CNA 2) came to assist him to transfer Resident 1 from the floor to the shower chair using the Hoyer lift. CNA 1 stated he did not report the incident of Resident 1 falling to the charge nurse and proceeded with showering Resident 1, because she did not complain of any pain or discomfort. CNA 1 stated there was no redness or injury on Resident 1?s body. A review of the facility?s policy and procedure (P/P) titled, ?Accident and Incidents-Investigation and Reporting,? revised November 2012, indicated that any incident involving residents, employee, or visitors, should be reported to the immediate supervisor as soon as practical. On 6/14/16 at 2:01 p.m., during a telephone interview, the assistant director of nurses (ADON) stated CNA 1 was aware a two-person assist was needed during a resident?s transfer. A review of the facility's policy and procedure (P/P) titled, ?Moving a resident from bed to chair/chair to bed,? revised on November 2012, indicated that if a resident cannot stand alone, to use two people to transfer the residents, one on each side of the resident. Another facility?s P/P titled, ?Lifting machine by mechanical device,? revised in November 2012, indicated the facility?s staff are to follow the manufacturer?s instructions for use of each specific type of lifting machine. The policy stipulated a minimum of two staff members should be used in using a lift machine to reduce the risk of staff or resident?s injury. A review of CNA 1 personnel file, indicated CNA 1 was hired on 3/9/16 and was terminated on 6/7/16, due to violating established company rules. A review of an ?Employee Separation Report,? indicated CNA 1 failed to follow the facility?s policy to have a two-person assist during a transfer, which resulted in a resident?s injury (Resident 1). On 6/21/16, at 1:51 p.m., during a telephone interview, the ADON stated CNA1 was terminated for not following the facility's policy and procedure on transferring residents with two people when using a transferring device. The ADON stated CNA1 should have called for help and should not have transferred Resident 1 by himself. The facility failed to ensure the residents environment remained as free from accident hazards as was possible; and each resident received adequate supervision and assistance devices to prevent accidents, including but not limited to: 1. Failure to follow its policy and procedure regarding transfers with mechanical lifts. 2. Failure to ensure CNA 1 used a two-person assist while transferring Resident 1. 3. Failure to follow Resident 1?s assessment that indicated the resident required a two-person physical assist in transferring. 4. Failure to timely report Resident 1?s fall accident, as per the facility?s policy. The above violations presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical or mental harm would result. |
| 940000099 |
Windsor Gardens Convalescent Center of Long Beach |
940012432 |
A |
11-Aug-16 |
4NLR11 |
6954 |
?483.13(a) Restraints The resident has the right to be free from any physical or chemical restraint imposed for purposes of discipline or convenience, and not required to treat the resident?s medical symptoms. On 3/24/16, at 11:46 a.m., an unannounced visit was conducted at the facility to investigate an entity reported incident and a complaint with the same allegation that Resident 1 was inappropriately restrained in a wheelchair by certified nursing assistant, (CNA 1) for staff convenience. Based on observation, interview, and record review, the facility failed to ensure that Resident 1 was not tied up in a wheelchair with a cloth-sheet for staff convenience. As a result, Resident 1 reported an increase in anxiety and fear that required the routine administration of anti-anxiety medication. A review of Resident 1's Admission Record, indicated Resident 1 was admitted to the facility on 3/12/14, with diagnoses that included dementia (a general term for a group of brain disorders that cause memory problems and make it hard to think clearly), anxiety disorder (A category of mental disorders characterized by feelings of anxiety and fear, where anxiety is a worry about future events and fear is a reaction to current events), and COPD (chronic obstructive pulmonary disease which is a lung disease that makes it hard to breathe). A review of the Minimum Data Set (MDS, an assessment care and screening tool), dated 1/14/16, indicated Resident 1 had unclear speech, able to make self-understood and had the ability to understand others. The resident?s cognitive skills for daily decision-making were severely impaired and had signs and symptoms of delirium (a state of mental confusion that develops quickly and usually fluctuates in intensity) and disorganized thinking. The MDS indicated the resident required extensive assistance from the staff with bed mobility, transfers, dressing, toilet use, and personal hygiene. On 3/24/16, at 12:18 p.m., Resident 1 was observed asleep in front of the nurses? station. Resident 1 was sitting in a wheelchair with a self-release belt (A belt prescribed by the doctor to prevent sliding and getting up unassisted), around her waist. During an interview on 5/18/16, at 12:40 p.m., Resident 1 stated words repeatedly and tensed up as she tried to respond to questions. Resident 1 was offered a pen and paper which she used to communicate. Resident 1 was unable to elaborate on what had occurred on 3/10/16, which was the alleged day when CNA 1 restrained her to a wheelchair. When asked if CNA 1 applied a blanket over her chest to keep her in the wheelchair, Resident 1 stated "Yes," and indicated that it made her feel like a prisoner. On 5/18/16, at 1:35 p.m., during an interview, Resident 2 stated she witnessed CNA 1 tie Resident 1 to a wheelchair. According to Resident 2, she saw CNA 1 place what looked like a long towel under Resident 1's breasts, wrapped it around the wheelchair and "tied her (Resident 1) to a dinner chair." Resident 2 stated the dinner chair was heavy and Resident 1 could not get up. Resident 2 stated the incident happened in March 2016 and she recalled the incident clearly because she just got admitted to the facility at that time. Resident 2 stated she could not help Resident 1 because she was scared that CNA 1 might hit her. Resident 2 stated that after CNA 1 left their room, she stopped the head nurse in the hallway and showed her where Resident 1 was. During a telephone interview with CNA 1 on 5/19/16, at 8:51 a.m., she stated that at around 7:00 p.m., on 3/10/16, she used the bed sheet to tie Resident 1 in her wheelchair. CNA 1 stated Resident 1 kept getting up from the wheelchair. CNA 1 acknowledged that she should not have tied the resident in her wheelchair. CNA 1 stated, "I should have looked for somebody to help or I should have stayed with her." In a telephone interview with registered nurse 1 (RN 1) on 5/18/16, at 2:54 p.m., she stated that at around 7:00 p.m., on 3/10/16, Resident 2 called her attention and indicated that Resident 1 was tied in a wheelchair inside their room. RN 1 stated that Resident 1 and Resident 2 were roommates. RN 1 stated that she saw Resident 1 tied to a wheelchair when she went in the residents' room. RN 1 stated she asked one of the CNAs to untie Resident 1. RN 1 stated she investigated the incident immediately, and found out that CNA 1 tied Resident 1 to the wheelchair, and CNA 1 was escorted out of the facility. When asked if she was aware of any concerns regarding CNA 1, RN 1 stated that other CNAs have complained that CNA 1 did not help them in answering call lights. During a telephone interview with CNA 2 on 5/19/16, at 12:29 p.m., CNA 2 stated that CNA 1 never asked for help, and never helped other CNAs on the team. A review of the Psychological Services Progress Notes, dated 3/11/16, indicated that Resident 1 stated she has had increased anxiety and fear since the incident. The documentation indicated that Resident 1 has had nightmares since the incident, and would like to have a medical evaluation as her current medication was not effective and would like to address her increased anxiety. A review of the Progress Notes written by the assistant director of nursing (ADON) dated 3/11/16, at 8:55 a.m., indicated that the psychiatrist was called regarding Resident 1's continued restlessness behavior. On 3/11/16, at 11:02 a.m., the psychiatrist called back and changed Resident 1?s Ativan medication (A medication used to treat anxiety) from one (1) milligram every 12 hours as needed (PRN) to 0.5 mg every 6 hours routinely. A review of the Medication Administration Record from 3/11/16, at 12 p.m., to 5/31/16 indicated Resident 1 received Ativan 0.5 mg every 6 hours routinely. A review of the Progress Notes written by the social worker dated 3/11/16 at 2:44 p.m., indicated that the social worker asked Resident 1 how she was doing, and the resident stated ?I?m afraid.? The documentation indicated when Resident 1was asked what she was afraid of, she stated that she was afraid that she was going to be tied up again. A review of the 2/2014, facility?s policy and procedure titled, "Care of Resident with Dementia & Behavior Assessment Policy" indicated that the physician and the staff will review situations requiring restraint use to ensure that they are beneficial to the individual and are not causing complications or disabling the individual. The facility failed to ensure that Resident 1 was not tied up in a wheelchair with a cloth-sheet for staff convenience. As a result, Resident 1 reported an increase in anxiety and fear that required the routine administration of anti-anxiety medication. The above violations presented either imminent dangers that death or serious harm would result or a substantial probability that death or serious physical or mental harm would result. |
| 940000019 |
WHITTIER HILLS HEALTH CARE CENTER |
940012629 |
A |
6-Oct-16 |
BD7911 |
11917 |
Class A Citation CFR 483.25 QUALITY of CARE F 309 Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. The violation was found during an unannounced complaint investigation regarding a resident who developed an infection (pain, redness, and yellow pus) on the Perma Catheter (PC) site. The facility failed to provide adequate care and services for Resident 1 by failing to: 1. Provide necessary assessment and dressing changes to Resident 1's Perma Catheter (PC- a vascular access inserted into a vein for dialysis, a treatment that performs some of the functions of healthy kidneys of filtering wastes and water from the blood). 2. Follow the facility's policy and procedure which stated, "Vascular access devices shall be removed upon therapy discontinuation or if deemed unnecessary and daily assessment of the vascular access need and removal when no longer needed" to decrease the risk of infection. 3. Notify the physician that Resident 1 was no longer receiving dialysis treatment as of 2/17/16 and to discuss the plan of care for the resident with a PC in place. 4. Consult with the physician to obtain an appointment for the removal of Resident 1?s PC when the resident's laboratory results indicated her kidney function normalized. These deficient practices resulted in infection of the Perma Catheter (PC) and the resident's admission to the acute hospital for the treatment of MRSA (Methicillin Resistant Staphylococcus Aureus). Findings: A review of Resident 1's Admission Record (Face Sheet) indicated the resident was admitted to the facility on 1/19/16 and readmitted on 3/10/16. A review of Resident 1?s Minimum Data Set (MDS), a resident assessment and care-screening tool, dated 1/9/16 indicated the resident was assessed with no cognitive impairment (ability to think and reason). The resident's history and physical dated 1/22/16, indicated diagnoses of acute or chronic kidney disease (kidney failure in which kidneys lose their filtering ability causing dangerous levels of wastes accumulation and unbalance of the body's chemical make-up) and hemodialysis. Resident 1's physician's orders dated 1/19/16, included: 1. Dialysis every Tuesday, Thursday and Saturday. 2. Dressing on access site (right chest PC) to be changed at the dialysis center and as needed (PRN) at the facility if soiled and dislodged. 3. Monitor dialysis access site for color, redness, warmth, edema, drainage, pain and bleeding. A review of Resident 1's progress note dated 1/26/16 indicated the resident had a PC on the right chest and was dependent on renal dialysis. During an interview on 3/21/16, Registered Nurse 1 (RN) stated that the dialysis nurse at the dialysis center was responsible for PC dressing changes. RN 1 stated the nurses at the facility were responsible for checking the PC site every shift and providing dressing changes only PRN when the site was soiled to prevent infection. During an interview on 3/22/16, the Director of Nursing (DON) stated that the RN's were responsible for the care of PCs that include: assessing the site every shift; providing dressing changes PRN when it had not been changed; and documenting these interventions on the Intravenous (IV) Medication Administration Record (MAR) , per facility's revised policy dated 6/2009. The DON stated when the PC had a gauze dressing, it needed to be changed every 24 hours, and when it had a transparent dressing, then it needed to be changed every 7 days. The DON also stated that the IV MAR for Resident 1 dated February 2016 and March 2016, did not indicate the facility staff changed the PC dressing from 2/16/16 to 3/7/16. The DON added if the PC dressing changes were not provided then there would be a risk for infection. A review of Resident 1's document dated 2/1/16 to 2/29/16, and titled "IV MAR" indicated an order for the dressing on the access site ( right chest PC) to be changed at the dialysis center and PRN at the facility if soiled or dislodged. There were no staff initials on the document for PRN dressing changes at the facility from 2/1/16 to 2/29/16. The above order was also reflected on the "IV MAR" dated 3/1/16 to 3/31/16. However, there were also no staff initials to indicate that PRN dressing changes were done at the facility from 3/1/16 to 3/31/16. A review of the facility's policy and procedures undated and titled, Peripherally Inserted Central Catheter (PICC) and Central Line Catheters, indicated that:? gauze dressing shall not be used unless ordered by a physician and all gauze under the transparent dressing shall be changed every 24 hours to observe the site. The vascular access devices shall be removed upon resolved complication, therapy discontinuation, or if deemed unnecessary and daily assessment of vascular access devices need and removal when no longer needed are components of the central line bundle known to decrease risk of infection." During an interview on 3/29/16, Resident 1 stated the facility staff did not clean nor change the dressing on the PC site. It was not changed at the last dialysis treatment by the dialysis center staff on 2/17/16 and the site had the same gauze dressing for 2 weeks. Resident 1 also stated she told the facility staff that she had PC site pain and staff responded that they could not assess and touch the site, so she called and notified the physician. The resident stated she checked the PC site and there were lots of yellow pus on the site. In an interview on 3/29/16, RN 2 stated she does not provide routine dressing changes because it was typically done, along with dialysis treatment, at the dialysis center. RN 2 stated the dialysis center would apply a gauze dressing to the PC site, which would last until the next hemodialysis treatment. RN 2 also stated that if the dressing was soiled or wet, then she would be responsible for providing dressing changes and would document it in the resident's IV MAR. RN 2 also added that the physician should be notified of any issues relating to the resident. During an interview on 3/29/16, the resident's physician (Physician 1) explained that Resident 1 called her and complained of redness and pain to the PC site. The physician stated she made a visit to assess Resident 1's PC site and observed redness to the site and started the resident on Keflex, an antibiotic that should be used only to treat infections that are proven or strongly suspected to be caused by susceptible bacteria per drug literature. The physician explained that the facility should have a policy and procedure, based on standards of care, to direct the care and frequency of dressing changes to the PC. She also stated the facility should have routinely assessed and provided dressing changes to the PC site to prevent infection. Review of a physician's History and Physical for the resident dated 3/11/16, stated, "Patient directly admitted to hospital from the Nephrologist?s? (Physician 2-a physician specializing in disease of the kidneys) office due to Perm-A-Cath site infection. Patient completed dialysis about a month ago since blood urea nitrogen and creatinine (BUN and Creat) improved. Perm-A-Cath was left in place." The resident's diagnoses included Status/Post line sepsis and was started on Vancomycin, another antibiotic. During an interview on 3/29/16, Physician 2 stated Resident 1, whose laboratory results indicated her kidney function normalized, missed her follow up appointment due to transportation issues. Physician 2 stated that the facility should have followed up with her to obtain another appointment for the removal of the resident's PC; otherwise, the PC site could become a source of infection. Physician 2 also stated Resident 1's PC site was infected and progressed to MRSA septicemia (bacteria in the blood that often occurs with severe infections), and the resident was started on antibiotics (medications that fight bacterial infections) for six weeks. Physician 2 also stated Resident 1 would be followed up by a Cardiologist (a physician that specializes in the medical management of heart diseases) to assess for endocarditis (infection of the inner lining of the heart that generally occurs when bacteria from another part of the body spread through the bloodstream and attaches to damaged areas in the heart). Physician 2 added that the facility, knowing that Resident 1 was no longer receiving dialysis, should have provided PC site assessment and dressing changes routinely. During an interview on 3/29/16, RN 2 stated Resident 1's PC had a white gauze dressing, and that to prevent infection and sepsis (a life-threatening complication of and infection potentially causing organ damage and failure), PCs with gauze dressing should be changed every 24 hours per facility's policy and procedures. RN 2 also stated the physician should have been notified that Resident 1 was no longer receiving dialysis treatment and to discuss the plan of care for the resident with PC in place. On 3/29/16, at 1:00 p.m., in an interview, the Case Manager (CM) stated when Resident 1 missed her appointment on 2/29/16, at 1:00 p.m., to see the Nephrologist they should have arranged a follow up with the Nephrologist. In an interview and record review on 3/29/16, at 4:04 p.m., the Assistant Director of Nursing (ADON) explained that "Dialysis Communication Record" (a communication between the facility and the dialysis center) was a form that included the facility's documentation of pre-assessment and post-assessment of the resident and dialysis access site, and the dialysis center's documentation of dialysis site dressing change. The ADON confirmed that this record documented the facility's pre-and/or post-assessment of the resident's PC site and whether the PC dressing was changed at the dialysis center or not. Resident 1's acute hospital documentation dated 3/7/16 indicated the resident was admitted due to infection of the PC and failure to remove the PC after hemodialysis stopped. Resident 1's dialysis catheter was removed on 3/7/16, and the tip of the catheter was sent for culture. The culture dated 3/7/16, revealed Resident 1's PC tip and cuff (a ring material that is around the catheter under the skin) had MRSA. The resident remained in the hospital for two nights and was discharged with a PICC line for long-term administration of IV (intravenous) Vancomycin (antibiotic) until 4/6/16. The facility failed to provide adequate care and services for Resident 1 by failing to: 1. Provide necessary assessment and dressing changes to Resident 1's Perma Catheter (PC- a vascular access inserted into a vein for dialysis, a treatment that performs some of the functions of healthy kidneys of filtering wastes and water from the blood). 2. Follow the facility?s policy and procedure which stated "vascular access devices shall be removed upon therapy discontinuation or if deemed unnecessary and daily assessment of the vascular access need and removal when no longer needed" to decrease the risk of infection. 3. Notify the physician that Resident 1 was no longer receiving dialysis treatment as of 2/17/16 and to discuss the plan of care for the resident with PC in place. 4. Consult with the physician to obtain an appointment for the removal of Resident 1?s PC when the resident's laboratory results indicated her kidney function normalized. These deficient practices resulted in infection of the Perma Catheter (PC) and the resident?s admission to the acute hospital for the treatment of MRSA (Methicillin Resistant Staphylococcus Aureus). These violations presented a substantial probability that death or serious physical harm to Resident 1 would result therefrom and did. |
| 940000112 |
WOODRUFF CONVALESCENT CENTER |
940012673 |
B |
21-Oct-16 |
FSWN11 |
4888 |
Health and Safety Code ? 1418.91. Reports of incidents of alleged abuse or suspected abuse of residents. (a) A long-term health care facility shall report all incidents of alleged abuse or suspected abuse of resident of the facility to the department immediately, or within 24 hours. (b) A failure to comply with the requirements of this section shall be a class ?B? violation. On 8/10/16 at 2:30 p.m., an unannounced visit was made to the facility to investigate a complaint regarding an allegation of sexual abuse. Based on interview and record review, the facility failed to report Resident 1?s allegation of sexual abuse to the Department immediately or within 24 hours. The facility was informed by a hospital staff on 8/7/16 of Resident 1?s allegation of sexual abuse by an unnamed facility staff. The facility did not report this allegation to the Department immediately or as soon as possible of its knowledge of the allegation but made an agreement instead with the hospital staff for the hospital staff to make the report to the Department since the verbal report was made directly to them by the resident?s family. The hospital?s social worker reported Resident 1?s allegation of sexual abuse to the Department on 8/9/16. A review of the Admission Record indicated Resident 1 was a 46-year-old female, who was admitted to the facility on 7/21/16 with diagnoses that included malignant neoplasm of the brain (brain cancer) and secondary malignant neoplasm of unspecified kidney and renal pelvis (kidney cancer). A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 8/3/16, indicated the resident usually understands others and usually able to make herself-understood. The MDS indicated Resident 1 was in hospice care. On 8/10/16 at 2:45 p.m., during an interview in the presence of the administrator (ADM), assistant administrator (AADM), and social worker (SW), the administrator-in-training (AIT) stated there was a concern reported from the acute care hospital that Resident 1's family member informed a hospital staff that Resident 1 had a bruise on her face and someone touched her in her private area before her transfer to the hospital on 8/7/16. During the interview, the AADM stated that on 8/7/16, Resident 1 complained of abdominal pain and she was transferred to an acute care hospital. The AADM stated that about four (4) hours later, a hospital staff called the facility and informed the facility about an allegation that Resident 1 sustained a bruise and someone touched her private area, while she was at the facility. The AADM stated the resident's bruise was from a fall, which happened on 8/3/16. During the interview, the AADM stated an allegation of abuse had to be reported within 24 hours and a final result of the investigation had to be submitted within five (5) days to the Department. On 8/10/16 at 5:16 p.m., during an interview, the AADM stated the facility did not report Resident 1's allegation of sexual abuse to the Department because the allegation was not true due to her (medical) condition. The AADM stated the hospital staff told the facility that they (the hospital staff) would report this allegation to the Department; therefore, the facility did not report it. A review of the Final Summary Report, dated 8/10/16, which was received by the Department on 8/11/16 at 2:31 p.m., indicated the AADM received a call from a hospital staff nurse on 8/7/16 at 8 p.m. to report that Resident 1's family member made an allegation that Resident 1 was sexually abused by a facility staff. The hospital staff nurse informed the facility that the hospital would do the reporting (to the Department), the rationale being that the verbal report was reported directly to them. Both parties (the hospital and the facility) created a mutual agreement that the initial party (the hospital) will report the case. A review of the facility's undated policy and procedure titled, "Reporting Abuse to State Agencies and Other Entities/Individuals," indicated ?All suspected violations and all substantiated incident of abuse will be promptly reported to appropriate state agencies and other entities or individuals as may required by law.? The facility's policy indicated verbal/written notices to the state licensing/certification agency (the Department) will be made as soon as possible by fax. The facility?s reporting of abuse policy is not in compliance with this statute, which mandates that all incidents of alleged abuse or all suspected abuse shall be reported to the Department immediately, or within 24 hours. The facility failed to report Resident 1?s allegation of sexual abuse to the Department immediately or within 24 hours. The above violation had a direct or immediate relationship to the health, safety, or security of patients. |
| 940000112 |
WOODRUFF CONVALESCENT CENTER |
940012886 |
A |
18-Jan-17 |
BB5D11 |
11590 |
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.
Based on observation, interview, and record review, the facility failed to conduct a pain assessment and provide effective pain relief by failing to:
1. Reassess Resident 4 when he exhibited signs and symptoms of pain and the narcotic pain medication was not effective and the next routine dose was not yet due.
2. Medicate Resident 4 with a narcotic pain medication to manage his moderate level of pain as ordered by the physician.
3. Call the physician and obtain an order to relieve Resident 4?s severe pain.
4. Assess and document consistently the rate of Resident 4?s pain level every shift on the medication admission record as ordered by the physician.
As a result, Resident 4 experienced severe pain and discomfort.
A review of Resident 4's Admission Record indicated the resident was a XXXXXXX-year old female, who was admitted to the facility on XXXXXXX16 with diagnoses that included Stage 4 pressure ulcer (full thickness tissue loss reaching into the muscle and bone, causing extensive damage), osteoarthritis (inflammation of the bone and joints), muscle wasting and atrophy (decrease in the mass of the muscle and tissue), and acute respiratory failure (fluid that collects in the lungs, depriving the organs of oxygen).
A review of Resident 4's admission Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 9/2/16, indicated Resident 4 had a Stage 4 pressure ulcer upon admission to the facility that measured two (2) centimeters (cm) in length, one (1) cm in width, and one (1) cm in depth. The resident's cognitive skills for daily decision making was severely impaired. The MDS indicated Resident 4 was completely dependent for assistance with personal hygiene, required extensive assistance (resident involved in the activity; staff provide weight-bearing support) for bed mobility, had a functional limitation with range of motion (the full movement potential of each joint) due to impairment on both sides of the upper and lower extremities, and was always incontinent (insufficient voluntary control of defecation or urination) of bowel and had an indwelling urinary catheter (a flexible plastic tube used to drain urine from the bladder into a collection bag).
A review of Resident 4's care plan, initiated on 8/27/16, and titled, "Alteration in Comfort from Back Pain and Arthritic Pain," indicated a goal for the resident's pain to be relieved within one hour after pain medication was given. The approach included to assess Resident 4 for signs and symptoms of pain, to call the physician for any significant changes in the resident's medical condition, and provide measures to comfort and lessen the intensity of the pain.
A review of Resident 4's Physician Orders, dated 8/27/16, indicated to rate the resident's pain level every shift, according to the pain scale from zero to 10 (zero indicated no pain, 10 out of 10 indicated severe pain) as follows:
1-2 equals mild pain
3-6 equals moderate pain
7-10 equals severe pain
A review of Resident 4's physician orders, dated 8/27/16, indicated to administer to the resident Hydrocodone-Acetaminophen (a combination of a controlled-substance medication that relieves pain) tablet 5/325 milligrams (mg), one tablet via gastrostomy tube (a tube inserted through the abdomen that delivers nutrition directly into the stomach), every 12 hours prn (as needed) for moderate pain. Resident 4 did not have a prn order to manage his severe pain.
A review of Resident 4's Medication Administration Record (MAR), for the month of August 2016, indicated the licensed nurse did not document the level of the resident's pain as ordered by the physician, from 8/28/16 through 8/31/16 (for four days after the date of admission) during the day shift (7 a.m. to 3 p.m. shift), and on 8/30/16, during the evening shift (3 p.m. to 11 p.m. shift).
The August 2016 MAR indicated Resident 4 had a pain level of four out of 10 (moderate pain), on 8/27/16 and 8/28/16 during the night shift (11 p.m. to 7 a.m. shift), but there was no documented evidence the resident received medication for pain relief as prescribed.
A review of Resident 4's September 2016 MAR indicated the following:
1. The resident had severe pain (pain level 7/10) on 9/5/16 during the day shift and on 9/10/16 during the night shift but the resident was given one (1) tablet of narcotic pain medication (Hydrocodone-Acetaminophen), which was ordered to relieve moderate pain.
2. The resident's pain assessment was not documented for 18 days out of 30 days, during the day shift, and for two days during the evening shift (on 9/22/16 and 9/26/16).
3. The resident received one (1) tablet of the Hydrocodone-Acetaminophen for moderate pain (pain level 5/10) on 9/22/16 during the day shift but the "Individual Resident's Narcotic Record" (a disposition record of the narcotic medication) indicated the resident received the narcotic pain medication two (2) times (the documented time was not legible) on 9/22/16. There was no documented evidence the resident's pain level was assessed prior to the administration of the narcotic pain medication for the second time on 9/22/16.
4. The resident had severe pain (pain level 8/10) on 9/27/16 (the shift was not indicated) but the resident was given one (1) tablet of the narcotic pain medication (Hydrocodone-Acetaminophen), which was ordered to relieve moderate pain. The Individual Resident's Narcotic Record indicated the narcotic pain medication was administered at 1:30 am. during the night shift.
On 10/12/16, at 9:15 a.m., during an observation of morning care with the certified nursing assistant (CNA 1), Resident 4 was observed screaming and moaning, with facial grimacing (facial expression suggesting pain). The resident was observed with both arms flexed on top of her chest.
On 10/12/16, at 9:30 a.m., during an interview and a concurrent review of Resident 4's MAR for the month of October 2016, a licensed vocational nurse (LVN 2) stated Resident 4 did not receive pain medications during her shift. LVN 2 stated Resident 4's pain medication of Norco (the brand name for the narcotic pain medication, Hydrocodone-Acetaminophen), one tablet, was last administered to the resident on 10/12/16, at 1 a.m., and was not due to be administered because it was ordered for as needed every 12 hours. LVN 2 stated she did not know what else she could do if the resident was in pain and the pain medication was not yet due to be administered.
On 10/12/16, at 11 a.m., during an observation and tour of the facility, Resident 4 was observed moaning with facial grimacing, while LVN 1 was observed repositioning Resident 4 in the bed.
On 10/12/16, at 11:15 a.m., during an interview, LVN 1 stated Resident 4 would be given pain medication when it was due at 1 p.m., and 30 minutes prior to performing wound care treatment.
On 10/12/16, at 1:15 p.m., during an interview and concurrent observation of Resident 4's wound care treatment, Resident 4 was observed screaming with facial grimacing, while being repositioned by LVN 1. LVN 1 attempted to reposition the resident once again but the resident was observed still screaming. LVN 1 stated, "I can't go on with the treatment, I'll ask my supervisor." LVN 1 stated Resident 4 was in more pain than usual.
During a concurrent observation, LVN 2 spoke with LVN 1 and informed LVN 1 that Resident 4 received one tablet of Norco at 12:30 p.m., for a four out of 10 pain level (moderate pain).
On 10/12/16, at 1:20 p.m., during an interview and a concurrent record review of Resident 4's clinical record, LVN 1 stated Resident 4's family requested for the resident not to receive too much pain medication but LVN 1 was not able to find the family's request documented on Resident 4's clinical record.
On 12/14/16, at 4 p.m., during an interview, the director of nursing (DON), stated if Resident 4's physician ordered to check the resident's pain level every shift, the pain scale should be documented in the MAR.
On 12/15/16, at 10:45 a.m., during an interview, the DON stated the pain level of Resident 4 was not documented in the MAR on 9/22/16, and 9/26/16 during the evening shift, and for several days during the day shift (for the month of September).
On 12/15/16, at 10:45 a.m., during an interview, the DON stated a pain level of 7 and above out of 10, is considered severe pain. The DON stated Resident 4 only received pain relief medication adequate for moderate pain, and should have been reassessed for possible dosage increase or change of pain relief medication. The DON stated on Resident 4's September MAR, Resident 4 was documented to have a 7/10 pain during the day shift (on 9/5/16), but was only given Norco, during the night shift at 2 a.m. on 9/5/16 (prior to the start of the day shift at 7 a.m.).
On 12/14/16, at 10:45 a.m., during an interview, the DON stated the Individual Resident's Narcotic Record (the documentation of the number of narcotic medication disposed) and the MAR (the documentation of the number of narcotic medication administered) should match and not have inconsistencies. The DON stated no one was assigned to routinely review the MAR and the Individual Resident's Narcotic Record to check for discrepancies of medication administration. The DON stated the narcotics were counted by two licensed nurses (the incoming nurse and the nurse leaving the shift), before the start of the next shift.
A review of the facility's undated policy and procedure titled, "Comprehensive Pain Assessment," indicated a registered nurse (RN) or licensed vocational nurse (LVN) reassesses pain as necessary for the effectiveness of the pain control method and should notify the physician if measures were unsuccessful. The policy indicated the resident's pain should be alleviated or reduced to a level of comfort that is acceptable to the resident.
A review of the facility's undated policy and procedure titled, "Medication and Treatment Administration," indicated the licensed nurse administering the medications or treatment should record the date, time, and dose of the medication in the individual MAR immediately after giving the medication. The policy indicated that when a prn medication is administered, the complaint or symptom for which the medication was given must be documented on the back of the MAR, and the results achieved from giving the dose and time results noted in the space provided in the back of the MAR.
The facility failed to conduct a pain assessment and provide effective pain relief by failing to:
1. Reassess Resident 4 when he exhibited signs and symptoms of pain and the narcotic pain medication was not effective and the next routine dose was not yet due.
2. Medicate Resident 4 with a narcotic pain medication to manage his moderate level of pain as ordered by the physician.
3. Call the physician and obtain an order to relieve Resident 4?s severe pain.
4. Assess and document consistently the rate of Resident 4?s pain level every shift on the medication admission record as ordered by the physician.
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. |
| 940000111 |
WINDSOR PALMS CARE CENTER of ARTESIA |
940012913 |
A |
31-Mar-17 |
VAOZ11 |
6965 |
483.25(d) Accidents
The facility must ensure that-
(1) The resident environment remains as free from accident hazards as is possible
(2) Each resident receives adequate supervision and assistance devices to prevent accidents.
Based on observation, record review and interview, the facility failed to develop a written plan of care that ensured that (Resident 1) received adequate supervision to meet his toileting needs and prevent falls. As a result of this failure, Resident 1, who was assessed to be at a risk for falls, had a fall and sustained a right hip fracture which required surgery.
On 9/29/16, at 2:35 p.m., an unannounced visit to the facility was conducted to investigate an entity reported incident. On this date and time, Resident 1 was still in the acute hospital where he had surgery of the right hip due to the fracture sustained from a fall.
A review of the medical record of Resident I indicated the resident was admitted to the facility on XXXXXXX 16, with diagnoses that included hypertension, Parkinson's disease, (a brain disorder with symptoms of tremors of hands, arms, legs, jaw and face; stiffness of the limbs and trunk; slow movements and impaired balance and coordination) and altered mental status. His Minimum Data Set (MDS/a standardized assessment and care screening tool) dated 9/26/16, assessed the resident as bee ng totally dependent in all areas of activities of daily living (ADL) and bowel and bladder (B and B) incontinent. The Certified Nurses Assistant's (CNA 1) notes on 9/4/16 indicated the resident was yelling and non-compliant.
The fall risk assessment for Resident 1 dated 9/25/16, indicated he had a high risk for falls related to confusion, gait/balance problem, incontinence and unawareness of safety needs. The assessment also indicated the resident was verbally and physically abusive, noisy and screams, required hands on assistance to move from place to place, and exhibits jerking movements and instability.
Resident l?s record also indicated that on 9/25/16, the physician ordered a low bed with a floor mattress related to fall risks. To prevent falls, the resident's plan of care included hourly monitoring by staff and placement of the resident's bed in a low position at night.
In an interview on 9/29/16 at 4:30 p.m., concurrent with record review, the Director of Nurses (DON) indicated she did not see any documentation that the CNA's notes were reviewed and that the resident's above behavior should have been care planned. The DON stated she did not see any documentation that Resident l?s bed was in a low position and that a pad (mattress) was provided per physician's order. She added that these should have been documented. She also stated the RN did not set up in the task portion of the CNA's charting that the resident should be monitored for fall every one hour as care planned.
During a telephone interview on 10/3/16 at 2:00 p.m., LVN 1 was asked what the night licensed person reported to her. LVN 1 stated that the night shift informed her that Resident 1 was a new admit but that she was not informed that the resident was at a high risk for falls or that he was to be monitored every hour as care planned.
On 10/5/16 at 10:00 a.m., during an interview, Registered Nurse Supervisor (RNS) stated she admitted Resident 1 around midnight. She stated she completed the Admission Assessment but did not complete the Fall Risk Assessment Tool. She also stated she never saw the resident but presumed that he was at risk for falls because of his diagnosis of Parkinson's disease. She further stated she did a care plan for the resident which was computer generated and failed to check the every hour monitoring and determine if that was the accurate or achievable intervention for the resident.
In another interview on 10/5/16 at 4:38 p.m., the DON stated that the "intervention or the task" should be documented in the Documentation Survey Report where the CNAs record their care. She stated the CNAs are alerted from this report of the interventions for fall management and other care throughout the task identified in the report. She also stated that the care plans are supposed to be communicated to the CNAs and other licensed staff and documented as done. If the floor pad was provided and the "low bed positioned", the staff should have documented that. She further stated, "I don't see that these were documented" and also stated the documentation was not compl ete.
On I 0/12/16 at 12:45 p.m., during an interview, Resident l?s primary caregiver, (CNA I) stated that on 9/25/16, the resident was confused and insisted he wanted to go to the bathroom. She noticed the resident was weak, slow and unsteady, so she called someone for help. She stated she did not remember if the resident had a floor pad or bed alarm and that the resident was a new admit. She added that no one told her to monitor Resident I every hour or that he was a high risk for falls.
On 11/1/16 at 11:00 a.m., in a telephone interview, Licensed Vocational Nurse (LVN 2) stated that during the first hour after Resident l?s admission, the resident was trying to get up and go to the bathroom. She stated the resident was yelling at her, was combative and was getting frustrated because he wanted to go to the bathroom. When asked if she communicated this resident's behavior to the registered nurse (RN) to ensure a care plan was developed, she stated "No" and stated that the RN usually does the care plans on admission.
At 11:20 a.m., on 1 1/1/16, during a telephone interview, the Assistant Director of Nurses (ADON) stated Resident l?s records indicated the resident was yelling and screaming but she did not see a care plan. She also stated that the RNS should have developed a care plan in order to prevent a fall and meet the resident's toileting needs.
On 9/25/16 at 10:20 a.m., while passing by Resident 1?s room, LVN 1 stated she saw Resident 1 standing by his bed and holding on the night stand to push himself up. Resident 1?s legs were crossed and tangled. LVN 1 stated she saw that the resident was losing his balance so; she stood behind the resident and assisted him with the fall. She further stated that she could not hold on to him like she wanted to because the resident was ?too tall?. She added that Resident 1 fell on his right side and complained of pain (7/10) after the fall. An X-ray result dated 9/25/16, revealed Resident 1 sustained an acute greater trochanter avulsion fracture ( a bone of the hip that breaks and tears away from the main part of the bone) of the right hip. He was then transferred to the acute hospital where he had a surgical intervention.
Failure of the facility to develop a written plan of care which ensures that Resident I received adequate supervision to meet his toileting needs and prevent falls had a substantial probability that death or serious physical harm to Resident I would result therefrom and did. |
| 940000099 |
Windsor Gardens Convalescent Center of Long Beach |
940012984 |
A |
24-Feb-17 |
L4HV11 |
10000 |
?483.13(c) Staff Treatment to the Residents
The facility must develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property.
On 9/10/14 at 7 a.m., an unannounced visit was conducted at the facility to investigate an entity reported incident regarding resident-to-resident altercation.
Based on observation, interview, and record review, the facility failed to protect and prevent physical and psychological harm and implement effective measures to prevent the re-occurrence of Resident A's wandering behavior inside other residents' rooms by failing to:
1. Identify the risk factors of the aggressive and wandering behaviors exhibited by Resident A which could lead to altercations/conflict with other residents;
2. Thoroughly investigate the allegation of abuse against Resident A made by Resident B, by failing to interview other residents and family members to identify if they had been affected by Resident A's aggressive and wandering behavior; and
These deficient practices resulted in psychological harm to the female residents (Resident B, C, D, and E) and had the potential to result in physical harm to Resident A and the other residents.
A review of Resident A's clinical records indicated that the resident was admitted to the facility on XXXXXXX07 with diagnoses that included non-Alzheimer's dementia, psychotic disorder (loss of contact with reality; includes false beliefs; seeing or hearing things that aren't there), and anxiety disorder (unpleasant state of inner turmoil, often accompanied by nervous behavior, such as pacing back and forth).
The Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 8/14/14, indicated Resident A sometimes had the ability to understand and be understood by others, had short and long-term memory problems, was severely impaired in cognitive skills for daily decision-making, had disorganized thinking, and was short tempered and easily annoyed.
The MDS assessment also indicated Resident A at times rejected care, had wandering behaviors which placed the resident at significant risk of getting into a potentially dangerous place, and his wandering significantly intruded on the privacy or activities of others. The MDS indicated the resident required extensive assistance for activities of daily living (ADLs), and used wheelchair as a mobility device.
On 9/10/14 at 7:35 a.m., during an interview, Resident B, an alert female resident, stated on 8/30/14 at 11:40 a.m., Resident A entered her room against her will, as he always did. According to Resident B, she used her cell phone to call the front desk for assistance and when no one came, she started yelling for help. Resident B stated Resident A attempted to take her bedside table away, but she held on to the table. Resident B stated she tried to shoo Resident A away with her "reacher-device," but Resident A became hostile and started swinging at her, striking her left breast.
During the interview, Resident B stated she informed the facility she was scared when a male resident comes in her room. Resident B started crying and stated she did not feel safe being in the facility with Resident A, because she could not get away. Resident B stated she had also told the facility staff that Resident A went in her room, and she was fearful of him.
On 9/10/14 at 10:20 a.m., during an interview, Certified Nursing Assistant (CNA) 2 stated on 8/30/14, she heard Resident B scream for help several times and saw Resident A at Resident B's doorway. CNA 2 stated she removed Resident A and took him to the patio. When asked if she reported the incident to the charge nurse, CNA 2 stated, "No, because everyone knows," about Resident A's behavior of going inside female residents' rooms.
A review of the Interdisciplinary (IDT, a group of health care professionals from diverse fields who work in a coordinated fashion toward a common goal for the resident) Progress Notes, dated 9/4/14 at 4:48 p.m., indicated Resident B allegedly accused Resident A on 9/3/14, of slapping her on the left upper breast, and that someone escorted Resident A out of the room. The notes indicated Resident A was interviewed and did not recall the incident.
A review of the Health Status Note (a progress note), dated 9/4/14 at 9:11 p.m. indicated the staff was alerted after hearing Resident B screaming for the nurse. The notes indicated Resident A was seen sitting outside of Resident B's door. Resident A was moved away from Resident B's room and was re-oriented that it was not his room.
On 9/10/14 at 9:30 a.m., in an interview with Resident C, she stated Resident A had entered her room (she could not recall the exact date) while she was sitting in her wheelchair talking to her mother (Resident D), who was her roommate and also a resident of the facility. Resident C told Resident A to leave the room because he was in a female room. Resident A told Resident C, he was there to check her out. Resident C stated she was very scared of Resident A because she had witnessed him yelling very loudly and hitting staff members. Resident C stated she was afraid of Resident A because she was unable to defend herself if Resident A became physically aggressive.
On 9/10/14 at 10:40 a.m., during an interview with Resident D, as she was sitting in a wheelchair, wearing a neck/back brace (to immobilize the neck and the back bones), she stated she just had surgery and was not able to move without staff's assistance. Resident D stated Resident A entered their room (Resident C and D's shared room). Resident D stated she was very scared because she had seen Resident A hit staff members. Resident D also stated she was not able to stand up on her own in order to leave the room when she felt threatened by Resident A.
On 9/10/14 at 10:10 a.m., in an interview with the director of nursing (DON), while reading the facility's investigation, DON stated there were no interviews with other residents and family members in order to ensure a thorough investigation.
On 9/10/14 at 3:10 p.m., during an interview and record review with Registered Nurse (RN) 1, she confirmed that prior to the incident on 8/30/14 she had seen Resident A enter other residents' rooms. However, RN 1 could not find any documentation and/or care plans specifically addressing Resident A's wandering behavior into other residents' rooms. RN 1 could not find documentation indicating how Resident A and/or other residents were going to be protected from Resident A's behavior of wandering into other residents' rooms.
A review of the facility's 3/13, revised policy and procedures titled "Abuse Prevention, Investigation and Reporting," indicated the facility will ensure the resident's rights are protected by providing a method for prevention of any type of resident abuse ...All incidents of suspected or alleged abuse will be investigated by the assigned staff and continue the investigation process. The investigation and report shall include ...d) Names of the witnesses and their account when applicable ...g) Accounts of any other individuals involved ...The licensed nurse shall document the objective data in the medical record and initiate a care plan to reflect the resident's condition and measures to be taken to prevent recurrence."
A review of Resident B's Admission Records indicated the resident was admitted to the facility on 2/20/14, with diagnoses that included depressive disorder (described as feeling sad, blue, unhappy, miserable, or down in the dumps), and anxiety state (a feeling of fear, unease, and worry).
A review of Resident B's MDS, dated 3/5/14, indicated Resident B was alert and oriented, required extensive assistance with bed mobility, and was totally dependent on staff for transferring.
A review of Resident C's Admission Records indicated the resident was admitted to the facility on XXXXXXX14, with diagnoses which included chronic pain, and spinal stenosis (narrowing of the spine). The MDS assessment dated 8/6/14, indicated Resident C was alert and oriented, needing extensive assistance with bed mobility, transferring, and walking.
A review of Resident D's Admission Records indicated the resident was admitted to the facility on XXXXXXX14, with diagnoses which included rheumatoid arthritis (a long-term painful disease that leads to inflammation of the joints and surrounding tissues), and cancer of the back bone. The MDS assessment dated 9/2/14, indicated Resident D was alert and oriented, and needed extensive assistance for bed mobility, transferring, and walking.
A review of Resident E?s Admission Records indicated was admitted to the facility on XXXXXXX14, with diagnoses which included history of fall, and Alzheimer's disease (form of memory loss). The MDS assessment dated 7/14/14, indicated Resident E usually understand or is understood, was alert and oriented, and needed supervision with walking using a cane/crutch.
The facility failed to protect and prevent physical and psychological harm and implement effective measures to prevent the re-occurrence of Resident A's wandering behavior inside other residents' rooms by failing to:
1. Identified the risk factors of the aggressive and wandering behaviors exhibited by Resident A which could lead to altercations/conflict with other residents;
2. Thoroughly investigated the allegation of abuse against Resident A made by Resident B, by failing to interview other residents and family members to identify if they had been affected by Resident A's aggressive and wandering behavior; and
These deficient practices resulted in psychological harm to the female residents (Resident B, C, D, and E) and had the potential to result in physical harm to Resident A and the other residents.
This violation presented a substantial probability of death or serious physical/psychological harm to Residents B, C, D, and E. |
| 940000112 |
WOODRUFF CONVALESCENT CENTER |
940013137 |
AA |
31-May-17 |
575P11 |
32766 |
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
42 CFR ?483.13(a) Restraints
The resident has the right to be free from any physical or chemical restraints impose d for
purposes of discipline or convenience, and not re quire d to treat the resident?s medical symptoms.
42 CFR ?483.15(g) Social Services
?483.15(g)(1) The facility must provide medically-re late d social service s to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each reside nt.
42 CFR ?483.20 Resident Assessment
(b) Comprehensive Assessments - (1) Resident Assessment Instrument. A facility must make a comprehensive assessment of a resident?s needs, using the resident assessment instrument (RAI)
specified by the State. The assessment must include at least the following:
(i) Customary routine.
(ii) Cognitive patterns.
(iii) Mood and behavior patterns.
(iv) Physical functioning and structural problems.
(v) Activity pursuit.
(vi) Medications.
42 CFR ?483.20
(d) Use. A facility must maintain all resident assessments completed within the previous 15 months in the resident?s active record and use the results of the assessment to develop, review, and revise the resident?s comprehensive assessment.
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.
42 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.
42 CFR ?483.75 Administration
(e) Required training of nursing aides
(8) Regular In-Service Education. The facility must complete a performance review of every nurse aide at least once every 12 months, and must provide regular in-service education based on the outcome of these reviews. The in-service training must--
(i) Be sufficient to ensure the continuing competence of nurse aides, but must be no less than 12 hours per year;
(ii) Address areas of weakness as determined in nurse aides? performance
reviews and may address the special needs of residents as determined by the facility staff; and
(iii) For nurse aide s providing service s to individuals with cognitive impairments, also address the care of the cognitively impaired.
42 CFR ?483.75 Administration
(f) Proficiency of Nurse Aides. The facility must ensure that nurse aide s are able to demonstrate competency in skills and technique is necessary to care for residents? needs, as identified through resident assessments, and described in the plan of care.
42 CFR ?483.75(j) Laboratory Services
(2) The facility must-
(ii) Promptly notify the attending physician of the findings;
H&SC ?1418.6.ÿ
No long-term health care facility shall accept or retain any patient for whom it cannot provide adequate care.
On 1/4/17 at 10:53 a.m., an unannounced visit was conducted at the facility to investigate a complaint regarding Resident 1 sustaining several falls at the facility.
Resident 1 was a blind, 82-year old man with dementia, who was taking medications to thin the blood. Over a period of nine weeks living at the facility, Resident 1 had five falls that involved hitting his head. The facility identified restlessness and anxiousness as possible contributing factors to his falls. The resident was provided a non-self-release seat belt while in the wheelchair instead of a self-release belt ordered by his physician. No interdisciplinary team (IDT, a group of health care professionals from diverse fields who work in a coordinated fashion toward a common goal for the resident) care conferences were conducted to manage Resident 1's agitated behavior, to assess use of non-self-release seat belt, or to review and revise the care plan. The direct care staff (CNA 1, LVN 1, and LVN 3 ) were not given in-service education on how to provide appropriate care to a resident with dementia. On the resident's fifth fall on 11/2/16, the resident sustained a laceration on his forehead. The licensed nurse was not able to stop the bleeding and the facility called 911. The resident was transferred to a general acute care hospital (GACH 2) emergency department (ED).
Resident 1 had brain surgery to evacuate a hemorrhage (an escape of blood from a ruptured blood vessel, especially when excessive) on the surface of his brain. He also required placement of a percutaneous endoscopic gastrostomy (PEG, an endoscopic medical procedure in which a tube is passed into a patient's stomach through the abdominal wall, most commonly to provide a means of feeding when oral intake is not adequate). From GACH 2, the resident was transferred to another skilled nursing facility for hospice care (a specialized form of interdisciplinary health care for terminally ill patients that focuses on alleviation of their physical, emotional, social, and spiritual discomforts) on 11/22/16 and he died on XXXXXXX16.
Based on observation, interview, and record review, the facility failed to provide Resident 1 with necessary care and services to attain or maintain the highest practicable physical, mental, psychosocial well-being, in accordance with his comprehensive assessment and plan of care to meet the needs of the resident with dementia (decline in mental ability severe enough to interfere with daily life), including but not limited to:
1. Failure to provide adequate supervision of Resident 1 while he moved to and from different locations on the unit, consistent with his comprehensive assessment (Minimum Data Set), the rehabilitation screening or assessment, and plan of care for activities of daily living.
2. Failure to provide adequate supervision of Resident 1 while he was inside the bathroom, consistent with the comprehensive assessment and plan of care for activities of daily living. Resident 1 had an unwitnessed fall from the wheelchair while in the bathroom on 8/31/16.
3. Failure to complete and/or conduct neurological checks (an assessment of brain functions and level of consciousness) after each fall incident, as required by Resident 1?s falls episodic care plan.
4. Failure to assess Resident 1 for the use of a soft non-release seat belt, a physical restraint, and document the assessment and medical justification in the resident?s medical record.
5. Failure to monitor Resident 1's behavior and safety when in the wheelchair with a physical restraint. Resident 1 exhibited a behavior of removing the soft non-release belt by wiggling his body and lifting the seat belt over his head.
6. Failure to conduct an interdisciplinary team (IDT) process after each fall incident to assess Resident 1's behaviors of restlessness, anxiety, and removing the soft non-release seat belt; to determine appropriate interventions to manage the behaviors; and to determine the appropriateness and effectiveness of the use of a physical restraint to prevent falls while Resident 1 was on the wheelchair.
7. Failure to review and revise the care plan for falls, and evaluate the effectiveness of the current fall prevention interventions after each fall incident.
8. Failure to implement the physician order to obtain a psychiatric consultation to evaluate Resident 1?s behaviors of shouting and anxiety.
9. Failure to provide in-service training to the facility staff regarding monitoring the behaviors of residents with dementia and how to manage their behaviors to prevent falls.
10. Failure to notify the physician of an abnormal laboratory result obtained on 11/1/16 that indicated a prolonged time for Resident 1?s blood to clot.
A review of Resident 1's Admission Record indicated that Resident 1 was an 82-year-old male, who was admitted to the facility on XXXXXXX16 with diagnoses that included blindness of both eyes, anxiety disorder (a mental disorder characterized by feelings of worry, nervousness, or unease, typically about an imminent event or something with an uncertain outcome), and dementia.
A review of Resident 1's Fall Risk Assessment, dated 8/18/16, indicated the resident was a high risk for falls. The resident's fall risk assessment score indicated that the resident was given a score of 18 on 8/18/16, 20 on 8/31/16 and 9/29/16, and 22 on 10/16/16 (a total score of 10 or above represented high risk for falling).
A review of Resident 1's Physician's Psychotropic Order, dated 8/18/16, indicated to give the resident Ativan (an antianxiety medication) 0.5 milligrams sublingual (apply under the tongue) every six (6) hours as needed (PRN) for anxiety as manifested by agitation/restlessness, and to monitor the behavior of restlessness and tally by hash mark every shift.
A review of Resident 1's Minimum Data Set (MDS), a standardized assessment and care-screening tool, dated 9/16/16, indicated Resident 1's vision and cognition (the ability to think and reason) were severely impaired; had minimal difficulty hearing; was able to understand others and make himself understood sometimes; and required extensive assistance (for resident involvement in activity, staff provided support in bearing weight) with two person physical assistance with transfers (the moving of a patient from one surface to another) and toileting.
The MDS indicated Resident 1 required extensive assistance, with the assistance of one person while Resident 1 moved from one place to another (locomotion) inside his room and adjacent corridor on the same floor; he needed supervision while he moved to and returned from off-unit locations (areas set aside for dining, activities, or patio); and he used a wheelchair as a mobility device. The MDS indicated Resident 1's balance during transitions (transfer) and walking was not steady and he was only able to stabilize with staff assistance.
During an interview, on 3/23/17 at 10:52 a.m., the MDS nurse coordinator stated that Resident 1 requiring extensive assistance with locomotion on the unit meant someone had to push the resident's wheelchair and that the resident should not be left alone while in the wheelchair.
A review of Resident 1?s care plan for activities of daily living, dated 8/18/16, indicated the resident needed extensive assistance in transfers, ambulation, and toilet use, and total assistance in wheelchair propulsion.
A review of Resident 1's care plan titled "Resident Care Plan Potential for Fall," dated 8/18/16, indicated Resident 1 was at risk for falls related to his unsteady gait, poor safety awareness, behavior problems, behavioral problems (physical restlessness), and use of Ativan. The staff's interventions included observing Resident 1 for unsteady gait and poor balance, anticipating and meeting all his needs timely, and providing a low bed and a personal alarm in bed.
A review of the undated facility?s policy and procedure titled ?Fall Management Process,? indicated a fall risk score represents high risk for fall and will require the development of a nursing care plan with appropriate interventions initiated and implemented designed to prevent falls. When a resident, who demonstrates behavior that may cause a fall will be placed on immediate alert by the IDT. It may be necessary to apply the least restrictive form of restraint upon admission with informed consent of the responsible party. Restraint application and evaluation will be done by IDT, while ruling out other factor that may care the change in behavior. The important task is for the IDT to focus on the prevention of a potential fall by initiating a comprehensive care plan that is effective and efficient.
A review of the facility's policy and procedure titled "Resident Fall," with an effective date 10/21/16, indicated that the facility required staff to provide the necessary care and treatment to medically stabilize, and to initiate prompt interventions to prevent or reduce further falls with or without injury. Under this policy and procedure, the required care and treatment included neurological checks of the resident performed by a licensed nurse for 72 hours if a fall result in head injury or is unwitnessed. The facility's policy and procedure indicated the IDT will create or revise the care plan, assess if resident is in appropriate level of care, ensure adequate resources to implement plan of care as written, and inform direct care staff.
A review of Resident 1's care plan titled "Anxiety Care Plan," dated 8/18/16, indicated the resident had generalized anxiety and dementia manifested by restless fidgeting. The staff intervention included monitoring the resident for signs of disturbance, providing reassurance, providing redirection or diversion, and monitoring the significant side effects of the anti-anxiety medication, Ativan, such as drowsiness, sedation, dizziness, headache, nausea, and low blood pressure.
A review of Resident 1's record titled "Rehabilitation Screening? (an assessment tool), dated 8/19/16, indicated Resident 1 was not able to ambulate and needed assistance with wheelchair mobility.
During an interview, on 3/22/17 at 11:11 a.m., the physical therapist (PT 1) stated that needing assistance with wheelchair meant Resident 1 should not be left alone when he was sitting on the wheelchair because Resident 1 was screened as high risk for falls. PT 1 stated that Resident 1 should not be wheeling himself in the wheelchair and that a staff or a family member should push the wheelchair for the resident at all times. PT 1 stated he communicated verbally with the nurses that Resident 1 could not be left alone while in wheelchair and that he was not sure if the nurses created a new care plan.
A review of Resident 1's physician's orders, dated 8/29/16, indicated to order a psychiatric consultation for Resident 1's episodes of shouting and anxiety.
During an interview, on 1/5/17 at 1:36 p.m., the social services designee (SSD) stated that Resident 1 did not see a psychiatrist as ordered by the physician (on 8/29/16) because Resident 1's insurance did not cover the consultation. The SSD stated that Resident 1 should have been seen by a psychiatrist.
First Fall Incident:
A review of Resident 1's report titled "Report of Incident SBAR (Situation, Background, Assessment, Request/Responsible Party Notification/Response) - Actual or Suspected Fall," dated 8/31/16 and timed at 1:16 p.m., indicated Resident 1 had an unwitnessed fall in the bathroom and was found on the floor. Resident 1 was found by a certified nursing assistant (CNA) when the CNA responded to answer the alarm. A possible contributing factor for the fall was the resident's restlessness or anxiousness. The resident was unable to communicate what happened. The SBAR?s falls episodic care plan indicated to conduct neurological checks. The resident?s physician was notified of the incident and the physician did not give new orders.
A review of Resident 1's record titled "Incident Accident Report," dated 8/31/16, indicated that at 1:16 p.m., a loud "thump" and the sound of an alarm were heard. Resident 1 was on the floor holding his head. A registered nurse (RN) assessed the resident for injuries. Resident 1 did not have bruises or lacerations and he was assisted to the wheelchair.
A review of Resident 1's plan of care, dated 8/31/16, indicated the resident had an actual fall. The staff interventions included placing a sensor alarm in the wheelchair.
A review of Resident 1's physician orders, dated 9/2/16 and timed at 8 p.m., indicated that staff may apply a self-release belt when Resident 1 was on the wheelchair to prevent Resident 1 from getting up unassisted.
A review of Resident 1's care plan titled "Physical Restraint," dated 9/2/16, indicated the resident was provided with a self-release belt and the goal was to alert staff when the resident attempted to get up unassisted from the wheelchair.
A review of the Licensed Personnel Progress Notes, dated 9/2/18 and timed at 8 p.m., indicated Resident 1?s physician?s order to apply a self-release belt on the resident while he was on the wheelchair ?to prevent (the resident) from getting up unassisted? was noted by the licensed nurse and carried out. At 8:15 p.m., Resident 1 had increasing aggressive behavior; he was striking out and spitting at the staff; and the resident?s physician was notified. At 9 p.m., the physician?s nurse practitioner gave an order to transfer the resident to GACH 1 for evaluation and treatment. At 11:35 p.m., Resident 1 left the facility.
A review of the Licensed Personnel Progress Notes, dated 9/4/18 and timed at 12 a.m., indicated Resident 1 was readmitted to the facility from GACH 1.
Second Fall Incident:
A review of Resident 1's fall incident report, dated 9/29/16 and timed at 11 p.m., indicated a CNA called the charge nurse because Resident 1 fell on the left side of his head and had a red spot only on his head. The resident was found sitting at the end of his low bed.
A review of Resident 1's report titled "Report of Incident SBAR-Actual or Suspected Fall," dated 9/29/16, and timed at 11p.m., indicated Resident 1 had an unwitnessed fall from a low bed, which occurred during self-ambulation. A possible contributing factor to the fall was the resident's restlessness or anxiousness. Resident 1 was unable to communicate what occurred. The SBAR?s falls episodic care plan indicated to conduct neurological checks. The nurse practitioner was notified of the incident and the nurse practitioner ordered to ?just monitor? the resident.
A review of Resident 1's care plan, dated 9/29/16, indicated the resident had an actual fall without injury. The staff interventions included assessing causative factor and intervene accordingly, encouraging to call for assistance as needed, applying a sensor alarm in bed/wheelchair, and applying a landing mat.
Third Fall Incident:
A review of Resident 1's fall incident report, dated 10/6/16 and timed at 9:30 a.m., indicated that while passing medications, a licensed vocational nurse (LVN 2) heard the sound of the (wheelchair) alarm in the hallway and saw Resident 1 walking, losing his balance, and falling. LVN 2 saw Resident 1 landing on his bottom (buttocks) and then hitting his head on the floor. After LVN 2 assessed Resident 1, the resident was transferred to his wheelchair and placed back to bed. There was bruising on Resident 1's occipital area (the back of the head) and cold compress was applied. Neurological checks were initiated.
A review of Resident 1's report titled "Report of Incident SBAR-Actual or Suspected Fall," dated 10/6/16, and timed at 10 a.m., indicated a registered nurse and an LVN witnessed Resident 1 fall to the floor in the hallway. The SBAR report indicated the wheelchair alarm sounded and a possible contributing factor for the resident's fall was his restlessness and anxiousness. The SBAR?s falls episodic care plan indicated to conduct neurological checks. The physician?s nurse practitioner was notified and an order was received to obtain the resident?s skull x-ray (a picture of the bones surrounding the brain, including the facial bones, the nose, and the sinuses) to rule out intracranial (within the skull) bleed and to monitor the resident?s vital signs every shift for 72 hours.
During an interview of LVN 2 and concurrent review on 1/4/17 at 3:39 p.m., of Resident 1's record titled, "Report of Incident SBAR-Actual or Suspected Fall," dated 10/6/16, at 10 a.m., LVN 2 stated she was assigned to care for Resident 1 on 10/6/16 (the third fall incident). LVN 2 stated that Resident 1 was blind, hard of hearing, and needed supervision. LVN 2 stated that on the 10/6/16 fall incident, Resident 1 was walking by himself and that he lost his balance and fell and hit his head on the floor.
A review of Resident 1's physician's orders, dated 10/6/16 and timed at 10 a.m., indicated an order for a skull x-ray for Resident 1 to rule out intracranial bleed. The record titled "Final X-ray Report," dated 10/6/16, indicated Resident 1's skull had no fractures.
A review of Resident 1's physician orders indicated to administer to Resident 1 anticoagulants (blood thinner medications that help prevent the formation of blood clots) to treat deep vein thrombosis (DVT, a blood clot that forms in a deep leg vein). Resident 1 received the following anticoagulants: Lovenox (enoxaparin) 40 milligrams (mg) injection from 10/18/16 to 10/24/16, Coumadin 3 mg tablet from 10/19/16 to 10/21/16, and Coumadin 4 mg tablet from 10/22/16 to 10/24/16 and from 10/27/16 to 11/1/16.
Fourth Fall Incident:
A review of Resident 1's report titled "Report of Incident SBAR-Actual or Suspected Fall," dated 10/19/16, and timed at 7:30 p.m., indicated a CNA called the charge nurse to Resident 1's room. Resident 1 was found on the floor not far from his wheelchair. Resident 1 stated that he slid from the wheelchair while attempting to open the sliding door. The resident's wheelchair alarm sounded. A possible contribution factors were that Resident 1 was restless and anxious. The SBAR?s falls episodic care plan indicated to conduct neurological checks. The resident?s physician was notified and the physician had no new orders.
During an interview, on 1/4/17 at 3:19 p.m., LVN 1 stated she was assigned to Resident 1 on 10/19/16 (the fourth fall incident) and that usually she had up to 40 or more residents to pass medications and that it was hard to keep Resident 1 supervised. While reviewing Resident 1's medical record, LVN 1 stated that Resident 1 needed a different facility, such as a psychiatric facility, due to his behavior issues and that the facility's staff were not properly trained to care for residents who had behavior issues. LVN 1 stated that Resident 1 did not belong in the facility and that the facility's admission staff did not screen Resident 1 well to be admitted to the facility. LVN 1 stated that Resident 1's falls should have been prevented.
A review of Resident 1's record titled "Laboratory Report," dated 11/1/16, indicated Resident 1's prothrombin time (PT) result was 21.2 seconds and was high (it meant it would take longer for the blood to clot). The PT reference range is less than 14.5 seconds. PT is a laboratory test that measures the time it takes for the blood to clot.
During a review of Resident 1's medical record with the facility's administrator (ADM), on 1/4/17 at 2:23 p.m., the ADM stated that Resident 1 was taking Coumadin and was at higher risk for bleeding (internally and externally) and bruising. The ADM stated that Resident 1 had abnormal coagulation laboratory results prothrombin time (PT) results of 21.2 (seconds) on 11/1/17, and that the nursing staff did not inform the physician. The ADM stated that it was imperative for the nurses to notify the doctor of any abnormal coagulation laboratory results due to the high risk for bleeding for Resident 1.
Fifth Fall Incident:
A review of Resident 1's record titled "Licensed Personnel Progress Notes," dated 11/2/16 and timed at 1:45 a.m., indicated Resident 1 was screaming and wanted to sit on his wheelchair. The licensed progress notes indicated that staff sat him in a wheelchair and then applied a soft belt waist restraint, and a CNA placed the resident in front of his room for visual checks. At 2 a.m., Resident 1 was wheeling himself in front of nurses' station and he kept trying to stand up from the wheelchair and take off the soft belt waist restraint. At 2:15 a.m., PRN Ativan was administered for restlessness. At 3 a.m., the PRN Ativan was effective; Resident 1 was calm and sitting in his wheelchair in front of the nurses? station.
A review of Resident 1's record titled "Licensed Personnel Progress Notes," dated 11/2/16 and timed at 3:30 a.m., indicated Resident 1 was lying on the floor (at the hallway) and was bleeding from his left forehead and had a laceration (a deep cut or tear in skin or flesh). The progress notes indicated Resident 1 was nonverbal but responded to painful stimuli and that a facility staff called 911 (emergency service).
A review of Resident 1's report titled "Report of Incident SBAR-Actual or Suspected Fall," dated 11/2/16, and timed at 4 a.m., indicated Resident 1 was noted on the floor face down and sustained a laceration on top of his forehead and was bleeding. The report indicated that a facility staff was not able to stop the bleeding and a facility staff called 911.
A review of Resident 1?s Licensed Personnel Progress Notes, dated 11/2/16, indicated that at 3:45 a.m., the 911 emergency services (paramedics) arrived at the facility and the resident was transferred to GACH 2.
A review of Resident 1's GACH 2 record titled "Pertinent Report," dated 11/2/16 and timed 4:10 a.m., indicated Resident 1 was admitted to the GACH with diagnoses of intracranial hemorrhage (bleeding inside the skull that usually progresses rapidly and often results in permanent brain damage and death), fall at nursing home, left scalp (skin covering the head) laceration, acute on chronic ("rehemorrhage") right mass effect (the growing mass is pushing the surrounding tissue) subdural hematoma (SDH, a collection of blood in the brain's surface), acute on chronic left frontoparietal (the top and sides of the skull) subdural hematoma with maximum thickness of one (1) centimeter (SDHs greater than 1 centimeter at the thickest point generally require rapid surgical treatment), high blood pressure, and dementia.
A review of Resident 1's GACH 2 records titled "ED (Emergency Department) Notes," dated 11/2/17 and timed 4:46 a.m., indicated the resident's international normalized ratio (INR) results were 2.49 (high) and prothrombin time (PT) results were 26.8 seconds (high).
PT and INR are tests that measure the time it takes for the blood to clot. These tests are used to monitor the effectiveness of the anticoagulant therapy/treatment. The higher the PT/INR number, the thinner the blood, which means it takes longer for the blood to clot. With an INR of 2, the blood takes twice as long as normal unthinned blood. The normal range for a healthy person not using warfarin is 0.8-1.2, and for people on anticoagulant therapy an INR of 2.0-3.0 is usually targeted.
A review of Resident 1's GACH 2 records titled "Preoperative or Procedure Report,? dated 11/14/16, and timed 6:56 p.m., indicated Resident 1 underwent an urgent surgery under general anesthesia (a medically induced coma) for a craniectomy (a neurosurgical procedure in which part of the skull is removed to allow a swelling brain room to expand without being squeezed, it is performed on victims of traumatic brain injury and stroke) for evacuation of right subdural hematoma with harvesting of fascial graft (implant of fibrous tissue), repair of dural (dura mater, outermost membrane surrounding the brain) defect with cranial reconstruction (a surgical procedures used to repair or reshape the face and skull), insertion of subdural shunt (a surgical procedure creating a passage by which blood is diverted from one area to another), and microdissection (a microscope is used for dissection [to cut apart or separate]).
A review of Resident 1's GACH records titled "Discharge Summary," dated 11/30/16, and timed at 4:19 p.m., indicated Resident 1 had to be fed through an nasogastric (NG, a medical process involving the insertion of a plastic tube through the nose, past the throat, and down into the stomach). Resident 1 did not tolerate the NG tube feedings and required a PEG tube. Resident 1's family members opted for end-of-life comfort measures and Resident 1 was transferred to a hospice environment (to another skilled nursing facility) on XXXXXXX16.
A Review of Resident 1's death certificate indicated Resident 1 died on XXXXXXX16 and the immediate cause of death was an acute (sudden onset) and chronic (continuing or reoccurring for a long time) subdural hemorrhage and fall. The injury resulted from a fall from the wheelchair at the facility.
On 1/4/17 at 8:58 a.m., during an interview, Family member (FAM 1) stated that Resident 1 needed to be supervised due to his blindness and he required assistance from staff.
On 1/4/17 at 2:23 p.m., during an interview and record review of Resident 1's medical record, the ADM stated that the neurological (neuro) checks conducted after the resident's fall incidents on 8/31/16, 9/29/16, 10/6/16 were incomplete and the neuro checks were not done after the resident fell on 10/19/16. ADM stated that neuro checks should have been done for 72 hours after each of Resident 1's falls to detect any neurological abnormality (abnormal changes in relation to the brain's function) in accordance with the resident's fall care plan and the facility's policy and procedures. |
| 950000092 |
WOODS HEALTH SERVICES |
950012179 |
B |
11-Apr-16 |
YT9C11 |
5555 |
T 22Section: 72541 California Code of Regulations, Title 22, Licensing and Certification of Health Facilities, Section 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. Based on interview and record review, the facility failed to report an Influenza illness outbreak to Department of Public Health Facilities Inspection Division within 24 hours.Findings: On February 12, 2015, at 1 p.m., an Entity Reported Incident investigation was conducted regarding an Influenza Outbreak at the facility. The administrator and director of nursing (DON) were informed of the visit. On February 12, 2015, at 1:20 p.m., the evaluator conducted an interview with the administrator and DON regarding the influenza outbreak. During this interview, the DON stated that on January 13, 2015, the facility was informed by a family member that a relative, who was a former resident of the facility, was tested positive for Influenza A virus after he died in the acute hospital. The DON added that this case was reported to the Public Health Nurse at the Public Health Department and to the Health Facilities Inspection Division of the death of the resident on January 13, 2015.According to the Center for Disease Control, Influenza (flu) is a contagious respiratory illness caused by influenza viruses. It can cause mild to severe illness. Influenza (also known as the flu) is a contagious respiratory illness caused by flu viruses. It can cause mild to severe illness, and at times can lead to death. The flu usually comes on suddenly. People who have the flu often feel some or all of these symptoms: fever or feeling feverish/chills, cough, sore throat, runny or stuffy nose, muscle or body aches, headaches, fatigue (tiredness) and some people may have vomiting and diarrhea, though this is more common in children than adults. Serious outcomes of flu infection can result in hospitalization or death. Some people, such as older people, young children, and people with certain health conditions, are at high risk for serious flu complications.At 2:05 p.m., the administrator mentioned that the facility started, with the instruction of the Public Health Nurse (PHN) to start line listing (a table that summarizes information about persons who may be associated with an outbreak) on January 14, 2015. The administrator also stated that the PHN came to the facility and collected nasal swab on two residents that had coughing episodes on January 14, 2015. The DON stated the results for influenza A and B were negative. On January 15, 2015, the PHN performednasal swab on six residents that had shown signs and symptoms of influenza virus.On January 18, 2015, four of the six swabs were positive for influenza A and the two residents that passed away on January 15, 2015, also were positive for influenza A.On February 2, 2015, at 2:30 p.m., a review of the facility?s viral influenza line list (a tracking form to show who was affected when the outbreak onset occurred and if they had coughing, fever, chills and sore throat) was conducted. The tracking form report indicated that on January 8, 2015, one resident had a temperature of 101.8 degrees Fahrenheit (a temperature of 98.6 degrees Fahrenheit is baseline) with cough, one resident and one staff reported coughing and chills. On January 9, 2015 to January 16, 2015, there were 23 residents that had episodes of coughing with one complaint of sore throat. The line list for staff indicated seven staff members reported body temperatures ranging from 99.7 degrees Fahrenheit to 102 degrees Fahrenheit with abdominal cramps, chills, cough and runny nose from January 9, 2015, to January 25, 2015.On February 12, 2015, at 2:45 p.m., the evaluator reviewed the faxed report from the SNF to the Department, dated January 28, 2015, at 4:07 p.m. of the Influenza viral outbreak.January 16 there were 23 residents or more who were coughing and or had a sore throat. On January 18 there were four of six residents who tested positive for Influenza A. The facility did not report the outbreak until January 28, 2016. On February 12, 2015, at 3:45 p.m., the evaluator reviewed the facility's policy and procedure, dated January 24, 2013, Influenza and gastrointestinal illness, Preparedness and response Plan."The policy indicated, "Potential outbreaks will be reported to the Department of Public Health and Licensing (and Certification) agencies as required."On February 12, 2015, at 4:20 p.m., the evaluator conducted an interview with the administrator and the DON regarding the influenza outbreak. The administrator stated that the facility should have reported the outbreak to this Department, within 24 hours.This violation had a direct relationship to the health, safety or security of residents. |
| 950000092 |
WOODS HEALTH SERVICES |
950012914 |
A |
24-Feb-17 |
S0L311 |
8347 |
FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES
The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents.
On 3/25/15, at 2:30 p.m., an unannounced visit was made to the facility to investigate a self-reported incident involving a resident who fell and sustained a hip and rib fractures.
Based on interviews, and record reviews, the facility failed to:
1. Ensure Resident 1 had adequate supervision to prevent falls.
2. Ensure that staff assigned to monitor the activity room /dining room stayed in the room to monitor all residents while waiting to be wheeled to their rooms.
These deficient practices resulted in Resident 1, who had a history of falls, was not provided adequate supervision to prevent a fall onto the floor (on 3/20/2015) of the facility's dining/activity room area and sustain a fracture of the hip and right 7th rib. Resident 1 was transferred to an acute hospital for a two day stay and had a non-surgical management of the hip.
Review of the clinical records indicated Resident 1 was re-admitted to the facility on XXXXXXX15, with diagnoses that included difficulty walking, dementia (persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning) and personal history of falls.
Review of the Minimum Data Set (MDS- care and screening tool) dated 2/17/15, indicated Resident 1 required limited assistance with locomotion on unit and of the unit and extensive assistance from the staff for bed mobility, transfer, walking, personal hygiene and toileting. The MDS indicated that Resident 1 usually had the ability to make self-understood and usually had the ability to understand others. The MDS section G 0300 - Balance During Transition and Walking indicated Resident 1 was not steady, was only able to stabilize with staff assistance: on moving from seated to standing position, walking (with assistive device if used), turning around, moving on and off toilet and surface to surface transfer (transfer from bed and chair or wheelchair).
Review of the clinical records revealed Resident 1 had a history of six (6) falls in the facility, 9/5/ 11, 6/19/13, 10/21/13, 7/30/14, 1/17/15, and 3/20/15.
Further review of the fall incidents investigation by the facility on 6/19/13, 10/21/13, 7/30/14 and 1/17/15, revealed Resident 1 fell or was found on the floor in her room, and on 9/5/11 and 3/20/15, resident fell out of her wheelchair. The post fall report dated 1/17/15, documented that the resident sustained a skin tear to her lower leg 2.5 centimeter (cm).
Review of Resident 1's Fall Risk Assessment dated 2/17/15, showed a score of 14 (a score of 10 or above represents a high risk for falls).
Review of Resident 1's Care Plan dated 6/19/13, and revised on 7/30/14, indicated Resident 1 was identified at risk for fall/injuries related to unsteady gait, poor safety awareness/judgement, history of falls, behavior/impulsiveness, inability to follow commands/instructions, cognitive (mental). The care plan approaches/interventions included: assess resident's risk for falls and address problems identified, orient resident to the room and remind where things are, frequent visual checking at least every 2 hours, safety alarm in bed/chair. Discourage sudden change in position to prevent/minimize orthostatic (Orthostatic hypotension is a sudden fall in blood pressure that occurs when a person assumes a standing position) symptoms, assist resident to assume a position of comfort and body alignment and assist resident's needs for assistive device quarterly and as needed (prn).
Review of an annual Joint Mobility Assessment performed by a Licensed Vocational Nurse (LVN 1) dated 2/14/15, indicated that Resident 1's "range of motion (the measurement of the amount of movement around a specific joint or body part) was within normal (wnl), however had poor safety awareness, poor endurance, unstable gait (manner or style of walking)." The assessment indicated that Resident 1 was at risk for falls due to poor balance/unsteady gait, poor endurance, poor safety awareness and diagnosis of dementia.
Review of Resident 1's Licensed Nurse Weekly Summaries dated 3/19/15, indicated Resident 1 had impaired decision making, limited ability to understand and communicate. Her functional status for activities of daily living (ADL) showed she required extensive assistance with ambulation (walking), transfers and toileting.
Review of the LVN 2's notes dated 3/20/15, at 1:15 p.m., revealed that the Admission Coordinator reported that Resident 1 was found on the floor on her right side in the activity room/dining room. Resident 1 was unable to move her right leg and had a skin tear (partial or complete separation of the outer skin layers from the inner tissue) to left lower leg 5 centimeters (cm) by 3 cm and a bump (swelling on the head) to the right forehead. The LVN notes also indicated that Activity Staff A stated Resident 1, "Was up in a wheelchair in front of a table when Activity Staff A heard alarm sound and found resident on the floor, Resident 1 did not know what happened."
On 3/25/15, at 3 p.m., an interview with the Activity Director revealed that after lunch she would wheel the residents back to their rooms one by one and that there was no one left in the activity room/dining room to supervise and monitor the other residents that are still left in the room.
During an interview with the Director of Nursing (DON) on 3/25/15, at 3:30 p.m., she stated that she sent out an email dated 4/4/13, to nursing staff about Resident 1 that indicated, "Remove the soft belt and put a wedge cushion and an anti- slip mat in the wheelchair; put safety alarm while up in a wheelchair." The DON stated that the goal for the resident was to be restraint free and not to have falls. She explained that other interventions in place were: nursing staff, Interdisciplinary Team (IDT) (team of professional members) to monitor effectiveness of the restraint reduction and document in the nurse's notes, and the nursing supervisor was to get an order of the reduction of restraints from the physician and notify the family and update the care plan. Other interventions included frequent visual checks and put Resident 1 close in front of the Nurses Circle (nursing station). She also stated that there were no logs for Resident 1's history of falls, but instead the facility completed a post fall assessment and Interdisciplinary (IDT) review.
Review of one of the post fall assessment dated 1/17/15, reviewed with the DON indicated the corrective action was "continue to remind resident to call for assistance and frequent visual checks and to assist to toilet. When the DON was asked, "What did more frequent visual checks mean?" The DON stated, "More than every 2 hours or more frequent."
Interviews on 3/26/15, at 1 p.m., with Certified Nurses CNA 1, 2 and 3, revealed that they were not in the activity/dining room when Resident 1 fell. They stated that, "After lunch, we pick up the trays from the residents and return them back to the kitchen. Some of us take residents back to their rooms or assist them to the bathroom." CNA 2 explained that this is what they usually do after assisting residents with their meals.
A review of Resident 1's hospital History and Physical records dated 3/20/15 indicated Resident 1 had a right intertrochanteric (hip) fracture, nonsurgical management and right lateral 7th rib fracture. (She was re-admitted back on 3/22/15- 2 days).
The facility failed to ensure that the resident?s environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents, including but not limited to:
1. Ensure Resident 1 had adequate supervision to prevent falls.
2. Ensure that staff assigned to monitor the activity room /dining room stayed in the room to monitor all residents while waiting to be wheeled to their rooms.
The above violation presented either imminent danger that death or serious harm would result or a substantial probability that death or serious harm would result. |
| 220001063 |
Webster House |
070013668 |
B |
6-Dec-17 |
3SIP11 |
3913 |
F609 - 483.12(c), 483.12(c)(1) Report the Allegations of Abuse, Neglect, Exploitation, or Mistreatment
?483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must:
?483.12(c)(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.
?483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.
The facility staff failed to report a suspected allegation of resident abuse in a timely manner for Resident 1, when housekeeping A (HK A) witnessed certified nursing assistant B (CNA B) slapped Resident 1 on the left lower leg between 11/2/17 and 11/4/17 but did not report it until 11/17/17. This failure had the potential to delay identification and implementation of appropriate corrective action and put the residents at risk for abuse.
During an interview with HK A, a non-English speaking staff, on 11/28/17, at 1:35 p.m., using interpreter C (IPR C), she stated between 11/2/17 and 11/4/17 she witnessed Resident 1 took linen and washcloths from the linen cart, and CNA B wanted to take them back. Resident 1 did not allow CNA B to do so, and CNA B slapped Resident 1 on her left lower leg. HK A stated she did not report it to anyone until 11/17/17, which was 13 to 15 days later, when she told a CNA about it. That CNA told a nurse, and the nurse reported it to the social worker. During a telephone interview on 11/29/17, at 10:25 a. m., with IPR C, HK A acknowledged she should have reported it when she witnessed what happened.
Review of HK A's orientation document indicated HK A signed the facility's Reporting Elder Abuse on 6/26/17 stating she read the facility's Elder Abuse policy and procedure, viewed "Your Legal Duty" video and took pre and post video tests.
The Department received a faxed report from the facility on 11/17/17 which indicated a housekeeping personnel reported that she saw a CNA from the night shift slapped Resident 1 on her lower leg.
The facility policy and procedure titled "Elder Abuse Prevention" updated on 3/7/17, indicated "... all alleged violations and all substantiated incidents involving abuse, neglect, exploitation or mistreatment,... will be 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,... to the administrator of the community and to other officials, including to the State Survey Agency... in accordance with State law."
The facility staff failed to report a suspected allegation of resident abuse in a timely manner for Resident 1, when HK A witnessed CNA B slapped Resident 1 on the left lower leg between 11/2/17 and 11/4/17 but did not report it until 11/17/17. This failure had the potential to delay identification and implementation of appropriate corrective action and put the residents at risk for abuse.
This violation had a direct relationship to the health, safety, or security of residents. |
| 920000082 |
WEST HILLS HEALTH AND REHABILITATION CENTER |
920013473 |
B |
6-Sep-17 |
WPYZ11 |
12484 |
? CFR 483.90 Physical Environment
(i) (4) Maintains Effective Pest Control Program
Maintain an effective pest control program so that the facility is free of pests and rodents.
On 7/18/17, an unannounced visit was made to the facility to conduct a recertification survey.
Based on observation, interview, and record review, the facility failed to maintain an effective pest control program to ensure the facility is free of pests, including:
1. Failure to act upon the recommendations made by the pest control services on June 22, 2017.
2. Failure to implement the Integrated Pest Management Program (IPM, preventive measures to prevent pest infestations).
As a result, on July 20, 2017, there was infestation of cockroaches throughout the facility, placing the total census of 123 residents and the staff at risk of diseases. Cockroaches' saliva, droppings, and decomposing roaches' bodies contain proteins known to trigger allergies that can increase the severity of asthma symptoms. Cockroaches are capable of carrying disease causing organisms such as Salmonella typhimurium (is a type of bacteria that cause food poisoning), typhoid fever (an infectious bacterial fever with an eruption of red spots on the chest and abdomen and severe intestinal irritation), Entamoeba histolytica (a parasite that is transmitted to humans via contaminated water and food), poliomyelitis virus (a virus that enters the mouth and spreads from person to person and can invade an infected person's brain and spinal cord, causing paralysis), Staphylococcus spp (a bacteria that cause skin infections), Streptococcus spp (a bacteria that cause diseases such as sore throat), hepatitis virus (inflammation of the liver), and coliform bacteria (a bacteria found in water causing diseases).
On July 20, 2017 at 9:30 a.m., during an observation tour of the kitchen in the presence of Cook 1, a small live cockroach was observed crawling on the floor next to the floor drain located by the vegetable and meat sink preparation area. Cook 1 took a piece of paper towel and disposed of the cockroach. A square shaped plastic bait trap measuring 2 by 2 inches was observed attached to the tiled wall behind the juice dispenser machine, located next to the vegetable and meat preparation area. During a concurrent interview, Cook 1 stated he had seen cockroaches in different areas of the kitchen approximately two months ago.
On July 20, 2017 at 10 a.m., during an interview, the Dietary Service Supervisor (DSS) stated he did not know what the square shaped plastic (bait trap found behind the juice dispenser machine) was. The DSS stated the pest control company comes once a month and checks the entire kitchen.
On July 20, 2017, at 4:36 p.m., during another observation of the kitchen in the presence of Dietary Aide 1 (DA 1), two live cockroaches were observed crawling next to the floor drain under the shelf where the pots were stored. Upon interview, DA 1 stated he saw cockroaches under the shelf in between Refrigerator #1 and the stove two months ago and reported the sighting to the DSS.
On July 20, 2017, at 4:50 p.m., during an interview, DA 2 stated he saw a cockroach four days ago at approximately 2 p.m., under the shelf where the pots were stored (same area where the Evaluator observed cockroaches with DA 1). DA 2 stated he informed the DSS about the sighting and stated the DSS called the pest control company.
On July 21, 2017 at 7:51 a.m., during an interview, Resident 19 stated she saw the a roach in her room crawling on the floor the night before.
b. On July 18, 2017 at 12:00 p.m. in the presence of a Restorative Nursing Assistant (RNA 2), there were eight cardboard boxes observed in the Activity Room on top of the shelves strapped down with earthquake safety cords. On July 20, 2017 at 8 a.m. in the presence of the Housekeeping Supervisor (HS 1), the boxes were still observed in the same place as on July 18, 2017.
On July 20, 2017 at 4:45 p.m. during an observation of Resident 6's room in the presence of Registered Nurse 3 (RN 3), the floor had accumulated dust, dirt, debris, candy wrappers and an empty bag of chips.
c. On July 20, 2017 at 4:50 p.m. Random Sample Resident (RSR) 32's room was observed in the presence of RN 3. The floor had accumulation of dust, dirt, debris and an empty bag of chips. The table next to bed A was observed with food including rice, green beans, spinach, and cornbread. Two hard boiled eggs were in a container with a label indicating July 16, 2017. There was also a Chinese food box and a bowl of oatmeal.
On July 20, 2017 at 4:55 p.m., during an interview RSR 32 stated there was, "A little something crawling," but stated she did not notify staff. The resident stated she asked staff to clean her floor but the staff did not want to clean it.
During an interview with the DON on July 20, 2017 at 5:30 p.m., she stated the pest control specialist was contacted because there were cockroaches observed in the employee's break room in June 2017.
e. On July 19, 2017, at 10:53 a.m., at the Station 2 nursing workstation, a live cockroach approximately 0.5 centimeters (cm), was observed running on the counter top. The roach ran horizontally across the countertop from the direction of the portable flavored water dispenser, then vertically to a lower section of the countertop, then horizontally into a stack of residents' medical records. At the time of the observation, Registered Nurse Supervisor 1 (RNS 1) was present and called the Housekeeping Supervisor (HSK 1) and the DON. The cockroach was not captured.
On July 20, 2017 at 10:11 a.m., during an interview, the DON and administrator indicated the pest control company was scheduled to come the following day (July 22, 2017) for the monthly visit to service the employees' lounge and kitchen.
f. On July 19, 2017, at 12:13 p.m., a cockroach was sighted in the beauty shop in use by the Evaluators as a conference room. The roach was crawling from the direction of a cabinet closet to the door and then went up the wall. The administrator, who was outside the door, was called in to witness the roach sighting. The administrator used a paper towel, took the cockroach and disposed of it.
A review of the Pest Management Sanitation Report from January 12, 2017 to June 22, 2017, indicated the pest control provider came to the facility once per month. Each month from March 9, 2017 to June 22, 2017 the pest Management Report recommended to, "Keep doors closed, watch for food storage in rooms, food must be kept in plastic containers." The report dated March 9, 2017 had been signed by the administrator. The Report dated June 22, 2017 indicated roaches had been sighted in the employees' lounge.
On July 20, 2017, at 4:45 p.m., during an interview, Pest Control Tech 1 (PCT 1) stated she visits the facility monthly and if there is a problem the facility staff would call. PCT 1 stated she did, "A lot of preventive measures." When asked to give examples of the preventive measures, PCT 1 stated she implements the Integrated Pest Management Program (IPM). PCT 1 explained the Program included to use the least amount of chemicals, remove boxes from the facility, and caulking (seal a gap or seam, with a waterproof filler and sealant, to seal the gaps and cracks that exist between adjoining materials) and this was the reason she does not spray but uses bait in the kitchen, dish washer, and shelves. PCT 1 stated she uses long-term baits; the last time on June 22, 2017 when roaches were spotted in the microwave of the employees' lounge. PCT 1 also stated that ten or more roaches would be a problem but she only saw two baby roaches.
On July 21, 2017, the administrator provided an undated copy of IPM Program with key elements that include habitat modification that reduces or eliminates sources of food, water, shelter, and entryways for pests. Take preventive measures, as simple as, thoroughly cleaning food storage areas; caulking; daily removal of waste to dumpsters; and educating facility staff and occupants about the importance of proper waste disposal. Buildings should be designed to be as pest resistant as possible by caulking cracks and gaps in the building to block pest entry; and using door sweeps and screens. Sanitation is a must, food in resident rooms must be in a pest-proof airtight container; no corrugated cardboard boxes allowed in resident rooms, dead roaches must be vacuumed out of bedside cabinets to prevent re-infestation; all TV's, radios, phones, etc. must be checked for roaches before installed in residents' rooms. In the kitchen, corrugated cardboard boxes must be removed from storerooms (this includes non-food items too); store food in airtight containers; no personnel items are to be stored in the kitchens; floors are to be kept clean of food and grease build up including under tables and stoves, if not, any roach baiting program will not work. Kitchen walls, under steam tables, dishwashing area, behind stoves, around door frames must be caulked and sealed to prevent nesting places for roaches. Dead roaches must be swept up, as to prevent re-infestation.
g. On July 21, 2017 at 7:15 a.m., during a meal preparation observation in the kitchen, in the presence of the administrator, the following was observed:
1. One foot by one (1 by 1) foot square exhaust opening above the dishwasher machine without any type of covering to prevent any pest entry and infestation into the kitchen.
2. One cockroach under the dishwasher was observed lying on its back with twitching antennae and appeared to be dying. A cockroach shell was observed on the floor beside the stove.
3. The plumbing drain pipes had cracks at least one centimeter around the pipes into the wall where the meat and vegetable would be prepared. The administrator stated the cracks and openings will be sealed.
h. On July 21, 2017 at 7:55 a.m., during a tour of the kitchen with the administrator, the following was observed:
1. Missing grout/caulking on the floor and base board tiles around the area by the kitchen entrance door.
2. There were crevices on the wall along the base edges of the new electrical panel that had been recently installed.
3. Under a new sink there were floor tiles with holes that measured approximately 2 by 2 inches. Also, underneath this sink there was a hole on the wall approximately 4 by 4 inches.
On July 21, 2017, at 12:20 p.m., during an interview with the administrator, in the presence of the Regional Operations Manager, when asked when he had implemented the Pest Management Sanitation Report recommendations, the administrator stated, "Just now."
A review of the facility's undated policy, titled "Housekeeping - Pest Control," indicated that the administrator arranges for a pest control company to visit and inspect the facility at least once a month, ensuring that: immediate action is taken to rid the facility or its grounds of any environmental pest as noted in the inspection report; after exterminating or spraying for insects, as the situation warrants, the facility is once again inspected by the pest control company to ensure that all environmental pests were removed from the premises. The company representative issues an additional report to the administrator, verifying that all environmental pests were removed.
The facility failed to maintain an effective pest control program to ensure the facility is free of pests, including:
1. Failure to act upon the recommendations made by the pest control services on June 22, 2017.
2. Failure to implement the Integrated Pest Management Program (IPM, preventive measures to prevent pest infestations).
As a result, on July 20, 2017, there was infestation of cockroaches throughout the facility, placing the total census of 123 residents and the staff at risk of diseases. Cockroaches' saliva, droppings, and decomposing roaches' bodies contain proteins known to trigger allergies that can increase the severity of asthma symptoms. Cockroaches are capable of carrying disease causing organisms such as Salmonella typhimurium, typhoid fever, Entamoeba histolytica, poliomyelitis virus, Staphylococcus spp, Streptococcus spp, hepatitis virus, and coliform bacteria.
The above violation had direct or immediate relationship to the health, safety, or security of all 123 residents in the facility. |
| 970000147 |
WESTLAKE CONVALESCENT HOSPITAL |
910013561 |
A |
25-Oct-17 |
MPHQ11 |
10054 |
F-309
?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.
F-323
?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 July 20, 2017 at 7:10 a.m., an unannounced visit was made to the facility to investigate an Entity Reported Incident (ERI) regarding Resident 1?s fall and injury.
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, failed to ensure its resident environment remains as free of accident hazards as is possible and that each resident receives adequate supervision to prevent falls and injuries, including:
1. Failure to evaluate if an alarm on an unlocked gate leading to a 15-flight of stairs to a lower floor, was effective in ensuring safety and was functional to alert staff when Resident 1or any resident opened the gate to go downstairs.
2. Failure to re-evaluate Resident 1?s risk plan of care for injury/fall and self-care deficit with locomotion to include interventions related to his ability to propel self in the wheelchair, to ensure the interventions met Resident 1?s safety needs including increased monitoring frequency while propelling self around the facility.
3. Failure to closely monitor Resident 1?s suicidal thinking and worsening of depression after started on the anti-depressant medication Lexapro.
As a result, on 7/8/17, while unsupervised, Resident 1 opened the gate leading to a lower level floor and intentionally fell down a 15- flight of stairs, when attempting suicide. The gate alarm did not go off to alert staff of the opening of the gate. Resident 1?s fall resulted in head concussion (brain injury that is caused by a sudden blow to the head), scalp laceration (cut) that required eight staples, skull fracture (break of the left parietal bone), right knee swelling and pain, and multiple neck bones fractures which required cervical spine (c-spine) surgery.
On 7/20/17, at 8 a.m., during a tour of the facility with Registered Nurse 1 (RN 1), the patio, used by residents, was observed to have a gate which led to a lower level floor (first floor) by a 15-flight of stairs. The gate had a latch to close the gate but did not lock it. The gate had a functioning alarm to alert the staff when someone was attempting to open the gate. The lower level (first floor) housed the kitchen and garbage bins. During a concurrent interview, RN 1 stated the second floor patio gate remained closed but unlocked because locking it presented a potential hazard during fire emergency.
A review of the Admission Face Sheet indicated Resident 1 was admitted to the facility on 1/7/17, with diagnoses including chronic respiratory failure with tracheostomy tube (a surgically created hole in the windpipe or trachea that provides an alternative airway for breathing. A tube is inserted through the hole and secured in place with a strap around your neck), cardiac arrest (heart attack), anoxic (lack of oxygen) brain damage, gastrostomy tube (GT ? a flexible tube surgically inserted in the stomach through the abdominal wall to administer medications and nutrition), major depressive disorder (characterized by a persistent low mood that is accompanied by loss of interest or pleasure in normally enjoyable activities), and epilepsy (seizures or uncontrolled shaking movement).
A physician?s order dated 1/7/17 indicated Phenobarbital 97.2 milligrams (mg) daily for epilepsy. The Nurse's Drug Guide 2017 indicates Phenobarbital is classified as a sedative - hypnotic, with adverse effects of anxiety, thinking abnormalities, dizziness, confusion and depression.
A review of a Care Plan initiated on 1/9/17, with a target date of 7/20/17 developed for Resident 1?s self-care deficit with activities of daily living (ADLs) such as locomotion, included in the approaches assisting Resident 1 to move around the unit and facility as needed.
A review of the Care Plan dated 1/10/17, developed after Resident 1 fell out of bed, indicated Resident 1 was at risk of falling due to history of fall and poor safety awareness. The interventions included monitoring Resident 1 for sedation, dizziness, and location with visual checks every two hours and as needed.
According to the Minimum Data Set (MDS - standardized assessment and care plan planning tool) dated 4/19/17, Resident 1 had moderate cognitive impairment (memory and thinking skills), had slurred speech, was unable to walk, required extensive assistance with one-person physical assist with bed mobility, transfers and bathing. Resident 1 was assessed as needing limited assistance (resident highly involved in the activity with one-person physical assist) with locomotion and used a wheelchair as mobility device. Depression was not documented as an active diagnosis for Resident 1.
A review of the nursing Progress Notes dated 7/3/17, indicated Resident 1 verbalized he was sad and depressed.
A review of the Physician?s Order dated 7/3/17 indicated Lexapro 10 mg daily for depression manifested by self-isolation. The Nurse's Drug Guide 2017 indicated Lexapro has a black box warning as Lexapro is associated with suicidal thinking, and to closely observe for worsening of depression or suicidality.
A review of the Care Plan dated 7/3/17, developed for Resident 1?s diagnosis of depression and use of anti-depressant medication, included in the interventions to encourage verbalization of feelings and concerns, monitor Resident 1's activity, behavior, spend time with resident on a one to one basis, and social service department to do room visit regularly and check needs and concerns. The interventions did not include monitoring Resident 1 for suicidal thinking, worsening of depression or suicidality
A review of the Medication Administration Record (MAR) indicated Resident 1 had episodes of isolation on 7/3, 7/4, 7/7 and 7/8/17. There was no documentation nursing staff were monitoring Resident 1 during the month of 7/2017 for side effects/adverse reactions from Phenobarbital and Lexapro.
A review of the Summary of Incident form, dated 7/8/17 by the Administrator, indicated Resident 1 was found outside, beside the kitchen, lying on his left side with the wheelchair beside the resident. Resident 1 was noted with a laceration on top of the scalp, paramedics (911) were called, and Resident 1 was transferred to General Acute Care Hospital 1 (GACH 1) for further evaluation and treatment.
A review of the clinical record from GACH 1 Transcription Report dated 7/9/17, indicated Resident 1 was a 45 year old male, who stated he wanted to kill himself and threw himself down 12 flights of stairs. Resident 1 was applied nine staples to suture a scalp laceration. The final diagnoses were suicidal attempt with poly-trauma (occurs when a person experiences injuries to multiple body parts), a concussion, skull fracture, and cervical spine fracture. The report indicated Resident 1 was transferred to GACH 2 due to the need of specialized care.
A review of the surgical progress note from GACH 2 indicated Resident 1 underwent neck surgery on 7/20/17.
On 7/20/17, at 11:45 a.m., during an interview, the Assistant Director of Nursing (ADON) stated when Resident 1 was found downstairs, the alarm did not go off. ADON stated Resident 1 was alone and nobody witnessed the incident.
On 7/20/17, at 12:15 p.m., during an interview, Certified Nursing Assistant 2 (CNA 2), stated she saw Resident 1 roaming around the facility in his wheelchair around 11:45 a.m., on the date of the incident (7/8/17). CNA 2 stated she did not hear the patio gate alarm going off when Resident 1 went through the gate.
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, failed to ensure its resident environment remains as free of accident hazards as is possible and that each resident receives adequate supervision to prevent falls and injuries, including:
1. Failure to evaluate if an alarm on an unlocked gate leading to a 15-flight of stairs to a lower floor, was effective in ensuring safety and was functional to alert staff when Resident 1or any resident opened the gate to go downstairs.
2. Failure to re-evaluate Resident 1?s risk plan of care for injury/fall and self-care deficit with locomotion to include interventions related to his ability to propel self in the wheelchair, to ensure the interventions met Resident 1?s safety needs including increased monitoring frequency while propelling self around the facility.
3. Failure to closely monitor Resident 1?s suicidal thinking and worsening of depression after started on the anti-depressant medication Lexapro.
As a result, on 7/8/17, while unsupervised, Resident 1 opened the gate leading to a lower level floor and intentionally fell down a 15- flight of stairs, when attempting suicide. The gate alarm did not go off to alert staff of the opening of the gate. Resident 1?s fall resulted in head concussion (brain injury that is caused by a sudden blow to the head), scalp laceration (cut) that required eight staples, skull fracture (break of the left parietal bone), right knee swelling and pain, and multiple neck bones fractures which required cervical spine surgery.
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. |
| 070000097 |
WILLOW GLEN CENTER |
070013502 |
B |
4-Oct-17 |
DM8E11 |
2618 |
F206 - 483.12(b) (3) POLICY TO PERMIT READMISSION BEYOND BED-HOLD
A nursing facility must establish and follow a written policy under which a resident whose hospitalization or therapeutic leave exceeds the bed-hold period under the State plan, is readmitted to the facility immediately upon the first availability of a bed in a semi-private room if the resident requires the services provided by the facility; and is eligible for Medicaid nursing facility services.
The facility failed to readmit Resident 1 during a seven-day bed-hold period and to follow the Department of Health Care Services,' Administrative Appeals' order to readmit the resident.
Resident 1's clinical record was reviewed. He had diagnoses including dementia (brain disease causing a long-term and often gradual decrease in the ability to think, remember, and affecting a person's daily functioning) with behavioral disturbance, anxiety disorder, and major depression.
Review of Resident 1's Progress Notes, dated 5/2/17, indicated the resident was transferred to EPS due to aggressive behavior.
Review of Resident 1's History and Physical from acute care hospital, dated 5/2/17, indicated the resident was cleared and ready to discharge to the facility by the EPS but the facility would not take the resident back. Resident 1 was admitted to the emergency department (ED) for skilled nursing facility (SNF) placement.
During an interview with the community relation director (CRD) on 9/13/17 at 1:25 p.m., he stated on 5/2/17 Resident 1 was transferred to EPS. The facility refused to take the resident back.
Review of the Department of Health Care Services', Administrative Appeals final Decision and Order dated 8/29/17, indicated the facility "...must immediately offer to readmit" Resident 1 to "...to his former bed or to the first available bed in a semi-private room."
During a facility visit on 9/13/17, Resident 1 was not in the facility. The facility did not readmit the resident after the court hearing on 8/29/17.
Review of the facility's policy "Bed Hold General Policy Guidelines" dated 10/13/05, indicated the right to exercise a bed hold is applicable to all residents and may not be used as a condition for admission or readmission.
Therefore, the facility failed to readmit Resident 1 during a seven-day bed-hold period and to follow the Department of Health Care Services,' Administrative Appeals' order to readmit the resident.
The above violation caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety, or other emotional trauma to residents. |
| 940000029 |
WINDSOR CONVALESCENT CENTER OF NORTH LONG BEACH |
940013539 |
A |
12-Oct-17 |
7FR711 |
16142 |
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.
F329
?483.45(d) Unnecessary Drugs-General.
Each resident?s drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used--
(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 (d) (1) through (5) of this section.
The facility failed to ensure Resident 1, who had a history of multiple falls was free from unnecessary drugs and the residents? environment remained as free from accident hazards as was possible, while receiving adequate supervision and assistance devices to prevent accidents, including but not limited to:
1. Failure of the facility to implement its fall policy and the IDT?s ([Interdisciplinary Team] a group of health care professionals working together for a common goal for the resident) recommendations and Resident 1?s plan of care.
2. Failure to provide adequate monitoring and supervision for Resident 1, who had a history of multiple falls and was receiving medications with high risk for falls.
3. Failure to ensure Resident 1 was free from unnecessary drugs, in duplication therapy. Resident 1 received Risperdal (Risperidone, is a medication used to treat mental and mood conditions), and Quetiapine Fumarate (Seroquel, a medication used to treat mental and mood conditions), simultaneously from June to July 2017 and not documenting that the resident was monitored for increased agitation while receiving Ativan.
These deficient practices resulted in Resident 1 receiving unnecessary medication use, which could lead to side effects from the antipsychotic medications, causing reoccurrence of falls, 10 within four months, requiring two transfers to a general acute care hospital (GACH), after sustaining a laceration (a deep cut or tear in skin or flesh) to the head, requiring wound closure, antibiotics, and pain medications, and blunt head trauma with an abrasion (a wound caused by superficial damage to the skin) to the head during another fall. This had the potential to result more serious injuries and/or death.
The Department received a complaint allegation on 6/23/17 that a resident (Resident 1) fell out a chair twice in a week and the last fall resulted in a facial scalp laceration requiring a transfer to the hospital.
A review of Resident 1?s Admission record Face Sheet indicated the resident was an 81 year-old female who was originally admitted to the facility on 2/8/16 and readmitted on 6/23/17. Resident 1?s diagnoses included abnormalities of gait and mobility, lack of coordination, dementia (chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning), with behavioral disturbances, schizoaffective disorder (mental disorder characterized by abnormal thought processes and emotions), anxiety disorder (a mental health disorder characterized by feelings of worry and fear strong enough to interfere with daily life), generalized muscle weakness, and unspecified psychosis (a mental disorder characterized by a disconnection from reality).
A review of Resident 1?s History and Physical (H/P), dated 6/29/17, indicated the resident did not have the capacity to make decisions.
A review of Resident 1?s Minimum Data Set (MDS), a resident assessment and care-screening tool, dated 5/3/17, indicated Resident 1 had short and long-term memory problems and had moderately impaired decision-making skills requiring cues and supervision. The MDS indicated the resident required extensive assistance with a one-person physical assistance for transferring between surfaces, toilet use, personal hygiene care, and locomotion on and off the unit. The MDS indicated Resident 1 did not have a steady gait and was only able to stabilize with staff assistance when moving to and from a seated to standing position, walking, turning around, and surface to surface transfer. The MDS indicated Resident 1 was frequently incontinent (having no or insufficient voluntary control) of bowel and bladder.
A review Resident 1?s ?Fall Scene Investigation Reports,? dated 4/5/17, and at 5:17 p.m., 4/12/17 and timed at 8:46 p.m., and 4/28/17 timed at 2:50 p.m., indicated the resident lost her balance and fell to the floor.
A review of Resident 1?s Care Plan titled, ?Resident had a fall in the dining room with no injury,? dated 4/28/17, indicated the staff?s intervention included to provide frequent visual monitoring for safety.
A review of a ?Documentation Survey Report,? for the month of 6/2017, indicated to document each time Resident 1 was provided with assistance for toilet use. According to the report, Resident 1 was provided toilet use assistance on 6/19/17 at 9:48 p.m., and 6/20/17 at 1:09 a.m., but was not always offered assistance.
A review of Resident 1?s ?Health Status Note,? dated 6/20/17 timed at 3:09 p.m., indicated on 6/20/17 at 7:15 a.m., Resident 1 was found lying on the floor on her back. The note indicated at 7 a.m., prior to the fall, the resident was seen propelling herself in the wheelchair.
A review of Resident 1?s Fall Risk Assessment, dated 6/20/17, indicated the resident had a high risk for falls.
A review of Resident 1?s ?Assessment Summary,? dated 6/20/17 at 1:52 p.m., indicated the IDT Team made recommendations to monitor the resident?s whereabouts every 30 minutes, and to offer assistance.
A review of Resident 1?s Care Plan titled, ?Resident had a fall incident on 6/20/17, no noted injury. Potential for complications related to the fall,? dated 6/20/17, indicated the goal was for the resident not to have complications related to a fall for the next two weeks. The staff?s interventions included to anticipate the resident?s needs and provide frequent monitoring every 30 minutes, and monitor the resident?s whereabouts.
A review of Resident 1?s ?Documentation Survey Report,? for the month of 6/2017, indicated to document each time the resident was monitored for her whereabouts every 15 minutes, and offered assistance. The report indicated Resident 1 was not monitored until 6/21/17, at 1 p.m.
A review of Resident 1?s ?Health Status Note,? dated 6/21/17 and timed at 4:51 a.m., indicated on 6/21/17 at 4 a.m., the ?resident woke up and started yelling and screaming for no apparent reason.? The note indicated Ativan (a medication used to treat anxiety disorders for short-term relief), one milligram (mg) intramuscularly ([IM], administered into a muscle), was administered to the resident. The note indicated the resident was remained agitated and would be provided with ?frequent visual monitoring.?
A review of Resident 1?s ?Health Status Note,? dated 6/21/17 timed at 5:42 p.m., indicated on 6/21/17 at 1:40 p.m., the resident fell forward, hit her head on the wall, and sustained a laceration to the middle frontal part of the scalp. The laceration with measured 4.0 centimeters (cm) in length by 0.5 cm in width, and 0.2 cm in depth. The note indicated Resident 1 was alert but lethargic after fall. The note indicated the resident was transferred to the general acute care hospital (GACH).
A review of Resident 1?s Trauma History and Physical (H/P) from the GACH, dated 6/21/17, and timed at 3:31 p.m., indicated Resident 1 was admitted as a trauma resident to the hospital, from a witnessed mechanical fall at the skilled nursing facility. The record indicated the resident sustained a ?frontal scalp laceration,? the resident was lethargic (weak and drowsy) appearing, opening eye intermittently, while mumbling her name. The record indicated the measurement of the resident?s laceration was seven cm linear to the middle front of the scalp, and the plan was to repair the laceration.
A review of Resident 1?s Physician Order Summary Report for the month of June 2017, indicated on 6/23/17, Quetiapine Fumarate ([Seroquel], a medication used to treat mental and mood conditions), 300 mg, one tablet, three times a day for unspecified schizoaffective disorder, manifested by throwing objects, was ordered for the resident. The report indicated on 6/23/17, Risperdal (Risperidone, a medication used to treat mental and mood conditions), 0.5 mg, one tablet, twice a day for schizoaffective disorder, manifested by yelling and screaming, was ordered for the resident.
A review of Resident 1?s Medication Administration Record (MAR), for the month of June 2017, indicated Resident 1 was administered Risperdal 0.5 mg, one tablet, twice a day, on 6/24/17, 6/25/17, and received one dose on 6/26/17. The MAR indicated Resident 1 was administered Seroquel, 300 mg, one tablet, three times a day, on 6/24/17, 6/25/17, and received two doses on 6/26/17.
A review of Resident 1?s Medication Administration Record (MAR), for the month of July 2017, indicated Resident 1 was administered Risperdal 0.5 mg, one tablet, twice a day, from 7/1/17 to 7/31/17. The MAR indicated Resident 1 was administered Seroquel, 300 mg, one tablet, three times a day, from 7/1/17 to 7/31/17, both are antipsychotic medications (medications used to treat symptoms of psychosis).
A review of an online drug reference, Daily Med, with a revision date of 2/2017, indicated elderly residents with dementia-related psychosis treated with antipsychotic drugs had an increased risk for falls with injury and death. The drug reference indicated ?somnolence (sleepiness or drowsiness), postural hypotension (occurs when a person?s blood pressure drops when suddenly standing up from a lying or sitting position), motor and sensory instability, have been reported with the use of antipsychotics, including Risperdal, which may lead to falls, and consequently, fractures (a complete or partial break in a bone), or other fall-related injuries. https://www.dailymed.nlm.nih.gov/dailymed/fda/fdaDrugXsl.cfm?setid=7e117c7e-02fc-4343-92a1-230061dfc5e0&type=display.
A review of an online drug reference with a revision date of 2/2017, indicated Seroquel may cause somnolence, postural hypotension, motor and sensory instability, which may lead to falls and, consequently, fractures or other injuries https://www.dailymed.nlm.nih.gov/dailymed/fda/fdaDrugXsl.cfm?setid=0584dda8-bc3c-48fe-1a90-79608f78e8a0&type=display.
A review of Resident 1?s ?Fall Scene Investigation Report,? dated 7/4/17 at 1:47 p.m., 7/22/17 at 3:12 p.m., 8/6/17 timed at 11:45 a.m., and 8/21/17, and timed at 3:30 p.m., indicated the resident lost her balance and fell on the floor without injuries.
A review of Resident 1?s ?Fall Scene Investigation Report,? dated 8/25/17 and timed at 7:19 p.m., indicated the resident was found on the floor. The report indicated the resident had an abrasion to the right side of her head measuring 2 cm in length by 2 cm in width (without depth) with blunt head trauma. The report indicated the resident was transferred to the GACH after the fall.
On 6/26/17 at 3:45 p.m., during an observation and interview, a Certified Nursing Assistant (CNA 1) stated that Resident was ?aggressive, confused, and sometimes fights staff.? CNA 1 stated the resident uses her hands to wheel herself in the wheelchair and tries to use her feet to propel herself, but does not get anywhere while propelling. CNA 1 stated the resident was usually assisted by staff to wheel her around the hallways. Resident 1 was observed in front of the nursing station in a wheelchair, accompanied by CNA 1, Resident 1 was observed with staples (used to close opened wounds) in the middle of the resident?s forehead. Resident 1 was alert upon approach, but was answering questions unrelated to the topic discussed. Resident 1 stated she did not remembered what happened to her forehead, but did recall going to the hospital.
On 8/29/17 at 11:20 a.m., during an interview, CNA 2 stated Resident 1 required increased supervision and needed to be monitored frequently. CNA 2 stated Resident 1 tries to transfer independently from the bed to the wheelchair, without calling for assistance. CNA 2 stated the resident had more falls and accidents after the removal of the bed and wheelchair alarms.
On 8/29/17 at 3:45 p.m., during an interview and record review, the director of nursing (DON) stated ?frequent visual checks,? could by shown by documentation of the tasks on the ?Documentation Survey Report.? The DON verified that there was no documentation on 6/19/17 at 4:50 a.m. from the Licensed Vocational Nurse 1 (LVN 1), to indicate what interventions were done in response to the resident?s behavior and if the interventions were effective. The DON stated she could not find any documentation to indicate Resident 1 was monitored every 30 minutes, on 6/20/17 as per the IDT recommendations and the resident?s plan of care. The DON stated the facility was a ?restraint-free? facility and the resident required more supervision than the facility could provide.
On 8/30/17, at 1:24 p.m., during a telephone interview, a Registered Nurse (RN 1) stated Resident 1 was difficult to care due to her aggressive behavior. RN 1 stated the resident may require a facility that allows more restrictive measures (alarms and restraints). RN 1 stated the resident exhibits sudden angry outbursts, becomes agitated, and throws objects. RN 1 stated the resident had behaviors of independently standing up unassisted with an unsteady gait, to remove items from her cabinet or to use the telephone at the nursing station without assistance.
A review of the facility?s Policy and Procedures titled, ?Falls Management,? with a revision date of 11/2012, indicated new or existing residents scoring as high risk will have interventions implemented to reduce the potential for falls outlined in their plan of care, as referred to ?Strategies for Fall Prevention.? The policy and procedure indicated recent falls would be reviewed daily by a designated facility fall team, to evaluate cause, determine strategies as needed to prevent recurrence for each resident and revise the care plan if needed.
A review of the facility?s undated policy titled ?Fall Prevention Strategies and Interventions,? indicated for the staff to add bed, chair or floor alarm, to add body or sensor pad alarm, or self-release belt alarm, and to provide 15 or 30 minute checks.
The facility failed to ensure Resident 1, who had a history of multiple falls was free from unnecessary drugs and the residents? environment remained as free from accident hazards as was possible, while receiving adequate supervision and assistance devices to prevent accidents, including but not limited to:
1. Failure of the facility to implement its fall policy and the IDT?s ([Interdisciplinary Team] a group of health care professionals working together for a common goal for the resident) recommendations and Resident 1?s plan of care.
2. Failure to provide adequate monitoring and supervision for Resident 1, who had a history of multiple falls and was receiving medications with high risk for falls.
3. Failure to ensure Resident 1 was free from unnecessary drugs, in duplication therapy. Resident 1 received Risperdal (Risperidone, is a medication used to treat mental and mood conditions), and Quetiapine Fumarate (Seroquel, a medication used to treat mental and mood conditions), simultaneously from June to July 2017, and not documenting that the resident was monitored for increased agitation while receiving Ativan.
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. |
| 920000048 |
Wellsprings Post-Acute Center |
920013485 |
B |
10-Sep-17 |
BFR311 |
18363 |
?CFR 483.60 (i) (1)-(3) Food Procure, Store/Prepare/Serve - Sanitary
(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety.
On July 24, 2017, at 8:30 a.m., during an unannounced recertification survey visit, an inspection of the kitchen was conducted.
Based on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety including:
1. Failure to monitor the cooling of a large beef roast and three large pieces of pork that had been prepared the day before. The exact time the food was placed in the refrigerator could not been determined but at 8:30 a.m., on July 24, 2017, approximately 13 hours after the kitchen closed, the temperatures of the beef and pieces of pork ranged between 50.8 and 58.2 degrees Fahrenheit (§F). The cooked beef and pork which are considered time/ temperature control for safety foods (formerly called "potentially hazardous foods"), were stored in the food danger zone for longer than six hours and prepared for service for residents on pureed diet. The meats were also being reheated for other residents after the registered dietitian had asked the FSD to discard it.
2. Failure to store food in a safe manner. The facility stored food in a refrigerator that was not functioning properly. Salads, sandwiches, yogurt and other time- temperature control for safety foods were stored in the refrigerator at 60 §F. The recommended refrigerator temperature is between 36 and 40 §F. Storage of food in the food danger zone could result in food borne illness.
3. Failure to ensure the dish machine was consistently spraying the dishes with adequate amount of sanitizer. Sanitizers and disinfectants are used on food contact surfaces to prevent foodborne illness. Sanitizers are used to reduce microorganisms to safe levels determined by public health codes and regulations.
4. Failure to ensure its thermometers were properly calibrated. A non-calibrated thermometer was used to test the final cooking temperature of food. This resulted in burnt food and possibility of under cooked food which could cause food borne illness.
As a result, the total census of 236 residents was placed at risk of foodborne illness, who had oral diets and those on tube feeding who received water flushes from water pitchers cleaned in the dish machine.
Nursing home residents risk serious complications from foodborne illness as a result of their compromised health status. Symptoms of foodborne illness include diarrhea, vomiting, headaches, fever, and confusion, loss of appetite, abdominal cramping and pain. When those conditions persist they can lead to dehydration and may require hospitalization and in some cases death.
The sandwiches and dairy products are considered time/temperature control for safety foods (formerly called "potentially hazardous foods") and were stored in the food danger zone.
"The food danger zone refers to temperatures above 41øF and below 135øF that allow the rapid growth of disease causing microorganisms that can cause foodborne illness. Foods held in the danger zone for more than six hours (if cooked and cooled) may cause a foodborne illness if consumed" (Center for Medicare and Medicaid, State Operations Manual).
1. During the tour of the facility kitchen on July 24, 2017 at 8:19 a.m., Food Service Worker (FSW) 1 was observed standing over a large piece of charred (badly burnt) meat, beef. This large piece of meat, weighing approximately 10 pounds was placed on a cutting board. Next to FSW1 on a cart were one large stainless steel pan with large piece of aluminum foil peeled back revealing a dark brown colored liquid (meat juices) with a large creamy yellow solid substance (fat) and smaller chunks of the same floating on top.
There was also another stainless steel pan covered with aluminum foil. When the aluminum foil in the second pan was peeled back, it revealed three large pieces of meat. Surrounding each piece of meat were a similar large creamy yellow solid substance (fat) and some dark brown liquid oozing from underneath the fat. These were also charred.
The observation revealed several of the "Don'ts" (what not to do) of proper cooling of previously cooked foods. The meats had not been transferred to shallow pans; they were in the same pans they had been roasted in, including the meat juices. The pans had been wrapped tightly instead of being uncovered and finally, the pieces of meat were not cut up into to speed up loss of heat and encourage faster cooling.
According to the facility policy and procedure titled "Cooling and Reheating Potentially Hazardous Food" dated 2015, when potentially hazardous food will not be served right away it must be cooled as quickly as possible. The method is "The Two Stage Method": Cool cooked foods from 140 §F to 70 §F within 2 hours. Then cool from 70 §F to 41 §F or less in an additional four hours for a total cooling time of six hours. The methods of cooling listed included: placing food in shallow pans, separating the food into smaller or thinner portions and using containers that facilitate heat transfer among other methods. The facility policy also recommended the use of the Cool Down Log to document proper procedure". The Cooling log instructions state "to speed up cooling process" included" ...remove meat from hot juice, ...do not cover".
FSW 1 in an interview on July 24, 2017 at 8:25 a.m., stated the largest piece of meat on the cutting board was beef and the smaller pieces still in the pan were pork. He further explained he was ready to slice up the beef and pork in preparation for lunch. FSW 1 was asked when the meat was cooked. He stated he was unsure when the meat was cooked because he had not worked the day before. FSW 1 stated he believes the AM cook may have cooked it and the PM cook took it out. FSW 1 was also asked if he took temperatures of any of the meats he was about to cut up. He stated he had not checked the temperature of the meats prior to slicing.
The temperature of the beef was 50.8 §F while the pork was between 54.6 and 58.2 §F (Pork 1 - 58 §F; 2 - 58.2 §F; 3 - 54.6 §F). FSW 1 was asked if the facility used a cooling log to monitor temperature of cooked items. He said "yes". A review of the facility cooling log revealed no documentation of beef or pork for 7/23/17. The FSD 1 who joined the observation at 8:35 a.m., and FSW 1 were told the temperatures of the meat items.
At 8:42 a.m., on 7/24/17, FSW 1 was observed placing sliced pieces of beef in a stainless steel pan and cutting and hand shredding finely cut pieces of beef in another pan. FSW 1 stated the finely chopped was for residents on ground diet. FSW 1 was asked in a concurrent interview what the temperature of the beef should have been before he cut it; he answered "about 155" §F.
At 11:15 a.m., on July 24, 2017, hamburgers were observed cooking on the griddle. FSD 1 stated the facility registered dietitian (RD) had asked that the residents be served hamburgers instead since there was no evidence of proper cooling. FSD 1 stated however that the meat and pork were being reheated "for safety". The FSD 1 pointed to pans in the oven.
In an interview with RD on July 24, 2017 at 11:16 a.m., RD explained that she had directed the FSD 1 to dispose of the meat and serve hamburgers instead. The surveyor then informed RD the meats were in the oven and was being reheated "for safety". RD returned to the kitchen and stated she stood with the staff to ensure that the meats had been discarded. It is unclear when FSD 1 would have served the meats if the surveyor had not informed RD 1 of the reheating of the meats. She also indicated that chicken was also being prepared for the residents who did not want pork.
During tray line observation on July 24, 2017 at 12:10 p.m., FSW 2 was observed setting up and getting items including pureed food items for lunch. There was a light brown colored food item in the pan on the steam table. FSW 2 was asked what the item was. He stated it was pureed pork. FSW 1 was asked what he had planned to serve residents on the pureed diet. FSW 1 stated pureed hamburger. FSW 2 was observed preparing the pureed pork in the food processor, adding water to it. He was asked who it was for; he stated it was for the residents on liquefied pureed diet. FSW 2 stated the pork had been pureed before the changes were made to the menu. The surveyor asked FSD 1 what the residents on pureed diet would be eating. FSD 1 said the hamburger.
FSW 2 was observed to dish out the liquefied pureed pork two trays for residents on the blenderized pureed diet. These trays were then placed in the food cart for transport to the resident rooms. Observing this, the surveyor asked the food service worker to remove the two food trays form the food cart. FSD 1 was informed about the pork being prepared for residents. She stated that she had asked FSW 2 to prepare pureed hamburgers. FSD 1 was then observed picking up several hamburger pieces and pureeing them in the food processor then handing it to FSW 2. There had been no pureed hamburgers until it was brought to the attention of FSD 1.
2. On July 24, 2017 at 8:24 a.m., prior to the taking of food temperatures of the beef and pork, the surveyor and facility thermometers were calibrated in ice water. The surveyor's thermometer read 31.7 §F, while both of the facility thermometers read 20 §F. These thermometers were 12 §F off. According to the United States Department of Agriculture, Food Safety and Inspection Services, a properly calibrated thermometer would read 32 §F (+/- 2 degrees) in ice water. In a concurrent interview, FSW 1 stated in response to the question regarding frequency of thermometer calibration that the facility thermometers are calibrated weekly.
Review of the facility Weekly Thermometer Calibration Chart for June 2017 showed thermometer calibration daily. It was not clear which one was calibrated as both were out calibration. The employee whose initial was on the log could not be interviewed because according to FSD 1 she was on vacation.
The out of calibration thermometer reading of 12 d §F is of significance with the cooling of the meat because in the case of the meat, the facility thermometer would have read 41 §F when it was actually 53 §F, a temperature in the food danger zone. The out of calibration was also a factor in the cooking of the hamburger because it resulted in dried out, burnt beef and chicken. FSD 1 failed to ensure the thermometer was calibrated. During cooking of the hamburgers at 12 p.m., the thermometer used was the same one the surveyors had identified as out of calibration. The thermometer in ice water read 24 §F, instead of 32 §F.
FSD 1 had explained in the concurrent observation and interview that the hamburger patties had been cooked first in the steamer, then browned on the griddle. The hamburgers were completely cooked through when they were taken out of the steamer. Observation of the cooking continued with the hamburgers on the griddle drying out and getting burnt. FSD 1 was asked what the final cooking temperature should be. She stated 155 §F. According to the United States Department of Agriculture Food Safety and Inspection Service, the safe minimum internal temperature for ground beef is 160 §F. The incorrect answer could have resulted in an undercooked hamburger that could result in food borne illness.
3. At 9 a.m., observation of the dish washing process revealed domes (a dome shaped plastic cover used to keep food temperatures constant) coming out of the machine with red colored and light brown food stain. FSW 3 was observed stacking and moving to place these domes on a drying cart. When the surveyor pointed to the food stains, FSW 3 returned the domes to be cleaned. FSW 3 was also asked about testing the dish machine to evaluate adequacy of the chemical sanitizer (chlorine).
FSW 3 immersed the test strip into the water on the counter. The test strip was blackish blue, approximately 200 parts per million (ppm) according to the color chart on the test strip container. According to the Federal Food Code, the recommended chlorine level for proper sanitization is 50 ppm. FSW 2 was directed to check the level of sanitizer on the dish surface. A test of the dish surface revealed no color change, implying no sanitizer. The FSD 1 who was present during the observation stated the level of sanitizer should be 50 to 100 ppm. A third try revealed a light purple color, about 10 ppm. FSW 4 tested the concentration for the fourth time, it was between 10 and 50 ppm, but not up to 50 ppm. It was not clear how long the problem with the machine may have existed since the food service workers were not testing the sanitizer at the dish surface.
The facility document titled "Dish Machine Temperature Log (Low Temperature)" dated June 2017 was reviewed. It revealed consistent recording of 100 ppm every meal throughout the month for the chemical concentration level. FSD 1 stated she will call the manufacturer.
On July 24, 2017 at 1:50 pm, RD 1 provided documentation, Ware Wash Service Report from the repair company dated "7/24/17" indicating there was a problem with the final rinse solenoids and solenoids. The report documented the action taken "replaced squeeze tube and a sanitizer delay to dishwasher to have a consistent sanitizer reading 100% of rack". There was another report titled "Delivery/Invoice" dated "7-3-17" by the chemical supply company, which lists parts/products. The document listed two items, one of then was "4 (quantity) 60-10 rinse jets" it was not clear if these were ordered or replaced during the service call. FSD 1 who signed the invoice could not be interviewed about this invoice because she was no longer in the building.
4. At 9 a.m. on July 24, 2017, the display outside the (snack) refrigerator behind the tray line showed 37 §F. The internal thermometer read 59 degrees F. The surveyor thermometer was used to measure the ambient air temperature of the refrigerator. It revealed the temperature was 60.9 §F. FSD 1 was informed at 9:02 a.m., about the discrepancy between the internal and external thermometers. FSD 1 stated in a concurrent interview she would put a new thermometer and that the refrigerator temperatures were recorded daily at about 4:30 a.m., by FSW 5.
The form titled "Refrigerator Temperature Monitoring" dated July 2017 was reviewed. The form revealed the Snack refrigerator (ref #2) was 32 §F for July 24, 2017. The form indicated "temps should read< or equal 41 §F. Further review of the form, showed there was a day the refrigerator was 45 §F, and there was no corrective action documented for the unusual temperatures as required by the form.
At 1:27 p.m. on July 24, 2017, the temperature of the snack refrigerator was rechecked. It was 60 §F. The FSD 1 had added a second thermometer inside the refrigerator and both thermometers read 60 §F. Inside the refrigerator were salads, egg and tuna sandwiches and yogurt. A check of the sandwiches showed the tuna salad was 52.4 §F and egg salad was 57 §F. FSW 6 who prepared the tuna salad stated she prepared it that morning and placed it in the refrigerator. The FSD 1 did not make it clear who and what time the sandwiches were prepared.
FSD 1 on July 24, 2017 at 1:45 p.m., stated the sandwiches are stored in refrigerator left overnight for residents who maybe hungry or have hypoglycemia. During tray line service, on July 24, 2017 starting 11: 30 a.m., food service workers were observed using the sandwiches as substitutes. FSD 1 failed to reassess the refrigerator to ensure it was working properly before food service workers were allowed to store food in it.
On July 24, 2017 at 8:33 a.m., there were items in the walk-in refrigerator that were not labeled. These items were six sandwiches with a "7/24" date, there three other sandwiches with a "7/23" date. There was a tray labeled pureed fruit with a date of "7/23". The type of fruit it was not identified.
The facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety including:
1. Failure to monitor the cooling of a large beef roast and three large pieces of pork that had been prepared the day before. The exact time the food was placed in the refrigerator could not been determined but at 8:30 a.m., on July 24, 2017, approximately 13 hours after the kitchen closed, the temperatures of the beef and pieces of pork ranged between 50.8 and 58.2 §F. The cooked beef and pork which are considered time/ temperature control for safety foods, were stored in the food danger zone for longer than six hours and prepared for service for residents on pureed diet. The meats were also being reheated for other residents after the registered dietitian had asked the FSD to discard it.
2. Failure to store food in a safe manner. The facility stored food in a refrigerator that was not functioning properly. Salads, sandwiches, yogurt and other time- temperature control for safety foods were stored in the refrigerator at 60 §F. The recommended refrigerator temperature is between 36 and 40 §F. Storage of food in the food danger zone could result in food borne illness.
3. Failure to ensure the dish machine was consistently spraying the dishes with adequate amount of sanitizer. Sanitizers and disinfectants are used on food contact surfaces to prevent foodborne illness. Sanitizers are used to reduce microorganisms to safe levels determined by public health codes and regulations.
4. Failure to ensure its thermometers were properly calibrated. A non-calibrated thermometer was used to test the final cooking temperature of food. This resulted in burnt food and possibility of under cooked food which could cause food borne illness.
As a result, the total census of 236 residents was placed at risk of foodborne illness, who had oral diets and those on tube feeding who received water flushes from water pitchers cleaned in the dish machine.
The above violation had direct or immediate relationship to the health, safety, or security of all 236 residents in the facility. |
| 920000048 |
Wellsprings Post-Acute Center |
920013486 |
B |
10-Sep-17 |
BFR311 |
6639 |
F-257
?483.15(h) (6) Comfortable and safe temperature levels. Facilities initially certified after October 1, 1990 must maintain a temperature range of 71 ? 81 degrees Fahrenheit (§F).
On July 25, 2017, during annual recertification survey facility?s temperature levels were investigated.
Based on observation, interview, and record review, the facility failed to maintain a safe and comfortable temperature levels ranging from 71 to 81 Fahrenheit (øF) by:
1. Failure to ensure the room of Residents 1 and 2 had a temperature reading below 83 øF.
2. Failure to evaluate the effectivity of placing three electric fans inside the room of Residents 1 and 2 by monitoring the room temperature achieved with the use of the fans and by not assessing the level of comfort of Residents 1 and 2.
3. Failure to implement the facility?s policy on Extreme Temperature when Residents 1 and 2 were still uncomfortable with the elevated room temperature and where not offered to move to a room with a safe and comfortable temperature.
As a result, Residents 1 and 2 suffered unnecessary exposure to elevated temperature in their room, making them feeling hot, uncomfortable, and unable to have a restful sleep. Prolonged heat placed Residents 1 and 2 at risk to become dehydrated.
On July 25, 2017, from 12:56 p.m. to 1:45 p.m., during environmental tour accompanied by the Maintenance Supervisor (MS), the external temperature was 95øF according to the weather broadcasts.
During a tour around the residents? living areas, Residents 1 and Resident 2 were observed to be roommates in a two-bed room. The room had three electric fans turned on. The MS checked the room temperature by using the facility?s laser room temperature and obtained a reading of 83øF.
According to the admission record, Resident 1 was admitted to the facility on April 27, 2017, with diagnoses including chronic obstructive pulmonary disease (COPD) and emphysema (a lung condition that causes shortness of breath).
The Minimum Data Set (MDS ? standardized assessment and care planning) dated May 3, 2017, indicated Resident 1 cognitive skills for daily decision-making were moderately impaired, needed extensive assistance from staff for bed mobility, transfer, walking in the room, locomotion on and off the unit, dressing, toilet use, personal hygiene, and bathing. The resident was always incontinent (no control) of bowel and urine. The resident had a pressure reducing device for bed and chair.
A review of Resident 1's care plan for emphysema, the interventions included to avoid extremes hot and cold temperature.
On July 25, 2017, at 1:45 p.m., Resident 1 was observed lying in bed, alert, awake, and oriented to person, place, and time and was receiving oxygen. Resident 1 was sweating, beads of sweat were visible in her forehead, and half of her body was covered with a blanket. Her face looked flushed and red. Resident 1 stated it was always hot in her room despite of the electric fans. She stated even at night it was and she was unable to sleep well. Resident 1 stated she did not like the hot room temperature which was ongoing 24 hours a day and she had already mentioned the issue to the staff but nothing happened.
According to the admission record, Resident 2 was readmitted to the facility on April 17, 2017, with diagnoses including atrial flutter (abnormality in the beating of the heart), quadriplegia (paralysis of all four limbs), and shortness of breath.
The MDS assessment dated May 2, 2017, indicated the resident's cognitive skills for daily decision-making were moderately impaired, and was totally dependent from staff for bed mobility, transfer, dressing, eating, toilet use, personal hygiene, and bathing. The resident had an indwelling catheter and was always incontinent for bowel.
A review of the care plan for at risk for decreased cardiac output related to atrial flutter and tachycardia (increased heart rate) dated April 18, 2017, indicated the goal for the heart rate to be normal every day for three months. The interventions included to provide a stress-free environment.
On July 25, 2017, at 1:50 p.m., during an observation, Resident 2 was lying in bed, alert, awake, and oriented. The resident looked red and flushed. Resident 2 stated she felt very hot in her room and this hot temperature had been going on for two months. She stated that she cannot sleep well at night and had lack of sleep most of the time because of the heat. She stated that even if there are three electric fans in the room, the air from the electric fans blow hot air.
On July 26, 2017, at 5:23 p.m., during an observation with MS, the room temperature reading in Residents 1 and 2's room was 81.3øF.
During an interview and record review with a licensed nurse, she was unable to provide documentation that Resident 1 and Resident 2 were assessed for comfort regarding the room temperature. There was no evaluation for the effectivity of using three electric fans inside the room for more appropriate temperature control.
The facility's undated policy and procedure titled "Extreme Temperatures," indicated procedures that included residents will be checked for appropriate dress and clothing may be added or reduced depending on the weather. Drapes may be closed to keep out both cold and warm weather. Small towels dipped in cool water will be available as needed in warm weather. Residents may be moved to other areas of the facility if areas become identifies as more appropriate climate controlled.
The facility failed to maintain a safe and comfortable temperature levels ranging from 71 to 81 Fahrenheit (øF) by:
1. Failure to ensure the room of Residents 1 and 2 had a temperature reading below 83 øF.
2. Failure to evaluate the effectivity of placing three electric fans inside the room of Residents 1 and 2 by monitoring the room temperature achieved with the use of the fans and by not assessing the level of comfort of Residents 1 and 2.
3. Failure to implement the facility?s policy on Extreme Temperature when Residents 1 and 2 were still uncomfortable with the elevated room temperature and where not offered to move to a room with a safe and comfortable temperature.
As a result, Residents 1 and 2 suffered unnecessary exposure to elevated temperature in their room, making them feeling hot, uncomfortable, and unable to have a restful sleep. Prolonged heat placed Residents 1 and 2 at risk to become dehydrated.
The above violation had a direct or immediate relationship to the health, safety, or security of Residents 1 and 2. |
| 070000042 |
WINDSOR THE RIDGE REHABILITATION CENTER |
070013503 |
B |
21-Sep-17 |
DT0W11 |
10231 |
F323-483.25(d)(1)(2)(n)(1)-(3) FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES
(d) Accidents.
The facility must ensure that -
(1) The resident environment remains as free from accident hazards as is possible; and
(2) Each resident receives adequate supervision and assistance devices to prevent accidents.
(n) - Bed Rails. The facility must attempt to use appropriate alternatives prior to installing a side or bed rail. If a bed or side rail is used, the facility must ensure correct installation, use, and maintenance of bed rails, including but not limited to the following elements.
(1) Assess the resident for risk of entrapment from bed rails prior to installation.
(2) Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation.
(3) Ensure that the bed's dimensions are appropriate for the resident's size and weight.
The facility failed to ensure Resident 1 who was identified as being at risk for elopement and used an exit alarm device (device attached to a person or wheelchair setting off an audible alarm when passing through an exit of a building), had adequate supervision to prevent the resident from leaving the facility unattended. On 9/4/17 at approximately 12:30 p.m., Resident 1 left the facility and was located down the street from the facility. This failure had the potential for further resident elopements and possible injury.
Clinical record review for Resident 1 was initiated on 9/13/17. Resident 1 had diagnoses including schizophrenia (a mental illness that interferes with a person's ability to think clearly, manage emotions, make decisions, and relate to others), muscle weakness, and was wheelchair bound.
Review of Resident 1's Minimum Data Set (MDS, an assessment tool) dated 8/18/17 indicated she had hallucinations (sensations that appear to be real but are created in the mind) and delusions (a belief that is firmly maintained despite being contradicted by what is generally accepted as reality).
Review of Resident 1's Wandering Risk Assessment dated 5/19/17 indicated she was at a moderate risk for wandering to potentially dangerous places (outside the facility). Resident 1's Wandering Risk Assessment dated 9/5/17, the day after her elopement, indicated a moderate risk for wandering.
Review of Resident 1's Physician Orders dated 8/11/17 indicated the use of an exit alarm device attached to her wheelchair for risk of elopement.
Review of the facility's High Risk to Wander list, kept at the receptionist desk, dated 8/27/17, indicated descriptive information and pictures of ten residents, including Resident 1, with the direction to "please keep your eyes out for these residents at all times".
Review of Resident 1's Care Plan dated 9/4/17 indicated she had an elopement based on an acute delusion of thinking staff is poisoning her.
Review of Resident 1's nurses notes written by licensed vocational nurse A (LN A) dated 9/4/17 at 2:30 p.m., indicated on the same morning, Resident 1 refused her morning medications three times saying the medications were poisoned. At 12:40 p.m., LN A was notified the resident had left the front part of the building and went down the street to bring the resident back to the facility.
Review of Resident 1's Physician's Progress Notes dated 9/4/17 at 12:25 p.m. indicated Resident 1 was physically and verbally abusive, saying staff was trying to poison her, and the resident at the time did not have the capacity to understand and make medical decisions.
Review of Resident 1's Interdisciplinary Team (IDT) Progress Notes - Behavior, dated 9/5/17, indicated on return to the facility after the elopement Resident 1 stated she desired to go to the hospital because, "You guys are trying to poison me!" The IDT note indicated Resident 1 was sent to the acute care facility for further evaluation, and on return at 4 p.m., refused to get out of the facility van stating, "You guys are poisoning me." The IDT note indicated Resident 1 eventually required a 911 call with three police officers in attendance before she calmed and agreed to return to the facility and take her evening medications and meal.
Review of Resident 1's Psychological Consultation dated 9/5/17 indicated Resident 1 reported a "desire to escape" when questioned about the elopement incident of 9/4/17 and was observed as experiencing significant visual hallucinations (seeing things that are not present) and paranoid delusions (a fixed, false belief that one is being harmed by a particular person or group of people).
During an interview with the administrator (ADM) on 9/13/17 at 9:15 a.m., she stated she found Resident 1 on the nearest corner of the intersection one block away from the facility at approximately 12:40 p.m. on 9/4/17. Review of Google Maps (an Internet website) showed Resident 1 was found 0.2 miles walking distance from the facility.
During an interview and observation with Resident 1 on 9/13/17 at 9:30 a.m., she stated she did not remember the day the incident happened. Resident 1 stated, "I am not a prisoner here, I had permission, I pay rent here."
During an interview with certified nursing assistant B (CNA B) on 9/13/17, at 9:45 a.m., she stated she worked with Resident 1 frequently and sat with Resident 1 when she went outside, for safety reasons.
During an interview with CNA C on 9/13/17 at 10:25 a.m., she stated she worked with Resident 1 frequently and she would never let Resident 1 go outside by herself because she is someone who might want to leave. CNA C stated she and CNA B usually took turns going outside with Resident 1.
During an interview with CNA D on 9/13/17 at 10:55 a.m., she stated she was assigned to care for Resident 1 on 9/4/17. CNA D stated Resident 1 had to be supervised when she went outside.
During an interview with LN A on 9/13/17 at 10 a.m., she stated Resident 1 refused to take her medications on the morning of 9/4/17, stating they were poison. LN A stated Resident 1 was confused and delusional on the morning of 9/4/17. LN A stated when Resident 1 was delusional and confused she should be supervised when she is outside of the building. LN A stated Resident 1 and she agreed to go outside together after lunch. LN A stated when she finished her lunch she was told the assistant director of nursing (ADON) brought Resident 1 outside and the receptionist in the front lobby was watching her. LN A stated Resident 1 was calm so she thought it was okay if she was being watched by the receptionist.
During an interview with the ADON on 9/13/17 at 10:35 a.m., she stated she sat with Resident 1 at the front door sidewalk for five minutes and had to leave to answer a telephone call. The ADON stated she would not let Resident 1 go outside by herself unattended so she left Resident 1 in the care of CNA E who was working in the admissions office near the front of the building, and with receptionist F (REC F).
During an interview with the ADON on 9:13/17 at 12:15 p.m., she stated she communicated to REC F to keep an eye on Resident 1. The ADON stated she expected REC F to go outside with Resident 1 and to go after her if she left the area.
During an interview with the ADM on 9/13/17 at 9:15 a.m., she stated Resident 1 was at risk to wander, had an exit alarm device, had not taken her medications for her mental illness on the morning of the elopement and should not have been outside without someone watching her.
During an interview with the ADM on 9/13/17 at 11 a.m., she stated it would be difficult for CNA D to watch a resident because she was inside an office.
During an observation on 9/13/17 at 10:50 a.m., of the front door, the sidewalk, and benches near the front door, and the two windows next to the front door indicated the front door sidewalk was fully visible from the receptionist's desk.
During an interview with REC F on 9/13/17 at 1:35 p.m., she stated on 9/4/17 she was the receptionist for the day. REC F stated she was told by the nurse to keep an eye on Resident 1 every five minutes.
During an interview with REC G on 9/13/17 at 11:30 a.m., she stated she was careful to observe residents who had exit alarm devices or who were on the "High Risk to Wander" list kept at the receptionist's desk. REC G stated a receptionist would know to watch Resident 1 because she had an exit alarm device and was on the above list.
Review of the facility's job description for "Receptionist" indicated responsibilities include greeting visitors, answering telephones, and assisting with general administrative support functions of the facility. The job description does not include supervision or observation of residents.
Review of the facility's 2012 policy, "Wander-Guard, Code Alert etc. Resident Monitoring System", indicated it was the facility's policy to provide a safe and secure environment to ensure the safety of any resident attempting to elope from the facility. It indicated a determination would be made if a resident needs to be placed on a monitoring device system based on the Elopement Risk Assessment.
Review of the facility's 2008 policy, "Elopement Prevention", indicated to provide a safe and secure environment and ensure the safety of any resident attempting to elope from the facility. It indicated residents would have an elopement risk evaluation completed and residents determined to be at risk for elopement would have an exit alarm device placed. It indicated if a resident attempted to leave the facility by unauthorized departure, the nearest staff member should intervene or summon the help of others and redirect the resident to return to the building.
The facility failed to ensure Resident 1 who was identified as being at risk for elopement and used an exit alarm device, had adequate supervision to prevent the resident from leaving the facility unattended. On 9/4/17 at approximately 12:30 p.m., Resident 1 left the facility and was located down the street from the facility. This failure had the potential for further resident elopements and possible injury.
This failure had a direct relationship to the health, safety, or security of residents. |
| 920000058 |
WINDSOR GARDENS HEALTHCARE CENTER OF THE VALLEY |
920013487 |
A |
22-Sep-17 |
M7OJ11 |
16585 |
F157
CFR483.10 (g) (14)
(g)(14) Notification of Changes.
(i) A facility must immediately inform the resident; consult with the resident?s physician; and notify, consistent with his or her authority, the resident representative(s) when there is-
(A) An accident involving the resident which results in injury and has the potential for requiring physician intervention;
(B) A significant change in the resident?s physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications);
(C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or
(D) A decision to transfer or discharge the resident from the facility as specified in ?483.15(c) (1) (ii).
(ii) When making notification under paragraph (g)(14)(i) of this section, the facility must ensure that all pertinent information specified in ?483.15(c)(2) is available and provided upon request to the physician.
F309
? CFR 483.25 Quality of Care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents? choices.
On 4/28/17 at 12:30 p.m., an unannounced visit was made to the facility to investigate a complaint regarding Resident 1?s significant changed of condition.
Based on interview and record review, the Department determined 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, in accordance with the comprehensive assessment and plan of care when there was a significant change of condition, and failed to immediately inform the resident's physician when Resident 1?s condition changed, including but not limited to the following:
1. Failure to notify the attending physician (MD 1) of Resident 1's change of condition manifested by increased weakness of the legs, slurred speech [slow speech that can be difficult to understand. Common causes include nervous system (neurological) disorders such as stroke, brain injury, brain tumors, and conditions that cause facial paralysis or tongue or throat muscle weakness], fatigue, confusion, and inability to perform physical therapy exercises.
2. Failure to implement the facility's policy and procedure on Change of Condition by not informing the physician and intervening to provide medical or nursing care in a timely and effective manner; by not assessing Resident 1's condition including skin color, cognitive status or orientation and notify the physician of the clinical findings; by not monitoring and documenting Resident 1's condition at a minimum of every shift or more frequently until the acute episode has subsided; and by not completing an episodic care plan regarding the change of condition.
3. Failure to assess and continuously monitor Resident 1's level of consciousness to determine, if the resident?s usual condition had changed and was manifesting confusion, diminished alertness, lethargy, fatigue, changes in the ability to communicate and comprehend, and quality of the speech (slurred speech ? same causes as above).
4. Failure to continuously monitor Resident 1's condition for deterioration and to notify the attending physician (MD 1) of Resident 1's increased weakness on the legs, slurred speech, fatigue, confusion, and inability to perform physical therapy exercises.
As a result, Resident 1's condition deteriorated without medical and nursing interventions and on April 14, 2017, 4:01 a.m., Resident 1 was pronounced dead at the facility, 16 hours after Resident 1 was identified with increased weakness of her lower extremities.
According to the Admission Record, Resident 1 was admitted to the facility on March 22, 2017, with diagnoses including sepsis (life-threatening condition that arises when the body's response to infection causes a severe reaction), pneumonia (infection of the lungs), and chronic obstructive pulmonary disease (COPD ? lung disease that interferes with normal breathing).
A review of Resident 1's History and Physical (H&P) examination form completed by the attending physician (MD 1) and dated March 29, 2017, indicated Resident 1 had the capacity to understand and make decisions.
A review of the admission Minimum Data Set (MDS - standardized comprehensive assessment and care planning tool), dated April 2, 2017, indicated Resident 1 was cognitively intact (process of knowing, perceiving, thinking, reasoning, or remembering), had clear speech (distinct intelligible words), was understood when expressing verbal and non-verbal expression, and had clear comprehension with the ability to understand others.
According to a Late Entry Status Note for April 13, 2017, timed at 7:30 a.m., indicated at 12 p.m., Licensed Vocational Nurse 1 (LVN 1) spoke with MD 1, who called the facility to inform LVN 1, that Family Member 1 (FM 1) called him concerned about Resident 1, who was showing weakness of the lower extremities. There was no documentation LVN 1 reported to a Registered Nurse (RN) supervisor or checked Resident 1's voluntary movement, sensory status (feeling touch and pressure) and strength of the extremities which would suggest a significant change of condition and a possibility of a stroke. The lack of documentation was confirmed on April 28, 2017, at 12:30 p.m., during an interview and record review with the Assistant Director of Nursing (ADON).
A review of a Health Status Note by Registered Nurse 2 (RN 2) dated April 13, 2017, at 12:15 p.m., indicated MD 1 inquired about Resident 1's status due to receiving a report from FM 1 that Resident 1 was so weak she could hardly finish a sentence. RN 2 assessed Resident 1's vital signs: blood pressure 97/58 millimeters of mercury (mmHg - normal range 90/60 - 120/80); respiratory rate 18 breaths per minute (normal range 12 - 18); heart rate (pulse) 68 beats per minute (normal range 60 to 100); and no pain. There was no documentation RN 2 assessed Resident 1's verbal response, mental status, voluntary movement and strength of the extremities (neurological evaluation) which would suggest a possible stroke. There was no documentation MD 1 was relayed a neurological check performed on Resident 1 by RN 2. The lack of documentation was confirmed on April 28, 2017, at 12:30 p.m., during an interview and record review with the Assistant Director of Nursing (ADON).
The Late Entry Status Note for April 13, 2017, timed at 7:30 a.m., indicated at 1 p.m. Resident 1's B/P was 158/87 mmHg which was relayed to MD 1 with no new orders received. There was no documentation MD 1 was notified of a neurological check performed on Resident 1.
The lack of documentation was confirmed on April 28, 2017, at 12:30 p.m., during an interview and record review with the Assistant Director of Nursing (ADON).
A review of the Physical Therapy Treatment Encounter Note dated April 13, 2017, signed electronically at 5:34 p.m. indicated Resident 1 had increased confusion, decreased motivation to participate in physical therapy, complained of stomachache for which nursing administered Tums (treat stomach upset) and was also given pain medication for neck pain. The resident continued to need pain medication and more Tums, which made it difficult for Resident 1 to stay on task and required constant re-direction. The documentation by the Physical Therapist (PT) did not include a report was made to MD 1 or to a RN supervisor regarding Resident 1's significant change of condition during the physical therapy session (increased confusion, complaints of pain, and need of re-direction). The lack of documentation was confirmed on April 28, 2017, at 12:30 p.m., during an interview and record review with the ADON.
A review of Health Status Note dated April 13, 2017, at 9 p.m., indicated FM 1 called LVN 3 reporting Resident 1 seemed incoherent and she (FM 1) could not understand what the resident was saying. LVN 3 informed FM 1 she would continue to monitor Resident 1 during the shift. There was no documentation LVN 3 reported to a RN supervisor FM 1's concerns and there was no documentation LVN 3 checked Resident 1 for confusion; verbal response; ability to speak; and voluntary movement, sensory status and strength of the extremities. The lack of documentation was confirmed on April 28, 2017, at 12:30 p.m., during an interview and record review with the ADON.
A review of the Health Status Note dated April 14, 2017, timed at 4:30 a.m., indicated
RN 1 found Resident 1 at 3:45 a.m., unresponsive to verbal and tactile stimuli (does not respond to words or touch), with no pulse and was not breathing. Cardiopulmonary resuscitation (CPR - emergency procedure involving repeated chest compression and blowing air into the lungs in an attempt to restore the blood circulation and breathing) was started. Paramedics arrived at 3:50 a.m., took over Resident 1's care and pronounced Resident 1 dead at 4:01 a.m. FM 1 and MD 1 were notified of Resident 1's death. Resident died 16 hours after FM 1 reported to MD 1 Resident 1's initial symptoms of a change of condition.
A review of Resident 1's Certificate of Death signed on April 21, 2017 indicated Resident 1 died in the facility on April 14, 2017 at 4:01 a.m. The immediate cause of death was atherosclerotic cardiovascular disease. Other significant conditions contributing to death included medical history of COPD, chronic pain syndrome, depression and schizophrenia. No autopsy was performed.
A review of the facility's policy and procedure dated November 2012, and titled, "Change of Condition, Resident" indicated it is the policy of the facility to inform the physician and resident (or designated agent) and intervene to provide medical or nursing care for a resident who is experiencing an acute medical condition in a timely and effective manner. Upon receiving report of a change in the resident's physical, emotional or mental status the charge nurse or licensed nurse will assess the resident's condition which may include vital signs, skin color, cognitive status or orientation and notify the physician of the clinical findings. The resident will continue to be monitored and document resident's condition at a minimum of every shift for 72 hours or more frequently or longer as needed until the acute episode has subsided and the resident is stable. The licensed staff will complete an episodic care plan regarding the change of condition or revise a current care plan that addresses the change in condition.
A review of the facility's policy and procedure dated November 2012, and titled, ?Pain Management,? indicated under Policy, ?It is the policy of Windsor Healthcare to monitor both the cognitively intact and cognitively impaired resident for symptoms of pain, and when identified, promptly assess and intervene to prevent, minimize, and alleviate those symptoms.? Under the section Procedures, number 10, ?When there are no medications ordered for a resident in pain, when a resident?s medication regiment is ineffective at alleviating pain, or if pain is frequently severe in nature, the physician is to be notified for orders. ..?
On May 18, 2017, at 10:16 a.m., during an interview, MD 1 stated Resident 1 had the ability to speak and be understood. MD 1 stated he recalled receiving a call from FM 1 regarding Resident 1's slurred speech and increased weakness but did not receive a call from the facility's nursing staff informing him of a change of condition on Resident 1. MD 1 stated he called the facility inquiring about Resident 1 and had the Charge Nurse (LVN 1) check Resident 1. MD 1 stated the charge nurse (LVN 1) did not report Resident 1 had slurred speech. MD 1 also stated Resident 1's death was unexpected.
On June 13, 2017 at 9:32 a.m., a telephone interview was conducted with Certified Nursing Assistant 1 (CNA 1), who was assigned to Resident 1 during the day shift (7 a.m. to 3 p.m.). CNA 1 stated during the morning before Resident 1's death (April 13, 2017), Resident 1 was very tired, had weakness in both legs, wanted to stay in bed, and was speaking slower than usual. CNA 1 indicated she notified the charge nurse. CNA 1 stated she helped Resident 1 get ready for physical therapy at approximately 1 p.m.
On June 13, 2017, at 9:50 a.m. during an interview, RN 1 stated she was the RN on duty when Resident 1 died (11 p.m. to 7 a.m. shift). RN 1 stated she did not recall receiving endorsement from the evening shift (3 p.m. to 11 p.m. shift), regarding Resident 1's change of condition (weakness, confusion, slurred speech, pain, or and increased fatigue). RN 1 stated when she found Resident 1 unresponsive and without pulse, she called for help, started CPR, and paramedics (911) were called. RN 1 stated officers from the Police Department arrived and determined Resident 1 could be released to the mortuary.
On June 15, 2017, at 10:27 a.m., during an interview, LVN 1 stated CNA 1 reported
Resident 1 had increased weakness to the lower extremities at the beginning of the day shift (7 a.m. to 3 p.m.) and she (LVN 1) spoke to FM 1 regarding Resident 1's weakness but did not call MD 1. LVN 1 stated she was aware FM 1 reported Resident 1 had slurred speech but she did not report the slurred speech and increased weakness to MD 1, the RN Supervisor, or the incoming evening shift (3 p.m. to 11 p.m.). LVN 1 stated she did not perform a neurological check on Resident 1. LVN 1 was unable to provide evidence of a plan of care developed addressing Resident 1's change of condition.
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, in accordance with the comprehensive assessment and plan of care when there was a significant change of condition, and failed to immediately inform the resident's physician when Resident 1?s condition changed, including but not limited to the following:
1. Failure to notify the attending physician (MD 1) of Resident 1's change of condition manifested by increased weakness of the legs, slurred speech [slow speech that can be difficult to understand. Common causes include nervous system (neurological) disorders such as stroke, brain injury, brain tumors, and conditions that cause facial paralysis or tongue or throat muscle weakness], fatigue, confusion, and inability to perform physical therapy exercises.
2. Failure to implement the facility's policy and procedure on Change of Condition by not informing the physician and intervening to provide medical or nursing care in a timely and effective manner; by not assessing Resident 1's condition including skin color, cognitive status or orientation and notify the physician of the clinical findings; by not monitoring and documenting Resident 1's condition at a minimum of every shift or more frequently until the acute episode has subsided; and by not completing an episodic care plan regarding the change of condition.
3. Failure to assess Resident 1's level of consciousness to determine, if the resident usual condition had changed and was manifesting confusion, diminished alertness, lethargy, fatigue, changes in the ability to communicate and comprehend, and quality of the speech (slurred speech - speech that can be difficult to understand. Common causes include nervous system (neurological) disorders such as stroke, brain injury, brain tumors, and conditions that cause facial paralysis or tongue or throat muscle weakness).
4. Failure to continuously monitor Resident 1's condition for deterioration and to notify the attending physician (MD 1) of Resident 1's increased weakness on the legs, slurred speech, fatigue, confusion, and inability to perform physical therapy exercises.
As a result, Resident 1's condition deteriorated without medical and nursing interventions and on April 14, 2017, 4:01 a.m., Resident 1 was pronounced dead at the facility, 16 hours after Resident 1 was identified with increased weakness of her lower extremities.
The above violation presented either an imminent danger that death or serious harm would result to Resident 1. |
| 950000092 |
WOODS HEALTH SERVICES |
950013553 |
A |
19-Oct-17 |
UV8O11 |
11875 |
Based on observation, interview and record review, the facility failed to provide the necessary care treatment and services to prevent the development of an avoidable pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence), for Resident 5, from stage 1 pressure injury (skin is reddened without breaks or tears in the skin ) to stage III pressure injury (full thickness tissue loss with slough, a yellow, tan, gray or brown discharge that may be present on the wound bed) by failing to:
1. Accurately assess, identify, monitor and evaluate the skin treatments for Resident 5 with skin redness.
2. Adequately document the skin condition and characteristic of the wound.
3. Follow up and report the discovery of the pressure ulcers.
4. Properly train the primary Licensed Vocational Nurse (LVN 1) to identify, document and/or report skin breakdown.
5. Develop and implement an intra disciplinary team ([IDT] number of people in a similar field of interest to discuss a resident's wellbeing) and plan of care to determine the care and treatments necessary to promote wound healing.
As a result of these deficient practices, Resident 5 developed two Stage III pressure injuries to her left upper medial (toward the middle of the body) buttocks that were not previously identified by the treatment nurse.
During an interview with Licensed Vocational Nurse 1 (LVN 1) on 9/5/17 at 2:58 p.m., LVN 1 stated Resident 5 had a history of a stage II (partial thickness loss of skin with a shallow open ulcer, pink wound bed without slough) pressure injury on her buttocks, but does not have one now. LVN 1 stated, "She only has redness, no pressure sores."
A review of the Admission Record (Face Sheet) for Resident 5 indicated the resident was originally admitted to the facility on 8/24/11, and was readmitted on 2/24/12, with diagnoses that included atherosclerosis (hardening and narrowing of the arteries), dementia (a decline in mental ability severe enough to interfere with daily life), hemiplegia (weakness of the entire left or right side of body), malaise (generalized feeling of discomfort) and hypertension (high blood pressure).
A review of the Minimum Data Set ([MDS] a standardized assessment and care screening tool) dated 9/1/17, indicated Resident 5 had impaired short term and long term memory recall problems. Resident 5 required extensive assistance (staff provide weight support) with bed mobility (how resident moves to and from lying position, turn side to side while in bed/alternate sleep furniture) and dressing (resident puts on, fastens and takes off all items of clothing). Resident 5 was totally dependent (full staff assistance during the entire 7 day period) on staff for transfer (moves to and from bed or wheelchair), locomotion (moves between locations), hygiene (brush teeth, comb hair), bathing, and was always incontinent of bowel and bladder (lack of voluntary control over bowel movements and urination). Resident 5 was assessed to have one stage II pressure ulcer upon admission on 2/24/12.
A review of the Braden Scale for Predicting Pressure Sore Risk (a skin assessment tool which uses a scoring system to evaluate a residents' risk of developing a pressure ulcer) dated 8/31/17, indicated Resident 5 had a score of 13 (score of 13 indicates a risk for pressure ulcer development). Resident 5's risks for pressure ulcer were due to the resident's limited sensory perception, activity, mobility, and a problem with friction and shear (when skin, with gravity, continuously rub with a surface the result will be a superficial, partial thickness skin injury that looks like an abrasion).
During multiple observations on 9/5/17 at 1:10 p.m., on 9/6/17 at 8:03 a.m., 10:17 a.m., 1:35 p.m., 3:40 p.m., and on 9/7/17 at 8:00 a.m.,10:10 a.m., 2:30 p.m., 4:30 p.m., Resident 5 was observed lying on her back in bed with neck deviated to the left.
On 9/6/17 at 3:40 p.m., during an interview, LVN 1 stated she was responsible for pressure ulcer and wound treatments for Resident 5 and that the resident did not have a pressure ulcer, just an excoriation (loss of the superficial layer of skin) and redness on her buttocks.
On 9/6/17 at 3:42 p.m., during a review of the clinical record for Resident 5, a document titled "Treatment Sheet" dated 9/2/17, indicated Resident 5 had right buttocks excoriation and left buttocks redness. In a concurrent interview LVN 1 stated, "I don't do measurements, I just treat the wound and sign the treatment sheet that it's done." He stated that the Registered Nurses (RNs) assesses and stage the wounds on a weekly basis.
On 9/6/17 at 3:45 p.m., during an interview and record review, Registered Nurse 5 (RN 5) stated the facility does not have a wound specialist (health care professionals trained to care and treat all types of wounds), the LVNs do the treatments, assess the wound daily, and confirms with the RN supervisor daily. The RNs assess the progression of the wound weekly and document on the "Skin and Wound Progress Report".
Upon further review of the clinical records titled "Skin and Wound Progress Report," dated from May 2017 to September 2017, for Resident 5's left buttocks, documentation were as follows: 5/20/17 redness; 6/3/17 excoriation; 6/24/17 redness; 7/1/17 Stage II measuring 1.5 centimeters (cm) x 1.0 cm pink in color; 7/8/17 Stage II measuring 1.0 cm x 0.2 cm, pink in color; 7/15/17 excoriation; 7/29/17 redness; 9/7/17 Stage II: site 1 measures 0.5 cm x 0.5 cm, slough color and site 2 measures 1.0 cm X 1.0 cm, slough in color. RN 5 acknowledged wound assessment and documentation was incomplete, missing wound size, depth, drainage, color and odor.
On 9/7/17 at 4:30 p.m., during a treatment observation with RN 5, Resident 5 was observed with two open crater like wounds, both to the left medial upper buttocks, with slough noted. RN 5 stated, "The wounds look like stage II, it is on a bony area of the left buttocks/sacral area, is deep with some kind of yellow bed, maybe slough." Wound 1 was 0.5 cm (L) X 0.5 cm (W) and wound 2 was 1.0 cm (L) X 1.0 cm (W). RN 4 did not measure depth. In a concurrent interview, RN 4 could not define the characteristics of a Stage III from a Stage II pressure ulcer.
On 9/7/17 at 5:00 p.m., an interview with the Director of Nursing (DON) was conducted while reviewing the medical records of Resident 5. DON stated protocol for wound documentation is for the RN to assess and stage the wound, document the size, exact location, drainage, what layer of skin is exposed and the overall progression of the wound.
On 9/8/17 at 12:24 p.m., during an interview, Certified Nursing Assistant 3 (CNA 3) stated she had been taking care of Resident 5 for the last six months. CNA 3 stated, "She had redness on the buttocks for the last 6 months and six days ago (9/2/17). CNA 3 told the charge nurse (LVN 1) that there were two tiny open holes on the right buttocks that were pink with some white in it. The charge nurse just said, "Oh, ok." A written declaration dated 9/8/17 and timed at 12:24 p.m. was obtained from CNA 3 indicating the above statement.
A review of Resident 5's physician telephone order dated 9/2/17 at 11:00 a.m. indicated to treat right buttock excoriation and left buttock redness with Hydrocellular dressing (medicated dressings ideal for removal of dead, damaged or infected wounds) every other day and as needed for 30 days.
On 9/8/17 at 11:30 a.m., during an interview and wound observation, the Director of Staff Development/Clinical Specialist (RN 1) stated LVN's are responsible for wound treatments and daily assessment and RNs perform a weekly assessment and documentation of the wound. If there is a change in condition, RNs are made aware and reports to the physician. Direct patient care staff periodically receive in service training and education on pressure ulcers, repositioning, risk factors, and wound assessment (size, location, color, and odor). During Resident 5's wound observation with RN 1, Resident 5's left medial upper buttock/sacral area was observed with two Stage III wounds; site 1 was measured 0.5 cm (L) x 0.5 cm (W) with small amount of yellow slough on wound bed. Site 2, measured 1.0 cm (L) x 1.0 cm (W), wound bed covered with slough. RN 1 stated the wounds are Stage III pressure sores, not Stage II as previously assessed by RN 4; yellow slough is present on the wound bed. RN 1 stated, "The wounds progressed to a Stage III due to lack of repositioning and the failure to assess and properly document the wounds. An accurate assessment should have been done and reported as soon as the wounds were discovered."
On 9/8/17 at 3:00 p.m., during an interview and record review, RN 1 stated, "Skin and Wound Progress Report" for Resident 5's left and right buttocks dated from January 2017 to September 2017, was incomplete. The size, depth, width, color, order and wound progression are missing. Record reviews of the staff in service training records for pressure ulcer prevention was reviewed with RN 1. The in service sign in sheet roster titled "Pressure Ulcer Prevention" dated 1/11/17; "LVN/RN Pressure Injury Classification" dated 6/14/17; and "Pressure Ulcer" dated 9/8/17 , did not include LVN 1's name as an attendee. RN 1 stated LVN 1 does not possess specialized wound care credentials and did not receive wound care in service training. RN 1 stated she would definitely start an in service training regarding wounds and require all licensed personnel to attend.
A review of Resident 5's plan of care titled "Impaired Skin Integrity" related to excoriation/open wound on right buttock dated 1/12/17, and re-evaluated on 7/3/17, indicated a goal for the resident's skin condition will be assessed and identified and resolved by 14 days. Staff intervention included to turn and reposition for pressure relief at least every 2 hours and to assess and record wound progress. However, no care plan was found regarding Resident 5's two Stage III pressure ulcers to the right upper medial buttock/sacrum. There was no IDT documentation or plans of care addressing Resident 5's Stage III wounds to determine the proper care and treatments to promote wound healing.
A review of the facility's undated policy 2.128a, titled "Skin Integrity," indicated Residents are properly evaluated and assessed by a licensed nurse; care plans are developed to prevent pressure ulcers and other breaks in skin. Physicians will be informed and updated on changes in the skin. Furthermore, nursing staff are to inspect skin daily and any skin conditions (skin breakdown, abrasions, bruises, and rashes) documented each shift. Pressure wound documentation includes site, stage of wound, size, depth, order and treatment.
The facility failed to:
1. Accurately assess, identify, monitor and evaluate the skin treatments for Resident5 with skin redness.
2. Adequately document the skin condition and characteristic of the wound.
3. Follow up and report the discovery of the pressure ulcers.
4. Properly train the primary Licensed Vocational Nurse (LVN 1) to identify, document and/or report skin breakdown.
5. Develop and implement an intra disciplinary team ([IDT] number of people in a similar field of interest to discuss a resident's wellbeing) and plan of care to determine the care and treatments necessary to promote wound healing.
As a result of these deficiencies, Resident 5 developed two Stage III pressure injuries to her left upper medial (toward the middle of the body) buttocks that were not previously identified by the treatment nurse.
This above violation presented either an imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result. |
| 140001338 |
WINGS I |
020013595 |
B |
14-Dec-17 |
XFB611 |
23147 |
Title 22 ? 76878(a) Nursing Services - Staff.
(a) The facility shall provide by employment or formal contract for the services of a registered nurse to visit the facility for health services and client health assessment as needed, but no less than one hour per week per client.
Title 22 ? 76872(b) Developmental Program Services - Staffing.
(b) The facility shall provide through direct employment or contractual arrangement a qualified mental retardation professional who shall provide a minimum of 1.75 hours of service per week per client.
Title 22 ? 76913(c) Administrator.
(c) The administrator shall be on the premises of the facility the number of hours necessary to permit attention to the management and administration of the facility. The Department may require that the administrator spend additional hours in the facility whenever the Department determines through a written evaluation that such additional hours are needed to provide administrative management.
The facility violated the aforementioned regulations by failing to have an Administrator (Adm), Qualified Intellectual Disabilities Professional (QIDP), and Registered Nurse (RN) on site to provide for administrative, nursing needs, and to exercise general operating direction over the facility. The lack of leadership oversight failed to identify and resolve the serious, systemic, and recurring problems that placed six of six sampled clients at risk for accidents, potential health concerns, hazards, and injuries.
The Administrator failed to develop and implement a system that allowed for identifying, recording, reporting, and resolving maintenance issues in a timely manner. Adm/QIDP and RN/QIDP failed to provide oversight on staff training, obtaining orders for treatment, respecting client's rights to privacy, maintaining the facility in clean and sanitary conditions, obtaining routine and follow up health screenings, and obtaining nutritional assessments.
The Adm of the facility also acted as the QIDP (Adm/QIDP) from April 1, 2016 to January 2017. RN started on 4/1/2016, and then became the RN/QIDP on January 2017.
During an interview on 2/16/17 at 12:45 p.m., Adm/QIDP stated since she was the QIDP from 4/1/16 until January 2017, she never visited the facility. Adm/QIDP stated she used video and audio recording devices to monitor the staff and clients. For staff training, Adm/QIDP stated she called and discussed with staff over the phone about any training or concerns regarding the clients. Adm/QIDP would also fax training plans and have the staff read and acknowledge the training instructions. Adm/QIDP stated the RN was not the QIDP until January 2017.
During an interview on 2/23/17 at 2:37 p.m., the Adm/QIDP stated there were no governing body meetings held. There was no evidence of governing body minutes to review.
During an observation and concurrent interview on 2/15/17 at 4:13 p.m., there was visible dried blood on the right side of the back of Client 1's head. Caregiver (CG) 2 stated she brought Client 1 to the emergency room on 2/13/17 after getting instructions over the phone from the Adm/QIDP. CG 2 stated Client 1 had staples for the laceration on the back of her head.
During an interview and concurrent interview on 2/16/17 at 8:00 a.m., CG 5 stated on 2/13/17 at 6:30 a.m., she heard a noise from Client 1's room. When she went to the room, CG 5 saw Client 1 was on the floor. When CG 5 helped Client 1 up, CG 5 saw some blood on Client 1's right shoulder. CG 5 called the Adm/QIDP on the telephone and was instructed to put pressure on the bleeding site. Then, another staff came and brought Client 1 to a hospital. CG 5 stated she was not sure how Client 1 injured herself because there was no blood on the nightstand.
During an interview on 2/16/17 at 9:35 a.m., CG 2 stated the client came back to the facility the same day after visiting the emergency room. Client 1's discharge instruction for the head laceration was faxed to the Adm/QIDP. Then, the Adm/QIDP faxed back the nursing care plan to the facility. CG 2 stated the RN/QIDP had not been to the facility to assess Client 1.
During an interview on 2/16/17 at 8:00 a.m., CG 5 stated she was not sure who was supposed to clean Client 1's wound.
During an interview on 2/16/17 at 8:45 a.m., CG 1 stated he was not sure what they were supposed to use to care for Client 1's head laceration.
During an interview on 2/16/15 at 3:15 p.m., CG 3 stated she was not aware how to clean the client's laceration site.
During an interview on 2/17/17 at 11:45 a.m., Medical Director (MD) stated he received a call and had a message from the Adm/QIDP that Client 1 fell and was going to the emergency room. MD stated he was not notified Client 1 had a laceration that required two staples.
During an interview on 2/22/17 at 2:25 p.m., Adm/QIDP stated she did not do an investigation for Client 1's injury on 2/13/17.
During an interview on 2/23/17 at 2:45 p.m., RN/QIDP stated that she did not see Client 1 until 2/16/17 (three days after Client 1 fell out of bed). RN/QIDP stated she spoke to the caregivers about the nursing care plan created to monitor and wound care. RN/QIDP could not provide any documentation for monitoring the wound and neurological assessment. RN/QIDP also stated that Client 1's primary physician was not notified that Client 1 fell and had a head laceration.
During an interview on 2/16/17 at 1:25 p.m., CG 3 stated she was not trained on abuse prevention and reporting. The RN/QIDP just showed the video and staff signed the orientation sheet. CG 3 stated she did not do a pre/post abuse test, nor she signed mandated reporting form. CG 3 stated when she had new employees watch the abuse training video and the new employees had questions regarding abuse, RN/QIDP was not available to answer questions.
During an interview on 2/17/27 at 3:45 p.m., CG 4 stated she watched a video and did not do pre/post test or sign a mandated reporting form. She stated, RN/QIDP "was here but did not sign me off. I signed the form (trainer section) and no one else signed it."
Review of the employee records on 2/18/17 did not show CG 1 completed the tests, or signed the mandated reporting form.
During an interview on 2/22/17 between 2:10 p.m. and 3:30 p.m., the RN/QIDP stated she trained CG1 for abuse prevention and reporting training, which included the pre/post abuse test. RN/QIDP could not provide any evidence of pre/post test and mandated reporting form to show she did training for CG 1.
During an interview on 2/23/17 at 3:00 p.m., CG 1 stated he did not watch the whole abuse video required by Department of Justice during the initial and annual abuse training. CG 1 could not recall whether he took the pre/post test or if he signed the mandated reporting form.
During an interview on 2/17/17 at 3:12 p.m., CG 3 stated she did not have annual abuse training. CG 3 stated they had not been given in-service since last year and stated, "I know I haven't watched the video since I was hired." (4/18/2014)
Review of an employee record on 2/17/17 showed CG 2, 3, 5, 7 and RN/QIDP did not have any documented evidence in their records to show that they completed a training course in Cardiopulmonary Resuscitation (CPR).
During an interview on 2/22/17 between 2:10 p.m. and 3:30 p.m., the RN/QIDP stated staff were required to have CPR cards and had become aware of requiring having CPR cards two months ago. RN/QIDP stated some staff needed to take the CPR class, but the facility did not provide in-service regarding CPR. Staff needed to get it done at the outside of the facility.
During an interview on 2/17/15 at 2:15 p.m., Adm/QIDP stated she observed the clients through the video camera and audio recording when the staff were doing the Individual Service Plan (ISP). Adm/QIDP stated that she only had the view of the video camera from dining area, kitchen, parts of the living room and "garden room" (also called TV room). Adm/QIDP had no view from the video camera to other rooms if the ISP was being completed or being performed with the caregiver assistance. Adm/QIDP stated she reviewed the data collected by staff. Adm/QIDP was unable to answer if the clients' skills improved or lost their gained skills.
During an interview on 2/17/17 at 3:58 p.m., CG 3 stated most of the clients wanted to sleep or rest when they got home from the day program. CG 3 stated staff told the Adm/QIDP and the RN/QIDP, "Clients don't want to do their ISPs." CG 3 stated the Adm/QIDP and RN/QIDP have not come to the facility to see how clients were doing.
During an interview and concurrent record review on 2/22/17 at 1:45 a.m., the Day Program Director (DPD) stated when RN/QIDP (RN was in training for QIDP at that time) visited the day program on 9/21/16 for Client 2 and 3's annual meeting, she did not bring ISP paperwork to the meeting for each client. The day program still had not received the ISP to this day. The day program integrates the plan to ensure that clients would have continuous training from the facility to the day program. DPD stated that they usually focus on social skills and they integrate the facility's ISP and day program.
During an interview on 2/22/17 at 4:10 p.m., RN/QIDP stated staff read the ISP to get familiar with the clients and staff trained clients. RN/QIDP stated she went over the client's ISPs with the staff but she was not always present to observe if the client's ISPs were done correctly. RN/QIDP was not able to provide any evidence of in-service training sheet of client's ISP training for staff.
During an interview on 2/17/17 at 2:50 p.m., CG 4 stated when she started working for the facility, she was given a book and was told to read it. CG 4 stated that no one had trained her on how to do the task or the client's Individual Service Plan (ISP). CG 4 further added that she was not even aware the location where to log in the training data collected for clients' ISP. CG 3 also confirmed that was how she was trained as well.
During an interview on 2/23/17 at 3:00 p.m., during the exit conference, RN/QIDP asked the surveyors, "How should the staff be trained?"
Review of Client 1's ISP goals showed:
Goal 4: At medication time, Client 1 will pour water from a water pitcher into a cup and Client 1 will take a drink of water after taking her medication.
During a medication pass observation on 2/15/17 at 7:20 p.m., CG 3 brought the prepared medications mixed with applesauce to Client 1's room and tried to give the medication to Client 1. Client 1 was not given the opportunity to drink water from a cup after he took the medication.
Goal 5: In the afternoon during training time, Client 1 will exchange a coin for a toy (treat).
During an observation on 2/15/17 at 2:05 p.m., Client 1 was sleeping in her room. During an observation on 2/15/17 at 3:55 p.m., Client 1 was still sleeping in her room. Throughout the survey period, Client 1 was seen sitting or sleeping in a chair in the living room covered in a blanket.
Goal 7: Throughout the day as observed by staff, behavior of crying/screaming will be exhibited less than one time per month.
During an interview on 2/17/17 at 8:46 a.m., CG 3 stated Client 1 stopped going to the day program about one month ago because she was getting louder and was disrupting the other clients. CG 3 stated Client 1 was getting more angry and louder when someone got close to her, and she started hitting her face more. CG 3 stated that she informed the Adm/QIDP that Client 3 was getting louder and the Adm/QIDP told her that Client 3 was just "singing." Throughout the survey period, Client 1 was seen and heard making loud repeating noises during mealtime, while sitting on the chair, or when staff approached her.
Review of Client 2's ISP goals:
Goal 2: In the afternoon, during the training time. Client 2 will buy a treat from staff with a coin.
During the survey, Client 2's this activity did not occur.
During an interview on 2/23/17 at 9:08 a.m., CG 1 confirmed the data collection binder did not include the data for Client 2's money management goal. CG 1 further added, "It's not his fault if the goal was not done."
Goal 4: Throughout the day as observed by staff, Client 2 will decrease incidents of smearing stool to 0.5 x per month or less average.
During an observation on 2/15/17 at 2:05 p.m., upon opening Client 2's bedroom door, there was a very strong fecal odor even with the window being open. There was a dirty diaper on the floor.
During an interview on 2/15/17 at 4:28 p.m., CG 2 stated after Client 2 arrived home from the day program, she took off her diaper and left it on the floor.
During an observation on 2/16/17 at 8:13 a.m., Client 2's bedroom still had a very strong fecal odor.
During an observation and concurrent interview on 2/16/17 at 8:40 p.m., CG 2 agreed that Client 2's bedroom had a very strong fecal odor. CG 2 stated Client 2 smears the floor with fecal material and the brown stuff on the floor was feces.
During an interview on 2/23/17 at 9:08 a.m., CG 1 confirmed that data collection binder did not include the data for Client 2's fecal smearing goal.
Goal 6: Throughout the day as observed by staff, Client 2 will spit on at the table no more than 0.5 x per month or less for the year.
During an observation on 2/15/17 at 7:10 p.m., Client 2 coughed and spit on the dining table. CG 3 gave some paper towel to Client 2 to wipe the table. CG 3 did not disinfect the dining table or gave some extra paper towel to Client 2 to use for the next time if she spit. CG 3 did not remind Client 2 that she should not spit on the table.
Goal 8: At medication time, Client 2 will identity her vitamin tablet and will add it to her medications.
During an observation on 2/15/17 at 7:40 p.m., CG 3 poured all of Client 2's medications, including the vitamin. Then CG 3 gave the medications to Client 2. Client 2 was not given the opportunity to learn the skills.
Goal 9: Throughout the day as observed by staff, Client 2 will reduce spitting to less than once incident per month.
During an observation on 2/15/17 at 3:05 p.m., Client 2 was laying on the loveseat chair in the living room. Client 2 coughed and spit out on her hand and wiped it on her clothes. No staff came to clean Client 2.
During an observation on 2/15/17 at 5:16 p.m., Client 2 was seen coughing and spit out on her hand, then wiped the spit on her robe. No staff came to clean Client 2's hand and remind her not to spit on her hand.
Review of Client 3's ISP goals showed:
Goal 2: At mealtime and snack time, after eating, Client 3 will use his napkin to wipe his mouth.
During an observation on 2/17/17 from 7:00 p.m. to 7:25 p.m., Client 3 was served his dinner and the staff did not provide a napkin to the client so he could wipe his mouth.
Goal 3: In the afternoon during training time, Client 3 will buy a mint or small candy by exchanging a coin for a mint.
Multiple observations during the day 2/15/17, 2/16/17 and 2/17/17, Client 1 was not given opportunities to practice this goal.
During an interview on 2/17/17 at 3:58 p.m., CG 3 stated the facility used to buy mints and the client would exchange a coin for a mint. CG 3 stated the Adm/QIDP did not buy mints anymore and staff could not do the money management goal for Client 3 and other clients with the same goal.
Goal 4: At medication time, Client 3 will place his medications, which have been placed in applesauce, into his mouth with a spoon.
During an observation on 2/15/17 at 7:30 p.m., CG 3 administered Client 3's medication and did not allow Client 3 to spoon the medication into his mouth.
Multiple observations during the survey showed Client 3 was sitting in a chair in the Garden Room with no activity or staff interactions for prolonged period of time.
Review of Client 4's ISP goals showed:
Goal 1: Throughout the day after enjoying a drink at table, Client 4 will appropriately place the cup in the sink with one request or less.
During an observation on 2/15/17 at 3:10 p.m., Client 4 was given Kool-Aid in a cup at the kitchen table. After finishing his drink, Client 4 went to the living room to sit, and then he went to his room. Staff did not train Client 4 to put the cup in the kitchen sink.
Goal 4: In the afternoon during training time, Client 4 will buy a mint by exchanging a coin for a mint.
Multiple observations during the day 2/15/17, 2/16/17 and 2/17/17, Client 3 was not given opportunities to practice this goal.
Review of Client 5's ISP goals showed:
Goal 2: Throughout the day, Client 5 will not throw cup/glass on the floor. Staff will monitor the meal time and watch for signs that Client 5 was throwing her glass. Staff will ask Client 5 "hand me your glass, please, so I can put it in the sink."
During an observation on 2/23/17 at 7:54 a.m., Client 5 was finished eating her breakfast and threw her bowl, spoon, and her towel on the floor. There was no staff monitoring and no staff came to instruct Client 5 not to throw the dishes on the floor.
Goal 4: In the afternoon during training time, Client 5 will buy a treat by exchanging a coin for a treat.
Multiple observations on 2/15/17 from 2:45 p.m. to 6:30 p.m., Client 5 arrived from day program and then sat on a chair in the living room. At 4:05 p.m., Client 5 was given a snack while sitting on the chair. Client 5's hands were not washed before eating the snack. At 5:25 p.m., CG 3 got Client 5 up from the chair to go to the bedroom to change the incontinent pad. After changing, Client 5 was again seated on the same chair in the living room. No staff approached the client or offered activities to the client.
Record review showed Client 1 was admitted to the facility on 8/24/97 with multiple diagnoses that included severe intellectual disabilities and severe anxiety. Physician's orders showed Client 1 was prescribed Risperdal 0.5 milligram (mg) taken by mouth once a day (medication used to treat illness that caused disturbed/unusual thinking). This medication was started on 12/22/16. Seroquel 25 mg, taken one tablet two times a day (medication used to treat illness that caused disturbed/unusual thinking). This medication was started on 7/27/15. Physician's notes dated 2/4/17 showed "Significant drug side effects to Risperdal (undressing in public, confusion, sleeplessness, and shaking)."
During an interview on 2/17/17 at 8:46 a.m., CG 3 stated Client 1 stopped going to the day program about one month ago because she was getting louder and was disrupting the other clients. CG 3 stated Client 1 was getting more angry and louder. When staff and other clients got close to her, she started hitting her own face more recently. CG 3 stated that she informed the Adm/QIDP that Client 3 was getting louder and the Adm/QIDP told her that Client 1 was just, "Singing."
During an interview on 2/16/17 at 1:35 p.m., CG 2 stated the staff was not given any training on monitoring the side-effects of these medications. CG 2 added if the clients had side-effects of the medication, she would not know what the side-effects were.
During an interview on 2/17/17 at 2:45 p.m., RN/QIDP stated she had not trained the staff on monitoring the side effects on the antipsychotic medications.
Record review showed Client 1 was admitted to the facility on 8/24/1997 with multiple medical diagnoses that included severe intellectual disabilities. Record review showed there was no evidence that Client 1 was ever evaluated by a dentist.
During an interview and record review on 2/16/17 at 1:35 p.m., CG 2 confirmed there was no record of dental exam or visit on Client 1's record.
Record review showed Client 2 was admitted to the facility on 1/10/97 with multiple medical diagnoses that included severe intellectual disabilities. Record review showed there was no evidence that Client 2 was ever evaluated by a dentist.
Record review showed Client 5 was admitted to the facility on 12/9/16 with multiple diagnoses that included Down's syndrome (a congenital disorder causing intellectual impairment and physical abnormalities including short stature and a broad facial profile). Client 5 had a routine dental exam on 6/09/16 in a previous facility. Review of the dental record, the dentist could not do thorough oral examination because the client was not cooperating. The dentist recommended, "Twice daily gum brushing with finger toothbrush using non-alcohol mouth rinse (or extra soft toothbrush)." After Client 5 was admitted to the facility, she has not had a dental exam.
During an observation and concurrent interview on 2/23/17 at 8:15 a.m., CG 1 stated he only cleaned around the outside of Client 5's mouth. CG 1 stated that Client 5 had a large protruding tongue and he was not trained on how to clean Client 5's gums and tongue.
During an interview and concurrent record review on 2/23/17 at 2:45 p.m., RN/QIDP stated there was no dental appointment scheduled for Client 5. RN/QIDP confirmed that Client 5 had not been seen by a dentist since being admitted to the facility.
During an interview on 2/17/17 at 2:15 p.m., Adm/QIDP stated the Clients 1, 2, 3, and 4 had not been seen by a dentist since they do not have teeth. When interviewed about the need for a dentist to evaluate the overall health of the client's mouth, and not just look at the teeth, the ADM/QIDP did not reply. Client 6 was the only one seen by the dentist in 2015.
During an interview on 2/22/17 at 2:25 p.m., Adm/QIDP stated the records on the clients' charts for dental visits reflected the last visits made to a dentist.
The facility failed to ensure staff to have screening for communicable disease (tuberculosis). During an interview and concurrent record review of employee records on 2/17/17, CG2 confirmed that CG4, CG5, and CG6 showed there were no screenings for communicable disease (tuberculosis) done.
During an interview on 2/17/17 at 2:15 p.m., Adm/QIDP stated the clients nutritional needs had not been evaluated by a Registered Dietician (RD). Adm/QIDP was not able to given reason for lack of RD services.
During an interview on 2/22/17 at 2:25 p.m., Adm/QIDP stated she altered the clients menu without consulting an RD.
The facility failed to provide appropriate dishware to meet the clients' needs. During dinner observation on 2/15/17at 6:43 p.m., Clients 2, 3, 4, and 5 were eating on clear glass pie dishes and pillowcases were used as clothes protector/placemat.
Therefore, the facility failed to ensure the Administrator was onsite regular basis to provide leadership to ensure the clients' health and safety needs were being met, the QIDP did not integrate, coordinate, provide leadership, and monitor active treatment, and RN did not assess and follow up with client's injury and routine health care needs.
The above violation has a direct relationship to the health, safety or security of clients. |
| 070000041 |
WINDSOR MONTEREY CARE CENTER |
070013584 |
B |
3-Nov-17 |
M1VF11 |
6665 |
F431 - 483.45 (b)(2)(3)(g)(h) DRUG RECORDS, LABEL/STORE DRUGS & BIOLOGICALS
The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in ?483.70(g) of this part. The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse.
(a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident.
(b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who--
(2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and
(3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled.
(g) Labeling of Drugs and Biologicals.
Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable.
(h) Storage of Drugs and Biologicals.
(1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys.
(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected
The facility failed to follow their policy and procedure on controlled medication storage, when the narcotic (a substance which affects mood or behavior) count sheets (accountability records) were not physically inventoried by two licensed nurses and the narcotic count sheets were not consistently signed by two licensed nurses. These failures resulted in multiple missing narcotic medications and count sheets.
Review of the facility reported incident dated 10/13/17 indicated, on the morning of 10/7/17, during the narcotic count between the night shift and day shift, an entire narcotic medication card and its narcotic count sheet for one resident was missing. The facility started the investigation by searching all the medication carts and medication room. The narcotic medication card and its narcotic count sheet were not located.
During an interview with registered nurse A (RN A) on 10/23/17 at 9:10 a.m., she stated, on 10/7/17, she and night shift licensed nurse B (LN B) was counting the narcotic medication. They noted an entire narcotic medication card and its narcotic count sheet for one resident were missing. RN A stated, she immediately reported it to the director of nursing (DON) and she initiated an investigation. She also stated, on 10/9/17, three other residents' narcotic medications and narcotic count sheets were identified as missing.
During an interview with LVN C on 10/23/17 at 12:15 p.m., she stated, she did not remember counting the missing narcotic medication with LVN B. LVN C stated she had seen the medication card a day prior to the incident.
During an interview with RN A on 10/23/17 at 1:00 p.m., she stated, the facility received the pharmacist's report on 10/13/17 indicating licensed nurses were not signing the narcotic count sheets in between shifts and noting missing signatures on narcotic sheets when the narcotic medication was given.
Review of the pharmacist nurse consultant's (PNC) report dated 10/10/17, indicated a narcotic reconciliation was done for nurses stations 1, 2, and 3. The accountability records were incomplete and noted some missing signatures of the licensed nurses. The PNC also reported missing narcotic medication cards and its narcotic count sheets for all three nurses' stations.
Review of the consultant pharmacist's (CP) investigation report indicated, the total number of missing narcotic medication was 89 tablets; 23 tablets of Norco (narcotic pain medication) 10/325 milligrams (mg), 36 tablets of Hydromorphone (a narcotic pain reliever) 4 mg, and 30 tablets of Percocet (used to relieve moderate to severe pain) 10/325 mg. The CP's investigative report also indicated nurses were not signing the narcotic count sheet in between their shifts.
Review of the Narcotic Count Sheet for August/2017 indicated;
In Nurses Station 1 (Hillside), the LNs signatures were missing on 8/1, 8/2, 8/3, 8/4, 8/7, 8/9, 8/12, 8/13, 8/14, 8/16, 8/17, 8/18, 8/21, 8/22, 8/23, 8/24, 8/25, 8/29, 8/30, and 8/31.
In Nurses Station 2 (Horseshoe), the LNs signatures were missing on 8/5, 8/6, 8/8, 8/10, 8/11, 8/12, 8/13, 8/14, 8/15, 8/16, 8/17, 8/18, 8/21, 8/22, 8/23, 8/25, 8/26, 8/27, 8/28, 8/29, 8/30, and 8/31.
In Nurses Station 3 (Bayside), the LNs signatures were missing on 8/3, 8/6, 8/8, 8/10, 8/11, 8/12, 8/14, 8/16, 8/17, 8/18, 8/19, 8/20, 8/21, 8/22, 8/23, 8/24, 8/25, 8/26, 8/27, 8/29, 8/30, and 8/31.
Review of the Narcotic Count Sheet for September/2017 indicated;
In Nurses Station 1 (Hillside), the LNs signatures were missing on 9/3, 9/9, 9/13, 9/16, 9/17, 9/18, 9/19, 9/22, 9/23, 9/27, 9/28, 9/29, and 9/30.
In Nurses Station 2 (Horseshoe), the LNs signatures were missing on 9/1, 9/2, 9/3, 9/6, 9/7, 9/8, 9/9, 9/10, 9/11, 9/13, 9/14, 9/15, 9/16, 9/17, and 9/20.
In Nurses Station 3 (Bayside), the LNs signatures were missing on 9/2, 9/3, 9/4, 9/5, 9/6, 9/7, 9/8, 9/9, 9/10, 9/13, 9/14, 9/16, 9/17, 9/18, 9/19, 9/21, 9/28, 9/29, and 9/30.
Review of the Narcotic Count Sheet for October/2017 indicated;
In Nurses Station 1 (Hillside), no missing signatures.
In Nurses Station 2 (Horseshoe), the LNs signatures were missing on 10/4, 10/5, 10/10, and 10/14.
In Nurses Station 3 (Bayside), the LNs signatures were missing on 10/3, 10/4, 10/5, 10/7, 10/22, 10/24, and 10/25.
Review of the facility's policy and procedure on Controlled Medication Storage dated 8/14 indicated, each shift change, a physical inventory of all controlled medications, including emergency supply is conducted by two licensed nurses and is documented on the controlled medication accountability record.
These failures had a direct relationship to the health, safety, or security of the residents. |
| 100000814 |
Wagner Heights Nursing and Rehabilitation Center |
030013597 |
B |
6-Nov-17 |
MVZZ11 |
4298 |
California Health & Safety Code 1418.91
(a) A long-term health facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the department immediately, or within 24 hours.
(b) A failure to comply with the requirements of this section shall be a class "B" violation.
The following citation is written as a result of an investigation during the facility's annual federal re-certification survey on 9/11/17 through 9/14/17.
The Department determined the facility failed to report an allegation of abuse to the department within 24 hours.
This violation potentially placed vulnerable residents at increased risk of abuse.
Resident 14 was admitted to the facility in August 2017 with diagnoses of schizophrenia (a thought disorder marked by delusions, hallucinations, and disorganized speech and behavior) and bipolar disorder (a psychological disorder marked by manic and depressive episodes).
During a clinical record review of the Minimum Data Sets (MDS), a resident assessment tool dated 8/14/17 through 9/12/17, Resident 14's brief interview for mental status (BIMS) on dates 8/21/17 and 8/28/17 indicated the score was 15 on both assessments. The MDS Resident Assessment Manual qualified a score of 15 as cognitively intact.
A Progress Note titled "General Note" dated 9/3/17 at 21:28 p.m. (9:28 p.m.) indicated "Resident was sent out on a 5150 [code which authorizes a qualified officer or clinician to involuntarily confine a person suspected to have a mental disorder that makes him a danger to himself or others, and/or gravely disabled] due to harming other residents, staff, and himself. Resident [14] was sent out to general acute care hospital [GACH]. MD and RP made aware.
During a clinical record review of a facility document titled "...Change in Condition Evaluation" dated 9/3/17, it indicated the following: "Resident danger to self and others with aggression...Wanders and becomes aggressive...Resident attempted to hold resident wheelchair and shake the chair while resident was in it. Aggressive towards staff...Resident was harm [sic] towards self and other resident. Attempted to shake wheelchairs of other residents and is aggressive towards staff."
During a telephone interview with Licensed Nurse 5 (LN 5) on 9/12/17 at approximately 5 p.m., LN 5 stated she was familiar with Resident 14 as related to her nursing duties and knew Resident 14 was on a one (staff) to one (Resident 14). LN 5 stated that Resident 14 liked to follow other residents and on the evening of 9/3/17, Resident 14 was holding onto and shaking the wheelchair of Resident 29. LN 5 communicated that Resident 14 was getting more agitated and Resident 29 was getting scared and trying to get away. LN 5 relayed that on this same date and approximate time, Resident 12 was trying to go out onto the smoking patio and Resident 14 grabbed her wheelchair and pulled her back. "She was scared," LN 5 stated "He was trying to stop us from stopping him." LN 5 stated Resident 14 pushes CNAs away "when he doesn't get what he wants."
The facility policy titled, "Abuse Prevention, Intervention, Investigation & Crime Reporting Policy," revised 11/2016, indicated, "It is the responsibility of all employees to immediately report to the facility administrator, and to other officials in accordance with Federal and State law, any incident of suspected or alleged abuse...all reports shall be timely...in response to allegations of abuse...the facility will ensure that all alleged violations involving abuse...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...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 the long-term care facilities) in accordance with State law."
No report(s) regarding allegations of resident to resident abuse on 9/3/17 were received by the department in accordance with facility policy and California Health and Safety Code.
Therefore, the Department determined the facility failed to report an allegation of abuse to the Department within 24 hours. |
| 940000111 |
WINDSOR PALMS CARE CENTER of ARTESIA |
940013692 |
B |
13-Dec-17 |
VW6V11 |
7386 |
F226 ?483.12 (c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must:
F225 ?483.12(c)(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.
On 8/17/17, the Department received a report regarding an allegation of rape of a resident (Resident 1) by Certified Nursing Assistant 1 (CNA1).
Based on interview and record review, the facility failed to:
1. Report a known allegation of staff to resident abuse to the Department of Health within 24 hours.
2. Promptly initiate an investigation of the alleged incident for Resident 1, in accordance with the facility's policy and procedure.
These deficient practices had the potential of not protecting Resident 1 from further mistreatment, mental anguish, and the potential of exposing other residents to mistreatment.
On 8/18/17, an unannounced investigation was conducted at the facility.
A review of Resident 1's Admission Record indicated the resident was a 57 year-old male who was originally admitted to the facility on 1/8/14, and readmitted on 4/10/17. Resident 1's diagnoses included schizophrenia (a mental disorder affecting a person's ability to think, feel, and behave clearly), bipolar disorder (a brain disorder causing unusual shifts in mood, energy, activity levels, and the ability to carry out day-to-day tasks), and altered mental status.
A review of Resident 1's History and Physical (H/P), dated 4/11/17, indicated the resident did not have the capacity to make decisions.
A review of Resident 1's Minimum Data Set (MDS), a resident assessment and care-screening tool, dated 7/31/17, indicated the resident reported the correct year, month, and day of the week, and did not exhibit delusions (a persistent belief or altered reality held despite evidence or agreement to the contrary, generally in reference to a mental disorder), or hallucinations (a false perception of something that was not actually there). The MDS indicated Resident 1 required extensive assistance from one person for transfers and personal hygiene. According to the MDS, Resident 1 was receiving antipsychotic medications (a group of drugs used to treat serious mental and emotional conditions).
A review of Resident 1's Interdisciplinary ([IDT] a group of health care professionals from diverse fields, who coordinate toward common goals for the resident) Progress Notes, dated 8/18/17, and timed at 10:04 a.m., indicated Resident 1 reported to the Social Services Director (SSD) that he was raped by a "male certified nursing assistant (CNA) in his room." The note indicated the SSD initiated an investigation, on 8/16/17, and Resident 1 was transferred to the general acute care hospital (GACH) for evaluation. According to the GACH records, there was no evidence of trauma to resident?s anus.
A review of Resident 1's Health Status Note, dated 8/17/17, and timed at 1:05 p.m., documented as a late entry, indicated Resident 1 notified Licensed Vocational Nurse 2 (LVN 2) that CNA 1 sexually abused him "last night (8/14/17)."
A review of Resident 1's Social Services Progress Note, dated 8/17/17, and timed at 7:03 p.m., indicated Resident 1 continued to inform the SSD that he was raped by CNA 1 and was afraid of CNA 1.
A review of Resident 1's Health Status Note, dated 8/19/17, and timed at 2:21 p.m., documented as a late entry, indicated Resident 1 notified LVN 1 that CNA 1 sexually abused him "last night (8/14/17)."
On 8/18/17 at 2:05 p.m., during an interview, the Director of Nursing (DON), stated on 8/16/17, Resident 1 notified the SSD that CNA 1 "raped him" on 8/14/17. The DON stated on 8/14/17, during the 11 p.m. to 7 a.m. (night shift), Resident 1 informed LVNs 1 and 2 that CNA 1 "raped" him.
On 9/19/17 at 9:53 a.m., during an interview, LVN 2 stated Resident 1 informed her twice that he was raped by CNA 1. LVN 2 stated she wrote her statement of the incident on 8/14/17, but did not submit the form containing her statement to the abuse coordinator, until she returned to work a few days after the incident. LVN 2 stated she did not initiate an investigation and did not report the incident to the DON or Administrator. LVN 2 stated the allegation should have been reported and investigated immediately following the incident. LVN 2 stated an investigation was initiated on 8/16/17, when Resident 1 informed another staff member of his alleged sexual abuse that occurred on 8/14/17.
On 9/19/17, at 10 a.m., during an interview, LVN 1 stated Resident 1 reported to her that CNA 1 "butt fu-ked me." LVN 1 stated that everyone was a "mandatory reporter for allegations of abuse." LVN 1 stated she did not report or investigate the incident after Resident 1 reported the allegation to her.
On 9/19/17 at 2:28 p.m., during an interview, CNA 1 stated after he transferred Resident 1 into his wheelchair, the resident began yelling out that CNA 1 raped him. CNA 1 stated Resident 1 reported the allegation to LVN 2.
A review of the facility's policy and procedure titled, "Abuse Prevention and Prohibition Program," with a revision date of 4/2017, indicated if the suspected perpetrator was an employee, the facility would remove the employee immediately from the care or vicinity of the resident, and suspend the employee until the investigation was complete, and findings have been reviewed by the Administrator. The policy indicated the assigned staff would promptly investigate all incidents of suspected or alleged abuse and the facility would report known or suspected instances of physical abuse, including sexual abuse, to the proper authorities, within 24 hours of the observation, knowledge, or suspicion of physical abuse, as required by the state and federal regulations.
Based on interview and record review, the facility failed to:
1. Report a known allegation of staff to resident abuse to the Department of Health within 24 hours.
2. Promptly initiate an investigation of the alleged incident for Resident 1, in accordance with the facility's policy and procedure.
This violation had a direct relationship to the health, safety, or security for Resident 1 and other residents in the facility. |
| 940000111 |
WINDSOR PALMS CARE CENTER of ARTESIA |
910013602 |
A |
9-Nov-17 |
X15311 |
13937 |
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 plan of care and the Interdisciplinary Team?s ([IDT] professional staff who makes decisions about a resident?s care) in using Geri Sleeves (breathable cotton-blend that protects against skin irritation and injury).
3. Failure to follow the facility?s policy and the manufacture?s guidelines for safe technique in using the Hoyer lift (an assistive medical device used to transfer from a bed to a wheelchair, toilet, or chair).
The facility?s staff was observed improperly transferring Resident 1 from the bed to the wheelchair using a Hoyer Lift (an assistive medical device used to transfer from a bed to a wheelchair, toilet, or chair), in which the lift almost fell on the resident.
This deficient practice resulted in Resident 1 sustaining multiple bruises and skin tears, which had the potential for the resident to bleed and wounds to become infected and had an episode of falling out of the Hoyer Lift. The ongoing unsafe technique use of the assisted devices had the potential for the resident to sustain more serious injuries.
A review of Resident 1?s Admission Record indicated the resident was a 63-year-old male who was admitted to the facility on 10/13/16. Resident 1?s diagnoses included injury of the sciatic nerve (nerve roots coming out of the spinal cord into the lower back) at hip and thigh level, generalized muscle weakness, cerebral infarction (necrotic tissue in the brain resulting from a blockage or narrowing in the arteries supplying blood and oxygen to the brain), paralytic syndrome (loss of motor function due to dysfunction of the spinal cord) following the cerebral infarction, affecting the left dominant side.
A review of Resident 1?s Minimum Data Set ([MDS], a resident assessment and care-screening tool), dated 7/21/17, indicated Resident 1 was able to report the correct year, month and day of the week. The MDS indicated the resident?s memory was intact and had the ability to express ideas, wants and had the ability to understand other?s verbal content. The MDS indicated Resident 1 was totally dependent (full staff performance) on two or more staff for physical assistance with transferring (moving between surfaces). The MDS indicated the resident required the extensive assistance (resident involved in activity, with staff providing weight-bearing support) on two or more staff with physical assistance for bed mobility and toilet use. The MDS indicated Resident 1 had impairment to one side of the upper extremity and on both sides of the lower extremity, and used a wheelchair for mobility.
A review of Resident 1?s Care Plan titled, ?At Moderate Risk for Falls,? dated 10/13/16, indicated the staff?s interventions included to provide and maintain a safe and hazard free environment.
A review of Resident 1?s Care Plan titled, At Risk for Pressure Ulcer, dated 11/7/16, indicated interventions for the resident to be provided with an extensive two-person assistance with bed mobility. The Care Plan indicated to handle the resident gently during nursing care, and to observe for redness, discoloration, and open sites during provision of care.
A review of Resident 1?s Change of Condition (COC) Evaluation Record, dated 6/15/17, timed at 11:24 a.m., indicated the resident had a skin tear to the left forearm, measuring 2.3 centimeters (cm) in length, and 0.3 cm in width, with no bleeding noted. The record indicated an antibiotic (used to treat many common infection) ointment was provided as a treatment.
A review of Resident 1?s Change of Condition (COC) Evaluation Record, dated 7/16/17, and timed at 4:10 p.m., indicated the resident had an open wound to the rear of the left lower leg, with no measurements documented. The record indicated when the resident rubs the affected area, the condition or symptoms worsen. The record indicated antibiotic ointment, covered with dry dressing was provided as treatment.
A review of Resident 1?s Health Status Note, dated 7/17/17, and timed at 9 p.m., indicated the resident called the Police Department and indicated that his bruises (a discoloration of the skin resulting from bleeding underneath the skin) were caused from the ?gurney (a wheeled stretcher used for transporting) lifts [sic].?
A review of Resident 1?s Health Status Note, dated 7/18/17, and timed at 1:44 p.m., indicated the resident had red and brown discolored marks on his left arm, with measurements of 7 cm in length and 8 cm in width. The note indicated Resident 1 stated, ?Having bruises caused by the gurney lifts,? and Geri-Sleeves (breathable cotton-blend that protects against skin irritation and injury) were applied on the resident.
A review of Resident 1?s Social Services Progress Note, dated 7/18/17, and timed at 6:33 p.m., indicated the resident was observed with a bandage on his right arm. The note indicated Resident 1 informed the social services director (SSD) that his right arm was injured while on a Hoyer Lift. The note indicated the resident stated, ?They were rushing.?
A review of Resident 1?s Social Services Progress Note, dated 7/18/17 and timed at 6:48 p.m., indicated the resident had a bruise on his left arm and informed the SSD that the doors accidentally hit his arm and knee.
A review of Resident 1?s IDT Progress Note, dated 7/19/17, timed at 9:37 a.m., indicated on 7/17/17, staff observed a discoloration to the resident?s right elbow. The note indicated Resident 1 informed staff that the bruises were caused from the gurney lifts and while Resident 1 was transferred back to bed, ?another staff member? observed a skin tear. The skin tear measured 0.1 cm in length and 0.1 cm in width, with discoloration to the right elbow. The note indicated on 7/17/17 at 1:30 p.m., a social service assistant (SSA), observed Resident 1 on his electric wheelchair with blood on his right elbow. The note also indicated the IDT recommended for the staff to be educated on proper use of the Hoyer Lift and to apply Geri Sleeves to Resident 1?s arms to minimize potential future injuries.
A review of Resident 1?s Change of Condition (COC) Evaluation Record, dated 7/24/17 at 10:42 p.m., indicated the resident had ?open ecchymosis (bruises) on the left arm.? The record indicated the wound was measured at 1.5 cm in length and 0.5 cm in width, and was discovered while the resident was being showered by an unidentified certified nursing assistant (CNA). The record indicated frequent repositioning and the use of Geri Sleeves would help improve the ?condition or symptom.? The record indicated normal Saline (a sterile solution) with an antibiotic ointment was provided for the wound treatment.
On 7/31/17 at 4:35 p.m., during an observation tour of the facility and a concurrent interview with the Assistant Director of Nursing (ADON), Resident 1 was observed lying supine (face up) in bed with his left arm elevated on top of pillows without Geri-Sleeves in place. Resident 1?s arm was observed with multiple patches of uneven circular dark red discolorations to the left lower arm, (approximately the diameter size of a quarter coin). Resident 1 was observed with patches of uneven, circular redness on the right elbow with a small skin tear. The resident was observed unable to independently move his left arm and stated he could not feel sensation on his left upper extremity. Resident 1 stated his arm hitting the wall might have caused the bruises to his left arm. Resident 1 stated the redness and skin tear occurred while being transferred on a ?sling (Hoyer Lift).? The ADON stated the skin tear and redness on Resident 1?s right arm occurred while being transferred on the Hoyer Lift two weeks prior.
On 8/14/17 at 8:40 a.m., during an observation and interview, Resident 1 stated in the past, he had fallen from the Hoyer Lift and sustained bruises (Resident 1 could not recall specific dates).
On 8/14/17 at 9:30 a.m., during an observation of CNAs 1 and 2 transferring Resident 1 from the bed to the wheelchair, using a Hoyer Lift, the resident was observed positioned directly facing CNA 1 (away from the Hoyer Lift), while the machine was lifting the resident. CNA 2 positioned Resident 1?s wheelchair in between the legs (base) of the Hoyer Lift, with the wheelchair facing CNA 1, and the back of Resident 1, away from the Hoyer Lift. The rear locks of the Hoyer Lift were observed unlocked while the resident was being lowered onto the wheelchair. When Resident 1 was observed sitting on the wheelchair facing CNA 1, the Hoyer lift fell back, slightly sideways, toward the resident. The Hoyer Lift was observed unbalanced, while CNA 1 was on the floor, holding the base of the Hoyer Lift, and CNA 2 was holding the top part of the lift, pushing the machine away from Resident 1 and back to an upright position to prevent the lift from falling on the resident.
On 8/14/17 at 9:40 a.m., during an observation and interview, CNA 2 stated the Hoyer Lift might have fallen on Resident 1 because the resident weighs more than the Hoyer Lift?s maximum weight. CNA 2 stated he thought the Hoyer Lift can hold up to 300 pounds.
On 8/14/17 at 10 a.m., during an interview, CNA 1 stated the Hoyer Lift lost balance and slightly fell over sideways on Resident 1 and CNA 2. CNA 1 stated the Hoyer Lift might have fallen because the wheelchair was not inserted all the way inside between the legs of the Hoyer Lift. CNA 1 stated CNA 2 was still trying to adjust the position of the wheelchair to be centered after the resident was lowered down to the seat of the wheelchair, but the Hoyer Lift fell. CNA 1 stated the incorrect position of the wheelchair and the resident?s weight contributed to the Hoyer Lift falling. A review of Resident 1?s Monthly Weight Record, dated 8/3/17, indicated the resident weighed 254 pounds.
On 8/14/17 at 2:47 p.m., during an interview, Restorative Nursing Assistant 1([RNA 1] trained to help in restoring resident?s mobility), stated when using a Hoyer Lift to transfer a resident, one staff member should position the wheelchair in between the legs of the Hoyer Lift. RNA 1 stated once the wheelchair was in between the legs of the Hoyer Lift, facing the machine, the wheelchair and rear wheels of the Hoyer Lift are locked while lowering the resident. RNA 1 stated the resident should be positioned facing directly in front of the Hoyer Lift machine, while on the sling. RNA 1 stated the Hoyer Lift can hold up to a maximum weight of 400 pounds.
On 9/19/17 at 1:55 p.m., during an interview, Licensed Vocational Nurse 1 (LVN 1), stated Resident 1 had fragile (delicate, vulnerable and easily damaged) skin and it was important that the Geri Sleeves are applied to the resident?s arms, and to ensure pillows are placed below the arms for support and to prevent his left arm from hitting anything. LVN 1 stated the resident?s left arm was weak, and he used his right arm to assist his left arm. LVN 1 stated she observed Resident 1?s Geri Sleeves were not physically on the resident.
A review of the undated Instruction Guide for the Hoyer Lift, indicated before lifting the resident, ensure that the lifting accessory was correctly attached to the lift, and safely applied to the resident to prevent injuries. The guide indicated to ensure that the sling?s strap loops are correctly connected to the sling bar hooks when the sling straps are stretched up before the resident is lifted from the underlying surface. The guide indicated unbalanced lifted poses a tipping risk. The guide indicated the wheels should be locked if there is a risk of the lift rolling into the resident. The guide indicated the resident should be positioned facing the lift, and that an improper lift could be uncomfortable for the user and cause damage to the lift equipment. The guide indicated the Hoyer Lift?s maximum weight capacity was 440 pounds.
A review of the facility?s Policy and Procedure, titled, ?Lifting Residents by use of Mechanical Device,? revision dated 12/2012 indicated the facility?s staff are to follow the manufacturer?s instructions for use of each specific type of lifting machine. The policy and procedure also indicated to ensure the resident was turned facing the staff and not to pull the resident backward when transferring a resident from a bed to a chair.
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 plan of care and the Interdisciplinary Team?s ([IDT] professional staff who makes decisions about a resident?s care) in using Geri Sleeves (breathable cotton-blend that protects against skin irritation and injury).
3. Failure to follow the facility?s policy and the manufacture?s guidelines for safe technique in using the Hoyer lift (an assistive medical device used to transfer from a bed to a wheelchair, toilet, or chair).
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. |
| 940000019 |
WHITTIER HILLS HEALTH CARE CENTER |
940013625 |
B |
16-Nov-17 |
FDER11 |
32399 |
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
F441
?483.80 Infection Control
The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.
?483.80(a) Infection prevention and control program.
The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements:
(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to ?483.70(e) and following accepted national standards;
The Department received a complaint on 7/27/17 that included several allegations, one that alleged a resident (Resident 1) had a rash for months with intense itching that have not subsided, that was later diagnosed as scabies.
An announced complaint investigation was conducted on 8/4/17.
Based on observation, interview, and record review, the facility failed to:
1.Follow its policy policies and procedures and/or the Public Health Department's (PHD) Policy/Guidelines, regarding the management and prevention of suspected scabies outbreak (a contagious skin infestation by the mite Sarcoptes Scabiei, resulting in severe itchiness), for Residents 1, 2, 3, 4, and 5.
2. The facility failed to report the scabies outbreak to the PHD and perform environmental cleaning of the symptomatic resident's room or affected areas;
3. The Infection Control Preventionist ([ICN] Director of Staff Development) failed to initially provide a line listing (a table that summarizes information about investigations of outbreaks) of health care workers (HCW), and symptomatic residents with their contacts.
This deficient practice resulted in the residents complaining of ongoing rashes with severe itching for months, without surveillance and tracking to prevent the spread of the infection and had the potential to affect more residents, staff, and visitors, from cross-contamination.
a. A review of Resident 1's Admission Face Sheet indicated the resident was a86 year-old female who was originally admitted to the facility on 3/1/14, and readmitted on 12/30/16. Resident 1's diagnoses included hemiplegia and hemiparesis (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles), and contracture (a permanent shortening and hardening of a muscle or joint) of the right ankle and right knee.
A review of Resident 1's Minimum Data Set (MDS), a resident assessment and care-screening tool, dated 7/30/17, indicated Resident 1 was not able to report the correct year, month, and day of the week. According to the MDS, Resident 1 required extensive assistance (resident involved in activity, with staff providing weight-bearing support) from one staff with physical assistance for personal hygiene and toilet use. The MDS indicated Resident 1 had impairment to one side of the upper and lower extremity, and was always incontinent (insufficient or involuntary control over urination or defecation) of bowel and bladder.
A review of Resident 1's "Licensed Nurse (LN)-Skin Ulcer Non-Pressure Weekly" record, dated 6/5/17, and timed at 10:05 a.m., indicated the Treatment Nurse (TN) documented that the resident had a multiple, scattered skin irritation to the upper back, and was diagnosed with moisture associated skin damage ([MASD], an inflammation of the skin, caused by prolonged exposure to various sources of moisture). The TN described the wound bed as intact, flat, scattered, and slightly pinkish in color. The record indicated the TN documented, "skin irritation to the upper back," with diagnosis of MASD, on 6/12/17 at 3:10 p.m., and 6/26/17 at 2:18 p.m.
A review of Resident 1's Treatment Administration Record (TAR), for June 2017, indicated the resident received Triamcinolone Cream (a medication used to treat skin conditions by reducing the swelling, itching, and redness), 0.1%, applied to the upper back topically three times a day, for scattered, itchy red bumps, for 14 days, from 6/7/17 to 6/21/17. The TAR indicated Resident 1 received Zinc Oxide (a topical medication that provides a skin barrier to prevent and help heal skin irritation) ointment and Nystatin (a medication used to treat fungal infections) powder for MASD, to the left inner groin, left gluteal fold redness, left lateral thigh with multiple scattered redness, and right inner groin, daily, from 6/23/17 to 6/30/17.
A review of Resident 1's Care Plan titled, "Potential/actual impairment to skin integrity related to fragile skin," dated 6/23/17, indicated staff interventions to identify and document potential causative factors, eliminate, and resolve where possible.
A review of Resident 1's Nursing Progress Note, dated 7/1/17 and timed at 9:41 p.m., indicated the resident's responsible party (RP), expressed concerns to the facility regarding the resident's scattered redness on the skin with ongoing itching and ineffective treatment to resolve the rash.
A review of a Nursing Progress Note, dated 7/9/17 and timed at 2:42 p.m., indicated the RP complained again that Resident 1 was complaining of itching. The RP was requesting medication to relieve the resident's itching.
A review of Resident 1's "LN-Skin Ulcer Non-Pressure Weekly" record, dated 7/3/17 and timed at 8:36 a.m., indicated the Treatment Nurse (TN) documented that the resident had intact, multiple, scattered redness to the left and right inner groin, extending to the left gluteal fold, diagnosed as MASD.
A review of Resident 1's Physician Order, dated 7/9/17 and timed at 3:19 p.m., indicated to administer Ivermectin (an oral anti-parasitic medication), tablet, 12 mg, via GT, one time for prophylaxis (action taken to prevent disease) of scabies. Also, prescribed was Permethrin Cream ([Elimite] an anti-parasitic topical cream medication used for treatment of scabies), 5 %, applied to the neck topically in the morning every Monday for itching, for one week [sic], and shower eight to 12 minutes after the application [sic].
A review of Resident 1's "LN-Skin Ulcer Non-Pressure Weekly" record, dated 7/10/17 and timed at 10:46 a.m., indicated the TN documented the resident had left and right inner groin dermatitis, extending to the gluteal fold. The record indicated the TN identified "generalized body dermatitis (inflammation of the skin)" to the resident's left lateral thigh, left posterior knee, and trunk (the torso, or central part of the body), still indicating the wound was MASD. The record indicated the TN described the wound as, "multiple areas of erythema (redness), confluent (together) along sites, few dried papules (small, raised, tender bump on the skin) and vesicles-Millaria Rubia (rashes with or small, red bumps, caused by blockage of the sweat glands)." The record indicated Resident 1 received Claritin (medication used to treat allergy symptoms), and the first treatment of Permethrin Cream, and Ivermectin, as prophylactic treatment.
A review of Resident 1's TAR, for July 2017, indicated the resident received Miconazole Nitrate (medication used to treat fungal infections), 2% powder and Nystatin powder twice a day, for "generalized body dermatitis" to the resident's left lateral thigh, left posterior knee, and trunk (the torso, or central part of the body) of the body, from 7/5/17 to 7/17/17.The TAR indicated Resident 1 received Lotrisone (medication used to treat inflamed fungal skin infections) cream that was applied to multiple scattered skin redness to the resident's left lateral thigh, and right inner groin extending to the redness of the left gluteal fold, twice a day, for diagnosis of MASD.
A review of Resident 1's undated "Surveillance Data Collection Form," indicated the resident had an itchy rash, and was treated with Ivermectin, 12 milligrams (mg), via gastrostomy tube ([G-Tube], a tube inserted through the abdomen that delivers nutrition/water directly to the stomach), one time, for prophylaxis scabies treatment. The form indicated Permethrin Cream, five (5) percent (%), was ordered topically for prophylaxis treatment. The form indicated "N/A" was documented for the category "Isolation/Precaution."
A review of Resident 1's Medication Administration Record (MAR), for July 2017, indicated the resident received Claritin, 10 mg orally, every day for itching, from 7/10/17 to 7/31/17.
A review of Resident 1's Physician Order, dated 7/16/17, and timed at 2:07 p.m., indicated to apply 5 % Permethrin Cream, from the neck to the toes topically at bedtime for itching on 7/16/17, at 11:59 p.m., and shower on 7/17/17 at 9 a.m.
A review of photographs of Resident 1's shoulder (taken on 7/9/17 at 11:15 a.m.), face (taken on 7/2/17 at 11:12 a.m.), left thigh (taken 6/28/17 at 6:57 p.m.), and hand (taken 7/6/17 at 9:52 a.m.), indicated there was small pinpoint, raised, and circular redness. The photograph indicated the resident's left thigh had small, raised redness, in a linear form with the posterior thigh with patches of redness, with white, dried and crusted skin areas.
A review of an online article titled, "Scabies Frequently Asked Questions," by the Center for Disease Control (CDC), dated 11/2/10, indicated the most common signs and symptoms of scabies was intense itching and a pimple-like itchy rash. The article indicated itching and rash may affect much of the body, but was commonly seen in the wrist, elbows, armpit, knee, breast, in between the fingers, and shoulder blades. The article indicated scratching could cause skin sores and pending infections. https://www.cdc.gov/parasites/scabies/gen_info/faqs.html
b. A review of Resident 2's Admission Face Sheet indicated the resident was a 75 year-old male who was originally admitted to the facility on 4/27/14, and readmitted on 7/21/17. Resident 2's diagnoses included spondylopathy (disorders of the small bones forming the backbone or spine) and osteomyelitis (inflammation of the bone caused by infection).
A review of Resident 2's MDS, dated 5/4/17, indicated Resident 2 was able to report the correct year, month, and day of the week. The MDS indicated Resident 2 required an extensive assistance of one-person physical assistance for bed mobility, personal hygiene, and toilet use.
A review of Resident 2's Care Plan titled, "Potential/Actual impairment to skin integrity, related to multiple scratches in the upper chest," dated 4/28/17, indicated the staff's interventions to monitor and document the location, size, and treatment of the skin injury. The Care Plan indicated interventions to identify and document potential causative factors and eliminate and resolve where possible.
A review of Resident 2's undated Surveillance Data Collection Form indicated the resident had an onset of symptoms on 7/10/17, and Permethrin Cream 1 % was initially prescribed by the physician, but was discontinued thereafter. The form indicated Resident 2's criteria for scabies was not documented.
A review of Resident 2's MAR, for July 2017, indicated on 7/10/17 at 2:32 p.m., the resident had an order to receive an application of Permethrin Cream, 1 %, to the entire body (neck down), one time only, but was discontinued on 7/10/17 at 4:53 p.m., before applied. The MAR indicated Resident 2 did not receive Permethrin Cream.
A review of Resident 2's "LN -Skin Ulcer Non-Pressure Weekly record," dated 7/21/17, timed at 2:46 p.m., indicated the resident had "generalized body skin dryness," that was an MASD.
c. A review of Resident 3's Admission Face Sheet indicated the resident was an 80 year-old male who was originally admitted to the facility on 12/30/16, and readmitted on 4/18/17. Resident 3's diagnoses included difficulty walking, and generalized muscle weakness.
A review of Resident 3's MDS, dated 6/19/17, indicated Resident 3 was not able to report the correct year, month, and day of the week. The MDS indicated Resident 3 required extensive assistance from one staff with physical assistance for bed mobility, transfer, personal hygiene and toilet use. The MDS indicated Resident 3 was frequently incontinent of bowel and bladder.
A review of Resident 3's Care Plan titled, "Potential/Actual impairment to skin integrity, related to generalized body skin rash," dated 6/4/17, indicated the staff's interventions to identify and document potential causative factors and eliminate and resolve where possible.
A review of Resident 3's "LN (Licensed Nurse)-Skin Ulcer Non-Pressure Weekly" record, indicated the resident had an onset of "generalized body skin rash," on 6/4/17, with treatment to cleanse with Normal Saline Solution ([NSS], a sterile mixture of salt and water), pat dry, apply antifungal powder daily, and leave open to air for 14 days on the following dates:
1. 6/4/17 at 1:44 p.m.
2. 6/10/17 at 3:04 p.m.
3. 6/16/17 at 12:35 p.m.
4. 6/24/17 at 11:52 a.m.
A review of Resident 3's "LN-Skin Ulcer Non-Pressure Weekly" record, dated 6/16/17 at 12:35 p.m., and 6/24/17 at 11:52 a.m., indicated the resident's rash was "mostly around upper back," and was described as "intact, and scattered papule (small, raised, tender bump on the skin) with normal skin color."
A review of Resident 3's Care Plan titled, "Has rash generalized body rash," dated 7/10/17, indicated interventions to monitor skin rashes for increased spread or signs of infection.
A review of Resident 3's "LN-Skin Ulcer Non-Pressure Weekly" record, indicated the resident had an onset of "generalized body skin irritation," on 6/4/17, described as MASD. The record indicated treatment to apply an antifungal cream (2% Miconazole Nitrate), twice a day, for 21 days, for the generalized body skin irritation on the following dates:
1. 7/7/17 at 10:05 a.m.
2. 7/13/17 at 4:50 p.m.
3. 7/21/17 at 2:25 p.m.
A review of Resident 3's "LN (Licensed Nurse)-Skin Ulcer Non-Pressure Weekly" record, dated 7/21/17 at 2:25 p.m., indicated the resident's skin was "intact, with multiple scattered, slightly raised and pinkish/reddish in color." The record indicated Resident 3 always laid flat on his right side, causing more large areas of redness.
A review of Resident 3's Physician Order, dated 7/7/17 and timed at 9:53 a.m., indicated to apply an antifungal cream (2% Miconazole Nitrate), twice a day, for 21 days, for generalized body skin irritation.
A review of Resident 3's Physician Order, dated 7/10/17 at 2:24 p.m., indicated to apply Permethrin Cream 1% once to the resident's entire body (neck down), leave on for eight to 12 hours, and shower off in the morning, on 7/11/17 at 11:59 p.m.
A review of Resident 3's Physician Order, dated 7/10/17, timed at 2:27 p.m., indicated to place the resident on isolation precautions for 24 hours, due to skin rash.
A review of Resident 3's Physician Order, dated 7/10/17, timed at 4:59 p.m., indicated Permethrin Cream was discontinued per pharmacy.
A review of the facility's census, print dated 7/11/17 and 7/12/17 (current residents for 7/10/17 and 7/11/17, per DON), indicated Resident 3 continued to share the room with Residents 4 and 9, and was not placed in an individual room during treatment of scabies, as per the facility's policy and PHD guidelines for isolation precaution.
A review of Resident 3's Physician Order, dated 7/24/17 at 10:52 a.m., indicated to apply Permethrin Cream, from the neck to the feet, and wash off in eight to 12 hours.
A review of Resident 3's Physician Order, dated 7/25/17 at 4:28 p.m., indicated to apply Permethrin Cream 0.05 %, every evening shift, from the neck to the feet, and shower in the morning for rash prophylaxis.
A review of Resident 3's General Acute Care Hospital (GACH) records from the dermatologist (a medical practitioner qualified to diagnose and treat skin disorders), dated 7/24/17 at 10:15 a.m., indicated the resident had a rash on his body for two months. The record indicated the resident had "pink, inflamed papules and excoriations (superficial skin abrasions, due to scratching of the skin) on the scalp, neck, trunk, and extremities." The record indicated the plan was to assess the skin for "scabies versus contact versus drug." The record indicated Resident 3's scabies skin scraping was negative, but to apply Permethrin Cream to the resident on 7/24/17 at night, wash off cream in the morning, and wash all linens and clothing in the morning.
A review of Resident 3's undated Surveillance Data Collection Form indicated the resident received Permethrin Cream 1 %, on 7/25/17, for prophylaxis treatment, but did not meet the scabies criteria. The form did not indicate Resident 3's onset date of the skin symptom and the criteria for scabies was not documented for surveillance and tracking.
d. A review of Resident 4's Admission Face Sheet indicated the resident was a 69 year-old male who was admitted to the facility on 3/10/10. Resident 4's diagnoses included generalized muscle weakness, and cirrhosis (chronic liver damage from various causes that lead to scarring and liver failure) of the liver. Resident 4 was the roommate to both Residents 3 and 9.
A review of Resident 4's MDS, dated 6/28/17, indicated Resident 4 was able to report the correct year, month, and day of the week, with memory intact. The MDS indicated Resident 3 required extensive assistance from one staff with physical assistance for bed mobility, transfer, personal hygiene and toilet use. The MDS indicated Resident 3 was always continent of bowel and bladder.
A review of Resident 4's Physician Progress Notes, dated 7/10/17, indicated the resident had "dry, scaly, macules (a flat, distinct, discolored patch of skin)? around the bilateral elbows, and excoriated/scabbed scattered forearms. The note indicated the resident had been itching/scratching from possible liver disease, dry skin, or scabies.
A review of Resident 4's "Surveillance Data Collection Form," dated 7/10/17 at 5:30 p.m., indicated the resident had an onset date of symptoms on 7/10/17. The form indicated the resident had an itchy maculopapular rash (a flat or raised red bump on the skin), with a physician's diagnosis, that met the criteria for suspected scabies. The form indicated the resident would be placed on contact isolation precautions for 24 hours, until the skin treatment was completed. The form indicated the ICN recommended skin scraping to the physician, but the physician told the ICN, "no need."
A review of Resident 4's Progress Note, written by the ICN, dated 7/11/17 at 8 a.m., indicated the resident had itchy rashes with dry macules around both elbows and forearms. The note indicated the resident was placed on contact isolation precautions until the treatment was completed.
A review of the facility's Census, print dated 7/11/17 and 7/12/17 (current residents for 7/10/17 and 7/11/17, per DON), indicated Resident 4 shared the room with Residents 3 and 9, and was not placed in an individual room for isolation precautions, as per the facility's policy.
A review of Resident 4's MAR, for July 2017, indicated the resident received Permethrin cream 5 %, to the entire body (from the neck down), on 7/11/17 at 12:20 a.m.
On 10/10/17 at 4 p.m., during a telephone interview, the DON stated she could not find Resident 4's "LN-Skin Ulcer Non-Pressure Weekly" record, documented by the treatment nurse, for the month of July 2017. The DON stated the resident's rashes was only documented on the nurse's progress note and were not tracked as part of the facility's surveillance.
e. A review of Resident 5's Admission Face Sheet indicated the resident was a 75 year-old female who was admitted to the facility on 6/16/17. Resident 5's diagnoses included spinal stenosis (narrowing of the spaces within the spine), lack of coordination, and difficulty in walking.
A review of Resident 5's MDS, dated 6/23/17, indicated Resident 5 was not able to report the correct year, month, and day of the week. The MDS indicated Resident 5 required extensive assistance from two or more staff with physical assistance for bed mobility and toilet use. The MDS indicated Resident 5 was frequently incontinent of bowel.
A review of Resident 5's Care Plan titled, "Has rash to the right upper arm, related to contact dermatitis/skin irritation," dated 7/13/17, indicated interventions to monitor the resident's skin rashes for increased spread or signs of infection.
A review of Resident 5's MAR, for July 2017, indicated the resident received Triamcinolone cream, 0.1 %, twice a day, for 14 days, for left thigh and right upper arm skin irritation, from 7/14/17 to 7/27/17.
A review of Resident 5's "LN-Skin Ulcer Non-Pressure Weekly" record, dated 7/21/17 at 11:41 a.m., indicated the resident had "right upper skin irritation," and "left thigh skin irritation," described as "intact and spot/round, slightly raised with normal skin color." The record indicated Resident 5's skin condition was described as MASD, with treatment to apply Triamcinolone cream, 0.1 %, and to leave open to air for 14 days, twice a day.
A review of Resident 5's "Surveillance Data Collection Form," dated 8/2/17, indicated the resident's onset date of symptoms was on 8/1/17. The form indicated the criteria for scabies was not documented, and on 8/2/17, Permethrin cream was applied to the resident for prophylaxis. The form indicated Resident 5 was not placed on isolation precautions, per physician.
A review of Resident 5's MAR, for August 2017, indicated the resident received Permethrin cream, 0.05 %, applied from the resident's neck down to the feet, at bedtime, on 8/2/17 and 8/3/17.
On 8/4/17 at 10:43 a.m., during an interview and observation of Resident 5's skin assessment, accompanied by Certified Nursing Assistant 1 (CNA 1), the resident was observed scratching her breast. Resident 5 was observed with scattered clusters of small, red, circular, raised bumps to the left thigh, both breast, bilateral upper and lower extremities (with more on the left than right leg), back, and bilateral underarms. The small, red, circular, raised bumps were linear underneath the left thigh. Resident 5 stated she had more rashes on her right arm and noticed the rashes developed when she was admitted to the facility approximately two weeks prior. Resident 5 stated she had been complaining of severe itching (day and night), especially on her breast and underarms. Resident 5 stated sometimes she would leave the facility out on pass with her family to the family's house. Resident 5 was a roommate with Resident 11. There were no isolation precautions for Resident 5. |