| 230000284 |
Yuba Skilled Nursing Center |
230009241 |
B |
24-May-12 |
ZDTM11 |
1937 |
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. Based on interview and record review, the facility failed to report two abuse allegations made by two residents to the Department within 24 hours. Resident 1 was a 75 year old female admitted to the facility on 4/27/11 for rehabilitation for muscle weakness following acute hospitalization. Additional diagnoses included diabetes, depression, and Alzheimer's Disease. Resident 1's minimum data set (MDS - a standardized assessment tool), dated 10/5/11, noted that Resident 1 had no problem making herself understood or understanding others. She required the maximum assistance of one to two people to transfer out of bed, bathe, and dress herself, and used a wheelchair for mobility.The facility failed to report an allegation of abuse made by Resident 1 to the Licensed Nurse (LN) D on 5/28/11 and again to the social worker (SW3) on 5/31/11. Resident 1 complained that Certified Nursing Assistant (CNA) A "wiped too hard" during peri care (bathing of the perineum) on 5/27/11 at 7 pm. She claimed she told the CNA to stop cleaning, but the CNA continued rubbing the resident's perineum making the resident angry. On 4/16/12 at 11:45 am, SW3 was interviewed and stated that she had been informed on 5/31/12 of the abuse allegation by Resident 1. She acknowledged that she had not notified the Department. During an interview on 4/16/12 at 4:50 pm, LN D stated that Resident 1 informed her about the alleged incidence of abuse on 5/28/11. LN D also confirmed that she had not reported the abuse allegation to the Department.The facility failed to report two abuse allegation made by two residents to the Department. This violation had a direct relationship to the health, safety, or security of Residents 1 and 2. |
| 230000284 |
Yuba Skilled Nursing Center |
230009276 |
B |
24-May-12 |
ZDTM11 |
1837 |
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. Based on interview and record review, the facility failed to report two abuse allegations made by two residents to the Department within 24 hours. Resident 2 was a 62 year old female readmitted to the facility on 3/6/12 following hospitalization for a urinary tract infection and kidney failure. Additional diagnoses included diabetes, anxiety, morbid obesity, and asthma. Resident 2's minimum data set (MDS - a standardized assessment tool), dated 2/3/12, noted that Resident 2 was alert and oriented to person, place, time, and situation. She required the maximum assistance of two people to turn and position herself in bed, bathe, and dress herself. She refused to walk or be out of bed the majority of time.The facility failed to report an allegation of abuse made by Resident 2 to the assistant director of nurses (ADON) on 3/16/12. Resident 2 claimed the alleged abuse occurred two days after she was admitted on 3/6/12. Resident 2 complained that a male resident wheeled himself into her room, put his hands under her blanket, and touched her private area.On 4/17/12 at 8:15 am, SW3 was interviewed and stated that she was informed of the abuse allegation by Resident 2 on 3/16/12. After an internal investigation by SW3 and ADON, the facility's decision was made that since the allegation was not substantiated, it was not reportable. She acknowledged that she had not reported the alleged abuse to the Department. The facility failed to report two abuse allegation made by two residents to the Department. This violation had a direct relationship to the health, safety, or security of Residents 1 and 2. |
| 230000284 |
Yuba Skilled Nursing Center |
230009466 |
B |
24-Jan-14 |
WWV811 |
8294 |
F 282 483.20(k)(3)(ii) SERVICES BY QUALIFIED PERSONS/PER CARE PLAN The services provided or arranged by the facility must be provided by qualified persons in accordance with each resident's written plan of care. The facility failed to provide wound assessment and treatment from December 2011 to March 2012, as ordered by the physician and indicated in the plan of care, for one of 13 sampled Residents (Resident 16). Failure to wound assessments and treatments resulted in the development of infection to Resident 16's left thigh wound.Resident 16 was admitted to the facility on 11/29/11, following surgical repair of a fractured left distal femur (upper leg bone close to the knee) and diabetes (affects wound healing).On 8/16/12, Resident 16's admitting physicians wound care orders, dated 11/29/11, included, "Bruising to incision area. Monitor Incision to (26 cm [centimeters]) Lt (left) femur q (every) shift. Apply Betadine, cover c (with) dry dsg (dressing) then put ABD (army battle dressing; large absorbent pad) pad."Resident 16's November 2011 Treatment Administration Records (TARs) revealed that the admitting physician's 11/29/11 wound care orders were transcribed incorrectly as follows: "Clean Incision (26 cm) to left femur with Betadine, cover c dry dsg and put ABD pad over it q day (not every shift as ordered); and "Monitor bruising to incision site, Lt femur every q 3rd day until resolved." (Incision was ordered monitored each shift, bruise to "right" thigh was to be monitored every 3 days). Resident 16's December 2011 TARs revealed that the 11/29/11 order to monitor her incision was incorrectly transcribed again as follows: "Monitor bruising to incision site Q 3rd day for s/s (signs and symptoms) of infection."There were no documented nursing staff initials on 12/5, 12/19, 12/25, 12/26, 12/27, 12/28, 12/29, 12/30, or 12/31/12 to indicate that the incision was cleansed with Betadine and/or covered with the ABD.Resident 16's record included two different physician's telephone orders, dated 12/8/11. The first read, "D/C (discontinue) Staples, apply benzoin (enables sticking of steristrip bandages), steristrips; keep area dry and clean, monitor QSH (every shift) for s/s of infection." An adjacent notation read D/C 12/8/11 (discontinue the order). The second physician's telephone order, dated 12/8/11, read, "Monitor incision site QSH for s/s of infection." A third physician's telephone order, dated 12/31/11, read, "Apply steristrip now & prn (as needed) to Lt surgical site to thigh. Monitor Q shift for s/s of infection." Resident 16's record included an additional handwritten December 2011 TAR showed the PM (afternoon) shift for 12/16/11 and the AM (morning) shifts for 12/19 and 12/31/11 were not initialed by a licensed nurse to show that the wound had been kept clean and dry and monitored for s/s of infection. There was no documentation to show that the steristrips were checked or changed between 12/8 and 12/31/11 (for 23 days).The original admitting physician's wound care orders, dated 11/29/11, had handwritten notations of "D/C 12/30/11" written alongside them, although no physicians orders were found to discontinue the original 11/29/11 wound care orders.On 8/16/12 at 1 pm, the facility was not able to provide TARs to demonstrate documented monitoring or wound care to Resident 16's incision from 12/31/11 to 1/5/12 (5 days). Medical Records Director (MRD) stated that there was no documentation of monitoring or treatment to Resident 16's incision between 12/31/11 and 1/5/12 and could not confirm the physician's orders had been implemented.Resident 16's record included a Doctor's Progress Note, dated 1/5/12, that revealed the facility had called Resident 16's surgeon to report drainage from her surgical incision. The note showed that she was brought to the office very somnolent (sleepy), with slurred speech, and requiring maximum assistance for transfer, with no family or facility staff accompaniment. The note revealed that Resident 16 was diagnosed with an infection in her surgical incision to her left thigh, with purulence (thick pus) in the incision. The wound was scrubbed, surgically prepped, re-incised (cut open), cultured (CX, specimens obtained for lab testing) for infection, irrigated, packed, and dressed.Resident 16's orthopedic surgeon's orders, dated 1/5/12, changed her antibiotics for the incisional infection and issued new wound care orders that read, "Wound care to left leg: Change dressing daily: removed packing-irrigate wound c 100-200 cc (cubic centimeters/millimeters) of normal saline-pack c Betadine (antiseptic)/NS (normal saline) damp 1" (inch) Kerlix (bandage used for packing wound) or plain packing strip-cover c 4 x 4 (gauze pad) and ABD."Resident 16's January 2012 TARs included the new 1/5/12 wound care orders. The boxes for 1/8 and 1/9/12 were not initialed by licensed staff to show the wound care was done daily, as ordered by the surgeon.Following discharge from the acute care hospital on 1/18/12, Resident 16's physician ordered wound care BID (twice daily) to her left thigh as follows: Irrigate wound with sterile water; Wet to dry dressing twice daily; Follow up with orthopedic surgeon in 2 weeks. There was also an order, dated 1/18/12, to monitor her left thigh (incision site) BID for s/s of infection.Resident 16's January 2012 TARs included the 1/18/12 BID orders to irrigate and dress the wound. There were no initials by licensed staff to show the wound care was done for the AM shift on 1/19, 1/29, 1/31 nor during the PM shift on 1/20, 1/21, and 1/28/12. The 1/18/12 order to monitor her incision BID for s/s of infection was not initialed as completed on 1/19, 1/29, 1/30, and 1/31/12 during the AM shift; or on 1/27 and 1/28/12 during the PM shift.Resident 16's February 2012 TARs included the 1/18/12 wound care orders, incorrectly transcribed as follows: "Apply Q 2 days wound care BID to left thigh. Irrigate wound w (with) sterile water set to dry dressing." There were no initials to show the wound care was done during the AM shift on 2/2, 2/12, 2/14, and 2/28/12 or during the PM shift on 2/2, 2/22, and 2/23/12. The 1/18/12 orders to monitor the incision were incorrectly transcribed to the February 2012 TARs as follows: "Monitor daily. Wound on left thigh BID for s/s of infection." There were no initials by licensed staff to show that the wound was monitored for s/s of infection during the AM shift on 2/2, 2/12, or 2/29/12 (3 times); or during the PM shift between 2/2 and 2/29/12 (28 days/times).Resident 16's March 2012 TARs included the same incorrectly transcribed orders for wound care and s/s of infection monitoring as that of February 2012. There were no initials documented by licensed staff to indicate that the wound care was done during the AM shift on 3/1/12 or during the PM shift on 3/2 and 3/3/12. There were no documented licensed staff initials to show the incision was monitored for s/s of infection during the AM shift on 3/1/12 or all PM shifts from 3/1 to 3/6/12. The wound orders were discontinued on 3/7/12.On 8/16/12 at 12:10 pm, during a concurrent record review and interview, the Director of Nursing (DON) stated that Resident 16's wound had become infected by 1/5/12. The DON confirmed that Resident 16's Weekly Body Audit, dated 12/27/11 (one week prior to infection) indicated a healed incision was an inaccurate assessment and that the incision was not healed. The DON was not able to explain the repeated transcription errors of the physicians orders for Resident 16's incision care or why the orders were not implemented. She was not able to explain why Resident 16's incisional wound care orders on her TARs for December 2011 and January/February/March 2012 were not initialed as done by licensed staff and could not confirm that the physician's orders and plan of care were implemented.Therefore, the facility failed to provide wound assessment and treatment from December 2011 to March 2012, as ordered by the physician and indicated in the plan of care, for one of 13 sampled Residents (Resident 16). Failure to wound assessments and treatments resulted in the development of infection to Resident 16's left thigh wound.This violation had a direct relationship to the health, safety, and security of patients. |
| 230000284 |
Yuba Skilled Nursing Center |
230009805 |
B |
31-Jan-14 |
WWV812 |
3612 |
F 314 483.25(c) TREATMENT/SVCS TO PREVENT/HEAL PRESSURE SORES Based on the comprehensive assessment of a resident, the facility must ensure that a resident who enters the facility without pressure sores does not develop pressure sores unless the individual's clinical condition demonstrates that they were unavoidable; and a resident having pressure sores receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing. A resident having pressure sores receives the necessary treatment and services to promote healing, prevent infection and prevent new sores from developing. The facility failed to prevent the avoidable worsening of a pressure sore for one of 12 sampled Patients (Patient 9) when a physician ordered treatment and a special bed were not provided. This failure had the potential to cause the Patient 9 pain and infection and prevent the patient from reaching his highest practicable level of physical and emotional well-being. Patient 9 was admitted to the facility on 2/12/13 with diagnoses that included diabetes, anemia, weakness, and a pressure sore to the left heel. On 3/19/13, Patient 9's record was reviewed. The "Nursing History and Admission Notes," an assessment form, dated 2/12/13, reflected that Patient 9 was admitted with a pressure sore to his left heel that measured 2.0 by 1.5cm (centimeters, there are 2.5cm in one inch). The nursing assessment described the pressure sore as "eschar tissue," a dark brown or blackish area of dead tissue. On 2/12/13, Patient 9's physician ordered, "LAL Mattress (low air loss/air mattress that reduces pressure) " and "Float heels with pillows while in bed." (A pillow placed under the lower legs to elevate the heels off the mattress). "Patient 9's nursing notes contained documentation on 2/12/13 that indicated, "LAL mattress will be applied." Patient 9's Treatment Administration Record directed, "LAL mattress float heels with pillows while in bed," was documented as "FYI" (for your information only.Patient 9's "Wound/Skin Healing Record" reflected that on 2/12/13, the left heel pressure sore measured 2.0 by 1.5cm and one month later on 3/14/13, the pressure sore had increased in size to 3.5 by 4cm. On 3/20/13 at 8 am, Patient 9 was observed with Certified Nursing Assistant (CNA) A, lying in his bed with his heels directly on the mattress and not floated. Patient 9 was lying on a regular bed mattress, not the LAL mattress that his physician had ordered a month ago on 2/12/13. CNA A confirmed that Patient 9's heels were not floated and that he was not on a LAL mattress.On 3/20/13 at 11:30 am, an interview was conducted with the Registered Nurse Supervisor (RNS). The RNS confirmed that Patient 9 had a physician ordered treatment to float his heels on pillows while in bed and for a LAL mattress since 2/12/13, and those services had not been provided. The RNS confirmed that Patient 9's pressure sore to his left heel had worsened, as evidenced by the increased size, which could have been avoided had the facility implemented the physician ordered treatment and applied the LAL mattress. Therefore, the facility failed to prevent the avoidable worsening of a pressure sore for one of 12 sampled Patients (Patient 9) when a physician ordered treatment and a special bed were not provided. This failure had the potential to cause the Patient 9 pain and infection and prevent the patient from reaching his highest practicable level of physical and emotional well-being. This failure had a direct or immediate relationship to the health, safety, or security of patients. |
| 230000284 |
Yuba Skilled Nursing Center |
230010434 |
B |
07-Feb-14 |
WWV811 |
9986 |
F327 CFR 483.25(j) Hydration: The facility must provide each resident with sufficient fluid intake to maintain proper hydration and health.The facility failed to implement its Hydration/Dehydration assessment and care policies by failing to provide one of 13 sampled residents (Resident 4) with sufficient fluid intake to maintain proper hydration (adequate intake of fluids), monitor fluid intake and output, and identify and treat signs/symptoms of dehydration, to prevent dehydration (a significant shortage of body fluid). These failures resulted in Resident 4 requiring evaluation and treatment at an acute care hospital where Resident 4 was evaluated by a emergency room physician to be dehydrated, requiring extensive intravenous fluid (IVF) replacement.On 8/21/12, the facility's Resident Assessment Protocol (RAP): Dehydration/Fluid Maintenance document (undated), defined dehydration as a condition when loss of water or fluid far exceeds fluid intake and included a change in mental status and/or decreased urine output as symptoms. Consequences included a predisposition to infections, fluid and electrolyte imbalances, and ultimately death. The RAP read, "Nursing facility residents are particularly vulnerable to dehydration...identification of the most crucial symptoms of the condition are most difficult to identify among the aged...if resident cannot drink a minimum recommended 1500 cubic centimeters (cc or ml) of fluid every 24 hours." The facility's Hydration-Clinical Protocol, dated 4/07, was reviewed and showed that staff would identify individuals with signs and symptoms or abnormal labs (hypernatremia, elevated blood sodium caused by relative deficit of free water in the body and often synonymous with dehydration) that might reflect existing fluid and electrolyte imbalances (abnormalities of sodium, potassium, chloride, and other substances crucial for regulation of body functions that regulate body functions). The protocol showed the physician and staff would identify individuals at risk of dehydration and/or not eating or drinking well, and provide fluids.The facility's Resident Hydration and Prevention of Dehydration policy, dated 4/07, was reviewed. The policy showed that to prevent dehydration, nursing would assess for signs and symptoms of dehydration daily, nurse aides would provide and encourage intake of fluids, document intake in the medical records, and report intake of less than 1200 milliliters (ml) daily to nursing staff. The policy indicated that if potential inadequate intake and/or signs and symptoms of dehydration were observed, intake and output (I/Os) would be monitored and care planned, nursing would monitor and document fluid intake, and physicians would be notified.Resident 4 was admitted to the facility on 12/30/11 following gall bladder removal surgery on 12/27/11. His diagnoses included urinary retention (difficulty emptying bladder), high blood pressure, and chronic kidney disease (decreased ability for kidneys to filter wastes and excess water out of blood to make urine).Review of Resident 4's indwelling Urinary Catheter (FC, Foley catheter tube drains urine from bladder) care plan, dated 1/2/12, showed his I/Os would be monitored for 30 days.Resident 4's Bowel Function care plan, dated 12/31/11, showed nursing would encourage him to drink fluids and monitor and record the number of bowel movements for amount and consistency.Resident 4's Registered Dietitian (RD) Nutrition Assessment, dated 1/3/12, showed he weighed 85 kilograms (kg) and had fluid needs of 2550 ml daily, with 1320 ml included in foods and 1280 ml included in additional fluids. A nurses note, dated 1/7/12 and timed 10 pm, showed that Resident 4 complained of an upset stomach and had an episode of diarrhea.Resident 4's Daily Care Flow Sheet for January 2012 showed that on 1/8/12, he refused breakfast and dinner, and had poor intake (consumed 25-50 %) of his lunch; on 1/9/12 had poor intake of breakfast, fair intake (50-75%) at lunch, and refused dinner; on 1/10/12 had fair intake at breakfast and poor intake at lunch and dinner.The facility's Intake and Output Vitals Sheets for Resident 4 showed his fluid intake as follows: 720 ml on 1/8/12; 920 ml on 1/9/12; 1140 ml on 1/10/12; and 300 ml on 1/11/12 (significantly below the estimated fluid needs of 2550 ml daily recommended by the facility's RD).His urine output showed the following: 550 ml on 1/7/12; 150 ml on 1/8/12; 400 ml on 1/9/12; 5 ml on 1/10/12, and 25 ml on 1/11/12 (minimum urine output is 1020 ml in 24 hours [hr]; 0.5 ml/kg/hr).Resident 4's Bowel Record for January 2012 showed he had diarrhea as follows: 6 loose bowel movements (BM) on 1/8/12; 16 loose BMs on 1/9/12; 16 loose BMs on 1/10/12, and 2 loose BMs on 1/11/12. (Loose BM/diarrhea poses increased risk for dehydration).On 8/22/12 at 9:15 am, Licensed Nurse (LN) A was interviewed. She stated she did not know what Resident 4's fluid intake need was, that the resident needed FC urine output of 30 ml/hr or 240 ml/8hr shift. Resident 4's I/O record for 12/31/11 to 1/13/12 was concurrently reviewed with LN A. She confirmed that the Weekly Intake & Output Evaluation section at the bottom of the form was blank and that the sections for fluid needs, average intake, average output, and signs of dehydration items were not completed. LN A confirmed they had not followed Resident 4's care plan or the facility's Resident Hydration and Prevention of Dehydration policy by monitoring his I/Os or signs of dehydration.The facility's Acute Gastrointestinal Illness Case Log showed Resident 4 was admitted to the hospital on 1/11/12, during a Norovirus outbreak (stomach flu that includes diarrhea and vomiting) that occurred between 1/5 and 1/9/12 at the facility. A nurses note entry, dated 1/11/12 and timed at 3 am, showed Resident 4's blood pressure had dropped to 57/34 (normal is 90/60 or above), his heart rate had increased to 116-120 beats per minute (normal is less than 100), and his urine output was only 25 ml. An entry at 3:50 am showed Resident 4 was sent to the emergency room. On 8/21/12, the acute care hospital's admission history and physical (H&P), dated 1/11/12, showed Resident 4 was "severely dehydrated" and "severely hypovolemic (low blood volume)" and in hypotensive shock (when organs and tissues receive inadequate flow of blood and can lead to death). Resident 4's acute care hospital emergency room records for 1/11/12 showed that he required three liters of intravenous fluid (IVF) replacement as follows: One half liter of IVF at 6 am; One liter of IVF that completed at 6:33 am; One liter of IVF that completed at 7:26 am; One half liter of IVF that completed at 9:22 am. The nurses notes for 1/11/12 showed that Resident 4 continued to show signs and symptoms of dehydration (low urine out put, low blood pressure, elevated heart rate, dry mucous membranes) and to require IVF replacement as follows: At 7:48 am, Resident 4 had zero urine output from his FC at 7:48 am; At 10:39 am, Resident 4 continued to have signs of dehydration (mucous membranes in his nose, throat, and mouth were dry); At 11:10 am, Resident 4 received a fifth liter of IVF; At 12:06 pm, Resident 4's urine output continued to be low at 90 ml since 10:30 am; At 12:13 pm, the resident had low blood pressure at 85/33; At 2:03 pm, the resident required a sixth liter of IVF; At 2:20 pm, the resident continued to show signs of dehydration (mucous membranes were dry, his heart rate was fast, and his FC output was minimal); Resident 4 received approximately one and one half liter of additional IVF in medication solutions administered. On 1/11/12 at 9:46 am, an emergency room physician's orders showed Resident 4 would be admitted to the hospital's intensive care unit for further treatment.On 8/21/12 at 3:30 pm, Resident 4's nurse notes from 1/8 to 1/10/12 were reviewed concurrently with the Director of Nursing (DON) and compared with Resident 4's Activities of Daily Living charting (ADL, includes Daily Care Flowsheets, Intake and Output Vitals Sheets, and Bowel Records) for the same period. The DON confirmed that the nurses notes read, "No loose stools" and that there were no signs of dehydration identified on 1/8 and 1/9/12. The DON stated that the nurses notes charting did not make sense (accurately reflect identifiable risks and signs/symptoms of dehydration) when compared to the ADL charting.On 8/21/12 at 4:30 pm, Resident 4's Nutritional/Dehydration/Fluid Maintenance care plan, dated 1/2/12, was concurrently reviewed with the DON. She stated that it had not been completed for the dehydration. The DON stated that short term Dehydration care plans were to be done on all residents during the Norovirus outbreak, however, she was not able to locate a short term Dehydration care plan for Resident 4.On 8/21/12 at 5 pm, the DON confirmed that Resident 4's Intake and Output Record for 12/31/11 to 1/13/12 was not completed and that the Weekly Intake & Output Evaluation section at the bottom of the form was blank. She stated that nursing should have compared Resident 4's fluid needs as determined by the RD, and completed the blanks for fluid needs, average intake, average output, and signs of dehydration items, that were all left blank.Therefore, the facility failed to implement its Hydration/Dehydration assessment and care policies by failing to provide one of 13 sampled residents (Resident 4) with sufficient fluid intake to maintain proper hydration (adequate intake of fluids), monitor fluid intake and output, and identify and treat signs/symptoms of dehydration, to prevent dehydration (a significant shortage of body fluid). These failures resulted in Resident 4 requiring evaluation and treatment at an acute care hospital where Resident 4 was evaluated by a emergency room physician to be dehydrated, requiring extensive intravenous fluid (IVF) replacement.These failures had a direct relationship to the health, safety, or security of patients. |
| 230000284 |
Yuba Skilled Nursing Center |
230010435 |
B |
07-Feb-14 |
WWV811 |
9073 |
F327 CFR 483.25(j) Hydration: The facility must provide each resident with sufficient fluid intake to maintain proper hydration and health. The facility failed to implement its Hydration/Dehydration assessment and care policies by failing to provide one of 13 sampled residents (Resident 8) with sufficient fluid intake to maintain proper hydration (adequate intake of fluids), monitor fluid intake and output, and identify and treat signs/symptoms of dehydration, to prevent dehydration (a significant shortage of body fluid). These failures resulted in Resident 8 requiring evaluation and treatment at an acute care hospital where Resident 8 required treatment for altered mental status secondary to toxic metabolic encephalopathy (brain malfunction due to toxins [excess sodium and potassium]), which was secondary to hypernatremia (high sodium) and acute renal insufficiency (sudden deterioration of kidney function due to infection, dehydration, toxins, heart failure).On 8/21/12, the facility's Resident Assessment Protocol (RAP): Dehydration/Fluid Maintenance document (undated), defined dehydration as a condition when loss of water or fluid far exceeds fluid intake and included a change on mental status and/or decreased urine output as symptoms. Consequences included a predisposition to infections, fluid and electrolyte imbalances, and ultimately death. The RAP read, "Nursing facility residents are particularly vulnerable to dehydration...identification of the most crucial symptoms of the condition are most difficult to identify among the aged...if resident cannot drink a minimum recommended 1500 cubic centimeters (cc or ml) of fluid every 24 hours." The facility's Hydration-Clinical Protocol, dated 4/07, was reviewed and showed that staff would identify individuals with signs an symptoms or abnormal labs (hypernatremia, elevated blood sodium caused by relative deficit of free water in the body and often synonymous with dehydration) that might reflect existing fluid and electrolyte imbalances (abnormalities of sodium, potassium, chloride, and other substances crucial for regulation of body functions that regulate body functions). The protocol showed the physician and staff would identify individuals at risk of dehydration and/or not eating or drinking well and provide fluids.The facility's Resident Hydration and Prevention of Dehydration policy, dated 4/07, was reviewed. The policy showed that to prevent dehydration, nursing would assess for signs and symptoms of dehydration daily, nurse aides would provide and encourage intake of fluids, document intake in the medical records, and report intake of less than 1200 milliliters (ml) daily to nursing staff. The policy indicated that if potential inadequate intake and/or signs and symptoms of dehydration were observed, intake and output (I/Os) would be monitored and care planned, nursing would monitor and document fluid intake, and physicians would be notified.Resident 8 was admitted to the facility on 7/31/09, with diagnoses that included Alzheimer's dementia, heart failure, and high blood pressure. The facility's Minimum Data Set (MDS-a resident assessment), dated 10/31/11, described her as having both short and long term memory problems with moderate cognitive impairment (ability to think, reason, and make decisions).Resident 8's record included a care plan for Alzheimer's Dementia, dated 11/3/10, that showed the facility would monitor her appetite and hydration. Resident 8's record included a care plan, dated 11/21/11, that had a long term goal to maintain adequate nutrition and hydration.Resident 8's December 2011 physicians orders included an order, dated 2/2/10, that read, "Encourage resident to consume 1800-2000 ml fluid daily." The list of Resident 8's diagnoses on the physicians orders did not include kidney disease.A Nutrition Progress Note, dated 8/2/11, showed Resident 8 was getting approximately 744 ml fluid in her food when eating 93%, and 1340 ml of additional fluid with her meals. There were no RD assessments found in Resident 8's chart from 8/9 to 12/20/11 to indicate that she had been evaluated (for 120 days).Resident 8's weight record showed her weight dropped from 145.6 pounds (lbs) in November 2011 to 131.2 lbs in December 2011 (14.4 lbs or 9.9% in 90 days, which is significant), indicating her intake was not adequate. There was no notation to show Resident 8's physician or the RD had been notified of her weight loss or decreased intake.On 8/23/12 at 10:40 am, Resident 8's Daily Care Flow Sheet for December 2011 showed she had poor intake for breakfast, lunch, and dinner on 12/3 and 12/4/11. Her intake for breakfast on 12/5/11 was good at 75-100%, poor at lunch and she refused dinner. On 12/6/11 she had poor intake for breakfast, good intake at lunch, and was then sent to the emergency room. Assistant Director of Nursing (ADON) B concurrently confirmed Resident 8's intake was poor on 12/3, 12/4, 12/5, and 12/6/11. Resident 8's December 2011 Daily Care Flow Sheet showed she frequently emptied her bladder; 9 times on 12/1, 7 times on 12/2, 8 times on 12/3, 8 times on 12/4, 8 times on 12/5, and 5 times on 12/6, prior to her emergency room admission.On 8/22/12 at 3:45 pm, the Medical Records Director (MRD) stated there were no Intake and Output (I/Os) records for Resident 8 and the facility was not monitoring them on her.On 8/22/12 at 4 pm, Administrative Nurse (AN) E stated the facility should have been monitoring Resident 8's I/Os and was not following her care plan. AN E confirmed that without monitoring Resident 8's I/Os, there was no way to identify her potential inadequate intake and dehydration. On 8/23/12 at 1:10 pm, facility Vitals Sheets for 12/5 and 12/6/11 were concurrently reviewed with Licensed Nurse (LN) F. Although Resident 8's vital signs were documented in the top section of the form, there were no I/O entries for Resident 8 in the bottom section titled, "Resident Intake and Output." LN F confirmed that Resident 8's I/Os were not monitored or documented on the Vitals Sheets for 12/5 and 12/6/11. LN F stated that Resident 8 had the potential for inadequate intake, I/Os should have been done, and the facility had not followed their policy.A nurses note, dated 12/5/11 and timed 5:30 am, showed Resident 8's condition was declining; respirations were rapid at 28 (normal 12-20) and that her blood oxygen saturation was low at 88% (normal 96-100%) on room air. A second nurses notes timed at 10 am showed Resident 8's heart rate was 111 and fluctuated to 120 beats per minute (normal is less than 100), her blood oxygen saturation was low at 91% on 3 liters of oxygen/minute, via nasal cannula, and that a chest X-ray was ordered.The chest X-ray report, dated 12/5/11, showed "mild" congestive heart failure.Resident 8's lab report, dated 12/6/11, showed her sodium level was high at 155 (hypernatremia, normal 136-145), her potassium was high at 5.3 (normal 3.5-5.1), and her chloride was high at 121 (normal 98-107).A nurses note on 12/6/11 at 4 pm showed that following laboratory and electrocardiogram test results, Resident 8's physician sent her to the emergency room for evaluation and treatment.On 8/22/12, Resident 8's acute care hospital admission H&P, dated 12/6/11, showed that Resident 8 was brought to the emergency room for altered mental status and abnormal laboratory test results. The H&P revealed Resident 8 was hypernatremic (high blood sodium and related to altered mental status), had a urinary tract infection, pneumonia, and rapid heart rate.On 8/22/12, Resident 8's acute care hospital discharge H&P, dated 12/11/11, showed her discharge diagnoses included altered mental status with history of Alzheimer's dementia, altered mental status secondary to toxic metabolic encephalopathy (brain malfunction due to toxins [excess sodium and potassium]), which was secondary to hypernatremia and acute renal insufficiency (sudden deterioration of kidney function due to infection, dehydration, toxins, heart failure).On 8/28/12 at 2:30 pm, the MRD confirmed that the facility had not followed their policy to document Resident 8's I/Os. Therefore, the facility failed to implement its Hydration/Dehydration assessment and care policies by failing to provide one of 13 sampled residents (Resident 8) with sufficient fluid intake to maintain proper hydration (adequate intake of fluids), monitor fluid intake and output, and identify and treat signs/symptoms of dehydration, to prevent dehydration (a significant shortage of body fluid). These failures resulted in Resident 8 requiring evaluation and treatment at an acute care hospital where Resident 8 required treatment for altered mental status secondary to toxic metabolic encephalopathy (brain malfunction due to toxins [excess sodium and potassium]), which was secondary to hypernatremia (high sodium) and acute renal insufficiency (sudden deterioration of kidney function due to infection, dehydration, toxins, heart failure).These failures had a direct relationship to the health, safety, or security of patients. |
| 230000284 |
Yuba Skilled Nursing Center |
230011172 |
B |
14-Jan-15 |
EB8W11 |
9271 |
A165 T22 DIV5 CH3 ART3-72311(a)(1)(C) Nursing Service - General(a) Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (C) Reviewing, evaluating and updating of the patient care plan as necessary by the nursing staff and other professional personnel involved in the care of the patient at least quarterly, and more often if there is a change in the patient's condition.The facility failed to ensure the services necessary to care for Patient A to prevent elopement (exiting the facility undetected, unsupervised) by failing to develop, review, re-evaluate, and update the patient's elopement plan of care to ensure sufficient, effective interventions and care to prevent elopement. Patient A was identified as an elopement risk on 3/11/13; Patient A eloped a second time on 9/15/13, and was missing for 45 minutes before facility staff realized he was gone and facility staff could not find him. Patient A was found by the local police, seven hours and fifteen minutes later, in a parking lot two miles from the facility. These failures allowed Patient A to elope undetected and placed him at risk for future elopements, to be lost/missing, and injured.Patient A, a 70 year old male, was admitted to the facility on 10/14/11 with diagnoses which included altered mental status, anxiety state, and dementia with behavior disturbance. The facility's Minimum Data Set (MDS) assessment, dated 7/15/13, indicated that Patient A's cognitive status (thought process and state of mind) was severely impaired. Patient A had a history of elopement and remained at risk for further elopement. A nurse's note, dated 8/17/13, indicated that Patient A was able to walk independently.A review of Patient A's Behavioral care plan, initiated on 1/16/13, indicated the facility identified Patient A was "anxious, short tempered, easily annoyed, walks throughout the facility, sleeps in other beds, wants to leave, does not like change, and rummages through others belongings." An update to the care plan on 3/11/13 indicated Patient A had eloped from the facility. The care planned goals for Patient A were that he would have less episodes of disruptive behaviors and motor restlessness with exit seeking, remain in the facility, and staff would be informed of Patient A's elopement risk.A review of a nurse's note, dated 9/15/13, indicated, "found eloped at 10:30 PM." A nurse's note, dated 9/16/13 and timed 5:45 am, disclosed that Patient A was returned to the facility by the local police, seven hours and fifteen minutes later. A review of the facility's Elopement Risk Assessment indicated staff were directed to reassess the patient on a significant change and include the corresponding Summary of Review section. This was not completed following Patient A's 9/15/13 elopement.One month after Patient A's 9/15/13 elopement, on 10/13/13, the facility initiated an Elopement/Wandering care plan indicating Patient A had a history of elopement, dementia, and wandering; Ambulates throughout the facility most of the day. The care plan goal included "risk for elopement will be minimized with intervention." A Wanderguard (a device placed on the patient that will alarm if the patient attempts to leave the facility) and monitor whereabouts of resident" was added to the care planned interventions. Review of a second Behavioral care plan initiated on 10/14/13 indicated that on 9/16/13, Patient A eloped a second time on 9/15/13. The care planned goals for Patient A were that he would have less episodes of disruptive behaviors and motor restlessness with exit seeking, remain in the facility, and staff would be informed of Patient A's elopement risk.A review of the facility's policy titled, "Wandering, Unsafe Resident," dated 2007, directed the staff to institute a detailed monitoring plan for high risk residents. Patient A's Behavioral and Elopement/Wandering care plans did not include a detailed monitoring plan to track Patient A's whereabouts to prevent future elopements and ensure the patient's safety, as required by facility policy.During an observation and concurrent interview with Licensed Vocational Nurse (LVN) 1 on 10/14/13 at 12:50 pm, the patio doors, opening to the facility parking lot from Rooms 305 and 306, were fully opened. LVN 1 stated that she was unable to close the doors in either room because the doors were heavy and difficult to slide. There was no evidence that the doors were equipped with an alarming device. LVN 1 stated that she knew Patient A wandered, and was known to enter other patient's rooms, including Rooms 305 and 306. LVN 1 stated that she was unable to monitor Patient A at all times. On 10/14/13 at 1:05 pm, Patient A was observed pacing continuously in his room. He was dressed in jeans, a shirt, shoes, and a jacket. A Wanderguard device was on his left ankle. When asked, Patient A had no recollection of his elopement on 9/15/13. During an interview on 10/14/13 at 1:10 pm, Registered Nurse (RN) 2 stated that she was aware of Patient A's elopement risk and that it was an ongoing problem. RN 2 stated that Patient A wandered into other resident rooms. RN 2 stated that she was aware that Patient A required observation and redirection, according to the plan of care. RN 2 stated that they did not have a staff member to watch him. During an interview on 10/14/13 at 1:14 pm, Restorative Nurse's Aide (RNA) 3 confirmed she knew that Patient A was an elopement risk, and wandered freely throughout the facility. She stated, "Our problem is the back doors. The back doors don't have the Wanderguard system." During observation on 10/14/13 at 2:05 pm, a rear service door was opened. It alarmed for a period of approximately five seconds, until the door closed. No staff responded to the alarm. During an observation and concurrent interview on 10/14/13 at 2:45 pm, the Maintenance Supervisor (MS) demonstrated the service door alarm system by opening the door without using the security code. The alarm sounded until the door closed. MS demonstrated that after the door closed, the alarm did not sound again for 15 seconds. This feature allowed the door to open without alarming, demonstrating that a person could then pass through an unalarmed door, undetected.During a 30 minute observation on 10/14/13 from 3:35 pm to 4:05 pm, Patient A was observed wandering unattended throughout the facility. During this 30 minute observation, the staff did not approach or redirect Patient A. He wandered slowly back to the nurse's station, paused at doorways and looked in. When he approached the nurse's station he was intercepted by staff and directed to his room. He complied but in less than five minutes, left his room unattended and resumed wandering.During an interview on 10/15/13 at 1:30 pm, the Director of Nurses (DON) stated that the rear doors were service doors and visitors entered the facility from the parking lot through those doors, daily. She was unable to identify if there was a specific time when the doors were locked at night. She stated visitors came late in the evening and there were no visiting guidelines directing anyone to use the main entrance. During an interview on 10/15/13 at 2 pm, Certified Nursing Assistant (CNA) 4 stated that she cared for Patient A on the evening of 9/15/13. She stated that Patient A often wandered throughout the night and at 9:45 pm, observed him fully clothed and asleep on his bed. According to the nursing notes, dated 9/15/13 at 10:30 pm, Patient A was not on his bed and was noted to be missing. CNA 4 stated she was certain that the alarm had not sounded that evening. She said that Patient A had "escaped a few times before."During an interview on 10/18/13 at 8:30 am, Registered Nurse (RN) 5 stated that she was the evening Charge Nurse responsible for Patient A's care on 9/15/13. She confirmed her awareness of Patient A's elopements, both on 9/15/13, and "the ones before." Further stating, "... three or four, I think." She stated, "We are scared he would leave by the sliding doors too. He's so fast." She stated, "So many times that he has eloped and we brought him back. We don't know how he got out. The police knew him by sight and didn't even need the picture of him." She stated that the CNA's try to keep him in sight but they do not have a staff member to watch him.The facility failed to ensure the services necessary to care for Patient A to prevent elopement (exiting the facility undetected, unsupervised) by failing to develop, review, re-evaluate, and update the patient's elopement plan of care to ensure sufficient, effective interventions and care to prevent elopement. Patient A was identified as an elopement risk on 3/11/13; Patient A eloped a second time on 9/15/13, and was missing for 45 minutes before facility staff realized he was gone and facility staff could not find him. Patient A was found by the local police, seven hours and fifteen minutes later, in a parking lot two miles from the facility. These failures allowed Patient A to elope undetected and placed him at risk for future elopements, to be lost/missing, and injured.The violation of this regulation had a direct relationship to the health, safety, or security of the patients. |
| 240000585 |
York House |
240010521 |
AA |
07-Mar-14 |
WXT711 |
13749 |
REGULATION VIOLATION: TITLE 22 76885 Food and Nutrition Services - Therapeutic Diets Therapeutic diets shall be provided as prescribed by the attending physician and shall be planned, prepared and served with supervision or consultation by the dietician. FINDINGS: On December 26, 2012 at 8:50 AM an unannounced visit was made to the facility to investigate a complaint related to Client A's death.The facility failed to ensure that the physician prescribed textured diet for ground meat consistency, and bite sized pieces was followed when preparing Client A's lunch on October 29, 2012. This failure resulted in Client A choking on her sandwich which required the staff to attempt to clear her airway using the Heimlich maneuver (an emergency procedure to help someone who is choking because food is lodged in their airway). When this intervention failed, Client A went into full cardiac arrest (no heartbeat, respirations or blood pressure) which required cardiopulmonary resuscitation (CPR- the use of chest compressions and breaths to try to restart the heart) and eventually, mechanical ventilation (a tube is placed into the throat and attached to a machine to breathe for the person) had to be implemented. Client A died on November 2, 2012 at 6:27 PM, at the general acute care hospital (GACH). The Deputy Coroner reported the cause of Client A's death as, "Hypoxic encephalopathy (a sometimes fatal deprivation of oxygen to the brain) due to choking on food."During a review of the clinical record for Client A on December 26, 2012 at 8:50 AM, it revealed that she was a 56 year old woman admitted to the facility on April 5, 1988, with diagnoses including: profound mental retardation (IQ<20); schizophrenia (a thought disorder causing hallucinations and delusions) and osteoporosis (bones become hollow making them at risk for fractures).Client A could speak a few words and feed herself with supervision (staff sat with her and gave verbal cues or physical assistance). Her behavioral plan dated November 2012, noted she was to, "Set down utensil after most every bite throughout AM/PM meals with verbal cues," due to having a behavior of, "Stuffing food which placed her at risk of choking." Client A was on a, "No added salt (NAS), high fiber, carbohydrate controlled diet(CCD), heart healthy, with diet desserts, non-fat milk, bite sized texture except for meats which are to be ground pea sized"; per physician's order, October 19, 2011.
On December 26, 2012 at 9:00 AM, during a review of the occupational therapy note dated October 11, 2012, the Occupational Therapist (OT) had documented, "This objective [to set down her spoon between bites] slightly upgraded to current level D/T (due to) meeting previous target. Intended to slow her feeding pace and prevent overstuffing mouth. If allowed to eat fast-paced, more at risk for choking D/T limited mastication (chewing) and inadequately prepared bolus (a mass of food) for swallowing. She chews food more thoroughly when she follows procedure. Non-successes are D/T need for verbal prompts and occasional physical assist."
During an interview with the facility manager (FM) on December 26, 2012 at 8:50 AM, she was asked how the facility qualified "bite sized" pieces. She stated, "Bite sized pieces have to fit in a teaspoon. [Client A] could feed herself but she could stuff food, and had behavior plan for that."
On October 29, 2012, at approximately 11:00 AM, Client A was at the day program (DP) having lunch. The lunch menu for October 29, 2012 listed: "Sassy ham and coleslaw sandwich on a hamburger bun, cookies, a Jell-O cup and the beverage of choice." Due to Client A having the CCD restriction, she was to have turkey substituted for the ham, and a sugar-free beverage. In addition, under the section for the ground diet preparation menu it listed the turkey with coleslaw sandwich in its entirety was to be ground, as well as the cookies.
During an interview with the day program (DP) administrator on January 2, 2013 at 8:00 AM, she relayed the incident on October 29, 2012, as follows: "Staff claimed they cut the sandwich [for Client A]. I did scoop out a chunk of the sandwich [from Client A's mouth] showed quarter to half (dollar size with fingers). My lead staff (DP staff 1 and DP staff 2) worked with her because her regular staff was off that day. [DP staff 1] said she put food out and cut it, then turned around for a second and [Client A's] lips were blue. She tried the Heimlich maneuver, so did [DP staff 2], then they called for me. I checked her mouth to see if I could see anything and I didn't until we got her to the floor, then I saw a piece [of the sandwich]. Then I started CPR. [Client A] took one big sigh and then the paramedics took over. There was no response and they took her to the hospital."
During an interview with DP staff 1 on January 1, 2013 at 8:30 AM, she said she was only aware that Client A was to put her spoon down between bites, but not that her meat should be of a ground texture, or that the sandwich should be cut in pieces no larger than a teaspoon. "They [facility] would send a sandwich cut in fourths and we'd cut it a little more. That day she had like a hamburger bun, it was quartered, so I cut each piece in half again (when shown drawing of teaspoon size, DP staff 1 acknowledged, "It was a little larger than that."
During the same interview DP staff 1 stated, "[Client A] had her food and I was standing [demonstrated an arm length and a half] at an angle cutting up the other client's lunches.DP staff 1 further stated, "She didn't make no noise. She looked funny and turned purple then started to fall over towards the side [DP staff 1 demonstrated leaning to one side]. I started the Heimlich maneuver and called for [DP staff 2] who was with another client. [Client A] was dead weight. [DP staff 2] tried the Heimlich maneuver and then we called for [DP administrator]." DP staff 1 further advised she was unaware of the subsequent course of events for Client A, because she was sent to care for the other clients when the administrator took over care of Client A.During a phone interview on January 14, 2013 at 9:00 AM, with the direct care staff (DCS 1) who prepared the lunch for Client A at the facility on October 29, 2012, she stated, "I made her a ham and coleslaw sandwich that day." When clarified that the diet had required turkey to be substituted for the ham, DCS 1 stated, "Ok, turkey and coleslaw. I had to make her meat like ground, then I quartered it and cut again so there were eight pieces that were bite sized." When asked to define "bite-sized", DCS 1 responded, "Like a nickel size."During a further telephone interview with DP staff 1 on January 14, 2013 at 9:20 AM, DP staff 1 stated that the meat in Client A's sandwich, "was thin-sliced lunchmeat turkey." When questioned if it had been a ground texture, DP staff 1 stated, "No, it was not ground and the sandwich was cut in four pieces and I had to cut it up smaller for [Client A] to eat."
On December 26, 2012 at 1:45 PM, during a review of the emergency room (ER) record dated October 29, 2012 at 11:56 AM, the physician had written, "Patient appeared to be choking and went unresponsive while at adult living facility. Staff tried to clear her airway, pulled out "chunks" of turkey sandwich." The record further indicated, "The staff claimed to have started CPR but the EMS (emergency medical system-paramedics) didn't witness them performing it upon arrival." The physician further wrote that Client A was not breathing on her own in the ER. She did not respond to painful stimuli, she had no reflex to other stimuli, there was no gag reflex (reflex triggered when back of throat is touched), or reflex reactions when her muscles were tested. She was determined by an electroencephalogram (EEG- an instrument that detects brain wave activity) performed on October 29, 2012 at 10:13 PM, to have "probable brain death (brain lacks electrical activity) however, the patient is in hypothermia (The body is cooled to try to preserve brain function then slowly warmed again)."
During a review on January 2, 2013 at 10:40 AM, of the October 29, 2012 pre-hospital report completed by fireman paramedics, they had listed under Narrative Assessment", the following: "Patient found lying supine (face-up) on the floor with staff trying to clear the patient's airway and was pulling out large pieces of a turkey sandwich." Based on review of the pre-hospital report, the fire department paramedics had arrived on scene and had first contact with Client A at 11:07 AM. Client A was noted to have a weak pulse for approximately two minutes before CPR had to be initiated. She was stabilized (the paramedics had been able to re-establish a heartbeat, were providing artificial respirations, and had established an intravenous line (IV) for medication administration) for transport by 11:31 AM, arriving at the GACH (General Acute Care Hospital) ER (Emergency Room) at 11:48 AM.During a phone interview on January 9, 2013 at 12:00 PM, with the Deputy Coroner to ascertain the cause of Client A's death, Deputy Coroner stated, "The cause of death was determined to be hypoxic encephalopathy due to choking on food (time line showed "days") and the contributing causes were mental retardation and schizophrenia. The death was ruled accidental."
During a January 11, 2013 telephone interview at 11:50 AM with Paramedic 1, who responded to the 9-1-1 call at the DP, she stated, "When we arrived the fire paramedics were on site. I saw a large amount of fluid in her [Client A's] throat, any pieces of sandwich were mushy by then. I attempted to see if I could dislodge any food particle with the forceps but I couldn't. I had a hard time getting her airway so the fireman paramedic attempted to intubate her (procedure where a tube is placed in the airway to maintain it in an open position) and was successful." Paramedic 1 then advised of a sequence of potentially fatal heart rhythms and medical interventions before Client A could be stabilized for transport to the general acute care hospital emergency room.
On December 26, 2012 at 2:00 PM, during a review of the history and physical (H&P) completed by the admitting physician (MD 1) at the GACH, dated October 29, 2012, MD 1 had listed the following diagnoses:
a. "Out of hospital cardiac arrest presumably secondary to aspiration (inhaling) of foreign body obstructing the upper airway. Initial rhythm when paramedics arrived was a pulseless electrical activity (PEA-the heart continues to send electrical signals but there is not the mechanical response of pumping oxygen rich blood to the body), followed by ventricular fibrillation (uncoordinated contractions in the lower part of the heart making the heart quiver instead of pump blood to the rest of the body), with no history of cardiovascular disease."
b. "Respiratory arrest, apparently secondary to aspiration of foreign body or upper airway obstruction when eating."
c. "Mental retardation, schizophrenia and anoxic encephalopathy. Prognosis uncertain but likely poor due to lack of any neurologic response in deep coma. Rule out cerebrovascular accident triggering acute event (stroke)."
"Episode of dysphagia (inability or difficulty swallowing) causing aspiration with no known history of chronic aspiration."
The plan of care noted by MD 1 in the record included a Bronchoscopy (a lighted scope is inserted down the throat to view the lungs) "to look for foreign bodies," and "to admit to the intensive care unit."
During a phone interview with MD 1 on January 11, 2013 at 10:00 AM, he stated, "A bronchoscopy is done to ascertain if any material remained after a choking incident. A person can have an upper airway obstruction and aspirate (inhale fluids or food particles into the lungs) without evidence being found during a bronchoscopy. I remembered she had been eating a turkey sandwich and I can tell you she aspirated on food even though I didn't retrieve any from her lung."
Client A was in the GACH from October 29, 2012 through November 2, 2012. On November 2, 2012 the decision was made to remove her from a life-supporting ventilator. During her hospitalization, Client A experienced the following, as noted in her hospital clinical record:
1. Body temperature dropped to 33 degrees Celsius(C)/91 degrees Fahrenheit (F). Normal body temperature is 98.6 F;
2. Seizures (convulsions) secondary to drop in body temperature;
3. Insertion of a nasogastric tube (a tube inserted through the nostril into the stomach for suctioning or delivering medications and nourishment);
4. Hyperglycemia (high blood sugar, with no history of diabetes);
5. Placed on artificial ventilation;
6. Given intravenous medication (a needle was inserted into vein and connected to a tubing through which medications could be given) to sustain her blood pressure;
7. Placement of an indwelling catheter into her bladder to prevent skin breakdown.
8. Client A never regained consciousness following the choking incident.
The facility failed to ensure that the physician-prescribed diet of ground meat consistency, and bite sized pieces was followed when preparing Client A's lunch for the day program on October 29, 2012. This failure resulted in Client A choking on her sandwich, going into cardiac arrest, suffering hypoxic encephalopathy, being placed on an artificial respiratory device and dying four days later, on November 2, 2012, without regaining consciousness.
This facility's failure presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result and was a direct proximate cause of the death of Client A. |
| 970000107 |
York Healthcare & Wellness Centre |
940011868 |
A |
08-Apr-16 |
7EQ211 |
28405 |
F309 ? 42 CFR 483.25. Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. F327 ? 42 CFR 483.25(j). The facility must provide each resident with sufficient fluid intake to maintain proper hydration and health. Based on interview and record review, the facility failed to provide the fluid intake necessary for proper hydration and prevent complications, such as fecal impaction, for Resident 13 by failing to:1. Reassess the resident for increased risk for dehydration after being diagnosed with urinary tract infection (UTI- infection in the bladder that holds the urine and a trigger for dehydration) and hematuria (blood cells leaking into the urine). 2. Update a care plan to reflect the resident's diagnoses of UTI and hematuria, as the resident?s current health status, for interventions to be developed and implemented in accordance with the facility?s policy and procedure. 3. Implement the facility's policy and procedure to conduct a nutritional assessment when a resident had a change of condition. 4. Review the resident's fluid intake and potential for the presence of an acute underlying medical problem after the resident refused the first three (3) consecutive meals in accordance with the facility?s policy and procedure. The resident refused seven (7) meals consecutively without nursing intervention.5. Implement a fluid intake and output recording when the resident?s risk for dehydration increased after the resident had a UTI, to meet the resident's fluid needs in accordance with the facility?s policy and procedure. 6. Assess the resident for complications from dehydration, such as constipation (bowel movements that are hard to pass) to prevent the development of fecal impaction (solid, immobile bulk of human stool or feces that can develop in the rectum as a result of constipation). 7. Implement the resident?s plan of care to monitor for fecal impaction and stool consistency. 8. Administer the medication Milk of Magnesia (MOM, a medication that reduces stomach acid, and increases water in the intestines which may induce defecation) if the resident had no bowel movement for two days as ordered by the physician.These deficient practices resulted in Resident 13 being transferred to a general acute care hospital (GACH) for altered mental status, where she received large intravenous (IV, within a vein) fluid boluses (a large volume of fluid or dose given intravenously and rapidly at one time) for hydration and oral laxatives. The resident had a manual fecal dis-impaction (manual removal of feces or stool), which was related to undetected/untreated constipation (a complication related to dehydration).A review of Resident 13's Face Sheet (admission record) indicated the resident was admitted to the facility on December 12, 2014. The resident's diagnoses included dementia (loss of brain function which occurs with certain diseases and affects memory, thinking, language, judgment, and behavior) and pelvic (the area between the trunk or main body and the legs) fracture (broken bone) status post fall at home.A review of the Dehydration Risk Assessment form, dated December 12, 2014, indicated Resident 13 had an assessment score of 60 (a score of 50 and above was considered a high risk for dehydration). The assessment indicated that Resident 13 had difficulty swallowing liquids and required moderate or extensive assistance (resident involved in activity, staff provide weight-bearing support) with fluid intake.A review of the physician order, dated December 13, 2014, indicated an order to administer one liter of fluids (D5 « NS [5% dextrose or sugar in « normal saline or salt solution] at 60 cubic centimeters per hour) intravenously (IV, within a vein) for hydration. The IV Medication Sheet indicated the IV fluids were administered to Resident 13. A review of the Medication Record (a medication administration record), dated December 12 thru December 22, 2014, indicated Resident 13 was receiving a diet of pureed consistency (soft, smooth, thick paste consistency similar to a thick pudding) and nectar thick liquids (liquids that have been thickened to a consistency which coats and drips off a spoon, similar to unset gelatin) every meal.The Medication Record, dated December 12 thru 22, 2014, indicated Resident 13 received Ultram (an opioid pain reliever used to treat moderate to severe pain) 25 milligrams by mouth every six hours routinely. Resident 13 received a total of 38 doses of Ultram during her admission (a period of 10 days). Resident 13 also received 8 doses of Percocet (an opioid pain medication) during her admission for pain management.The facility's policy and procedure titled, "Pain Management," revised January 1, 2012, did not indicate the need to address constipation as a common adverse effect of elderly residents on routine opioid medications.Resident 13's Medication Record indicated a physician's order for milk of magnesia (MOM) 30 cubic centimeters (cc) oral as needed once a day for constipation or no BM (bowel movement) for two days, Dulcolax suppository (a stimulant laxative) 1 (one) rectal as needed once a day if MOM was not effective, and may give fleet enema (a lubricant laxative used to relieve occasional constipation and fecal impaction) if Dulcolax suppository was refused or not effective.The Medication Record did not contain documented evidence that MOM, Dulcolax suppository, or fleet enema were given during the resident's entire stay in the facility from December 12 to 22, 2014.A care plan, initiated on December 12, 2014, titled, "Resident Care Plan, Nutrition and Hydration" indicated Resident 13 was at risk for dehydration related to a decrease in fluid intake, decreased food intake, dysphagia (difficulty swallowing), the use of thickened liquids, pain, refusal of meals/fluids, decreased perception of thirst, and poor appetite.The care plan goals indicated Resident 13 will maintain adequate hydration as evidence by "... normal urinary output as well as adequate nutritional intake of at least 75% each meal." The approaches indicated in the care plan included maintaining an intake and output log as indicated, encouraging oral fluids and eating at each meal, offering fluids frequently, and monitoring signs and symptoms of dehydration.A care plan, initiated on December 12, 2014, indicated that Resident 13 was at risk for dehydration related to nausea. The approaches indicated in the care plan included monitoring for signs and symptoms of dehydration, providing/encouraging adequate hydration as tolerated, and assessing Resident 13 for possible constipation.A care plan for Resident 13 titled, "Resident Care Plan, Constipation," initiated on December 12, 2014, indicated the resident was at risk for constipation related to a decrease in mobility. The approaches indicated in the care plan included to monitor the resident for impaction, abdominal distention, nausea and vomiting, and effectiveness of medication and treatment; to monitor the bowel movements for consistency and frequency; to encourage increased fluids; to encourage increased mobility as tolerated; and to provide medication and treatment as ordered (an entry of PRN [as needed] medications, such as milk of magnesia (MOM), Dulcolax suppository, and fleet enema was hand written on the approaches).The care plan did not mention Resident 13 was receiving Ultram and Percocet for pain management, which may contribute to constipation. On January 7, 2015 at 9:15 a.m., Resident 13?s clinical record was reviewed with Registered Nurse (RN) 1. During a concurrent interview, RN 1 was asked what the facility's care plan for Resident 13 that addressed the side effects of opioid pain medications. RN 1 was not able to answer and could not find a care plan that addressed the effects of pain medications to a resident's bowel movement.The Speech Therapy evaluation, dated December 15, 2014, indicated without skilled intervention at this time, Resident 13 would be at an increased risk of dehydration.The 5-day assessment Minimum Data Set (MDS, a standardized assessment and care planning tool), dated December 19, 2014, indicated Resident 13 was severely impaired in cognitive skills, and needed extensive assistance (resident involved in activity, staff provide weight-bearing support) in bed mobility, transfer, walking in corridor, dressing, eating, toilet use, and personal hygiene. The MDS indicated Resident 13 was always incontinent (no control) of bowel and the resident's pain intensity was described as "very severe and horrible."On January 8, 2015 at 1:55 p.m. during an interview, Certified Nursing Assistant (CNA) 1 stated Resident 13 was a "total assist with feeding and required a lot of help and encouragement."A review of the physician's order, dated December 16, 2014, indicated to provide Resident 13 with Med-pass (a nutritional drink to supplement calories and protein) 60 milliliters (ml) by mouth daily and HPN (high protein nutrition) four (4) ounces by mouth three times a day with meals.There was no documented evidence the Med-pass was offered to Resident 13 and if the resident drank 60 ml a day of the Med-pass. There was no documented evidence of Resident 13's consumption of the HPN with meals.There was no documented evidence in the clinical record that the consistency (for example hard or liquid) of Resident 13's stool was monitored in accordance with the plan of care.A review of the Daily Licensed Nurses Notes, dated December 17, 2014 at 5 a.m., indicated that Resident 13 had a change of condition manifested by an episode of hematuria. The notes indicated, "...fluids encouraged as tolerated to maintain adequate hydration..." The laboratory report, dated December 18, 2014, indicated Resident 13 had a urinary tract infection and would be given Bactrim DS (an antibiotic) for seven days as ordered.There was no documented evidence in the clinical record that indicated how the facility encouraged Resident 13, who was confused and with dementia, to drink thickened fluids to maintain adequate hydration. There was no documented evidence to indicate if the encouragement was effective and if Resident 13 actually drank fluids. There was no documented evidence of the amount of fluids drank by the resident to prevent dehydration which could lead to complications, such as UTI, constipation, and fecal impaction.There was no documented evidence Resident 13 was re-assessed for increased risk for dehydration due to the development of UTI and hematuria, and how the facility was going to manage the complications of UTI, such as dehydration, constipation and fecal impaction.The last documented dehydration risk assessment for Resident 13 was at admission, dated December 12, 2014. There was no documented evidence the facility re-assessed the resident for increased risk of dehydration after developing UTI and hematuria. There was no documented evidence a care plan was developed for a new diagnoses of UTI and hematuria. On January 9, 2015 at 10:35 a.m. during an interview, Resident 13's care plans were discussed with Licensed Vocational Nurse (LVN) 4. When LVN 4 was asked if she reads her residents' care plans, she stated "I want to be honest with you. I don't read it all the time."On January 9, 2015, at 10:40 a.m., during an interview with LVN 1, she was asked how a licensed nurse assessed a resident at risk for constipation and impaction. LVN 1 stated licensed nurses had to monitor for bowel sounds, nausea, if a resident would not eat and had a feeling of being "full," hard abdomen, and small/hard bowel movements because "it could be impaction."A review of the facility's policy and procedure titled, "Change of Condition Notification," revised January 1, 2012, indicated, "...Update the Care Plan to reflect the resident's current status..." A review of the facility policy titled "Evaluation of Weight and Nutritional Status," revised August 1, 2014, indicated that ??The Dietitian will complete a nutritional assessment initiated by the Dietary Manager upon admission for residents. Nutritional assessments will be completed upon re-admission, annually, and upon change of condition?The Dietitian will provide a narrative of recommendations in the Assessment section and identify any weight loss or dehydration risk factors. The Dietician will complete the Nutritional Assessment within fourteen (14) days of admission??There was no documented evidence that Resident 13's nutritional assessment was completed by a dietitian when the resident had a change of condition on December 17, 2014, a condition that could affect her fluid intake.On January 8, 2015 at 9:45 a.m. during an interview, the dietary manager was asked if the facility's registered dietitian completes the nutritional assessment section of a newly admitted resident earlier than what was stated in the policy, which was 14 days. The dietary manager stated it is based from the "resident's diagnoses", or if they (the residents) are "high risk" (residents at risk for complications) "like dialysis residents or residents with weight fluctuations."There was no documented evidence Resident 13 was evaluated by a registered dietitian within the resident's 10-day stay at the facility when she was identified as high risk for weight loss and dehydration.During the interview with the dietary manager, on January 8, 2014 at 9:45 a.m., she was asked how Resident 13's fluid needs were calculated during her stay in the facility to prevent dehydration. The dietary manager stated the registered dietitian has not yet assessed Resident 13 during that time.A review of the Dietary Questionnaire, dated December 13, 2014, conducted by the dietary manager, indicated an incomplete documentation of Resident 13's dietary preferences. The food and dining location preferences portion was left blank. An assessment of the resident's oral status which can affect eating was also left blank. The snack and nourishment in between meals portion was blank. A handwritten entry in the questionnaire indicated, "Resident confused." There was no documented evidence the dietary manager attempted to complete the Dietary Questionnaire when Resident 13 had a change of condition on December 17, 2014. On January 8, 2015 at 9:45 a.m., during an interview with the dietary manager, she stated "I was not able to complete my questionnaire because she (Resident 13) was confused."A review of the Daily Licensed Nurses Notes, dated December 19, 2014, indicated that Resident 13's abdomen was slightly firm and tender to touch, urine still had blood, and she was receiving the antibiotics, Bactrim, for the urinary tract infection. The resident tolerated the thickened fluid offered and she was encouraged to increase her fluid intake.There was no documented evidence to indicate how the encouragement was provided. There was no documented evidence to indicate whether the encouragement was effective and the amount of the thickened liquid drank by Resident 13 and/or and if Resident 13 was able to increase her intake of the thickened liquid.A review of CNA (Certified Nurse Assistant) 1's documentation on the Facility ADL Flowsheet Record for the day shift, dated December 19, 2014, indicated a CNA reported to the nurse that Resident 13 had no bowel movement (BM) for three days (during the day shift), from December 16-18, 2014. The Facility ADL Flowsheet indicated the last recorded bowel movement of Resident 13 was two days prior, December 17, 2014 during the night shift.On January 8, 2015 at 1:55 p.m., during an interview, CNA 1 stated she reported Resident 13?s bowel status to her charge nurse because she noted the resident had no BM for three days during the day shift, from December 16-18, 2014. CNA 1 stated she remembered Resident 13 was moaning and crying and directed her discomfort to the area around the abdomen.A review of the Daily Licensed Nurses Notes completed by the night shift (11 p.m. ? 7 a.m.) licensed nurse, dated December 19, 2014, indicated Resident 13's abdomen was slightly firm and tender to touch, the resident tolerated the thickened fluid that was offered and she was encouraged to increase her fluid intake.There was no documented evidence that nursing interventions were implemented upon assessment of the resident's firm abdomen. There was no documented evidence of how the facility encouraged the resident to drink thickened fluids or how the procedure was conducted. There was no documentation of how the facility provided the encouragement and if the encouragement was effective. There was no documented evidence Resident 13 was able to increase her intake of the thickened liquid.On January 9, 2015 at 10:45 a.m., during an interview, LVN 4 stated if she could see a stool outside a resident's anal area, she could do the dis-impaction manually but she needs a physician's order for it. There was no documented evidence a licensed nurse assessed Resident 13 for impaction and constipation or that any laxatives were given. LVN 4 stated she would try to give a resident Milk of Magnesia (oral laxative) first, followed by an enema, and then she would call the doctor if the medications did not work.A review of the CNA (Certified Nurse Assistant) documentation on the Facility ADL Flowsheet Records indicated Resident 13 did not eat dinner (documented as zero intake) on December 19, 2014; the resident ate 50% of the breakfast on December 20, 2014 (Saturday), but she did not eat lunch and dinner. On December 21, 2014 (Sunday), Resident 13 did not eat all three meals and did not eat again on December 22, 2014(Monday) for breakfast and lunch. Resident 13 did not eat for seven (7) consecutive meals from December 20 (Saturday) thru December 22, 2014 (Monday).A review of a facility policy and procedure titled "Food Intake - Recording Percentage and Nutritional Assessment," revised January 1, 2012, indicated if three (3) consecutive meals were refused by the resident, the charge nurse will review fluid intake and the presence/absence of an acute medical problem. There was no documented evidence that a licensed nurse reviewed Resident 13's fluid intake or presence of an acute underlying medical problem after the resident refused the first three (3) consecutive meals.The Daily Licensed Nurses Notes, dated December 21, 2014 and timed at 2 p.m., indicated Resident 13 had a change of condition manifested by moaning, poor intake by mouth, and food pocketing (food stays inside the mouth, a common problem when there is a swallowing issue or the person does not want to swallow) and the physician was notified with no new order. The nurse's notes indicated Resident 13 opened her mouth to feed but she did not swallow; she was encouraged to increase her intake of food and fluid but it was not effective.On January 9, 2015 at 10:45 a.m., during an interview, LVN 4 stated she called the physician during her shift (7 a.m. to 3 p.m.) on December 21, 2014, and informed the physician Resident 13 was not eating, was pocketing food, and was moaning. LVN 4 stated the physician did not order anything. LVN 4 was asked what the next step was when a physician does not order anything. LVN 4 stated "I don't remember who told me but I remember somebody said that the physician is coming the next day anyway, to look at the resident."A facility policy and procedure titled "Intake and Output Recording, " revised January 1, 2012, indicated intake and output recording may be instituted per an attending physician's order or a licensed nurse for any resident with risk of dehydration. There was no evidence the licensed nurse instituted a fluid intake and output recording when Resident 13 risk for dehydration increased after the resident experienced a change of condition on December 17, 2014.On January 9, 2015 at 11:30 a.m., during an interview with the director of nurses (DON), she was asked when a licensed nurse initiates an Intake and Output (I&O) monitoring. The DON stated the facility monitored the I&O of residents with "new gastrostomy tubes (GT- a tube that is placed directly into the stomach through an abdominal wall incision for administration of food, fluids, and medications), new Foley catheters (a urinary indwelling catheter), intravenous fluid hydration, and intravenous antibiotics administration."During the interview, the DON was asked to clarify the facility's policy and procedure and was asked if I&O were supposed to be monitored for residents with risk of dehydration. DON stated the facility monitored resident's I&O but "only for the duration of the intravenous fluids."A review of the Daily Licensed Nurses Notes, dated December 22, 2014 (time not documented), indicated Resident 13 refused breakfast and medications (including antibiotics and pain medications). The physician and nurse practitioner (NP) were notified and an order for IV fluids of « NS (normal saline or salt solution) at 50 milliliters (ml) per hour was made. The IV Medication Sheet, dated December 22, 2014 at 12:20 p.m., indicated Resident 13 was started on IV fluids. A review of the CNA note documented in the Facility ADL Flowsheet Record, dated December 22, 2014, on a 7-3 a.m. shift, indicated a CNA reported to the nurse that Resident 13 had no bowel movement for two days, December 20 and 21, 2014. The ADL Flowsheet Record indicated the last recorded bowel movement for Resident 13 was on December 19, 2014 during the evening shift, and it was small in size.The Daily Licensed Nurse Notes, dated December 22, 2014 and timed at 1 p.m., indicated the interdisciplinary team (IDT, a group of health care professionals from diverse fields who work in a coordinated fashion toward a common goal for the patient) met and discussed the Resident's weight loss of three (3) pounds (lbs) in one week from 130 lbs to 127 lbs. There was no documented evidence that Resident 13's increased risk for dehydration, associated with weight loss, was discussed so that a plan of care could be developed to prevent complications, such as constipation and fecal impaction.The Daily Licensed Nurses Notes, dated December 22, 2014 at 2:50 p.m., indicated that Resident 13 refused her meal and meds and the physician was informed.A physician telephone order, dated December 22, 2014 and timed at 3 pm, was made to transfer Resident 13 to a general acute care hospital (GACH). Resident 13 left the facility via ambulance at 4 pm.The facility's "Resident Transfer Record" dated December 22, 2014 indicated that Resident 13's reason for transfer to GACH is altered mental status, and refusal of medications and meals. A handwritten entry documented in the transfer form indicated Resident 13's last meal/snack feeding was on December 20, 2014, two days before the transfer.A review of GACH's Emergency Department (ED) Report dated December 22, 2014 indicated Resident 13 had dry mucous membranes with mouth open with eyes closed on physical examination. A critical care note in the report indicated the resident was "...noted to be dehydrated with her mouth open and noted by family to not be eating or drinking as well as she normally does...contracted on one side in pain with bleeding from perineum (the area between the bottom of the vaginal opening and the anus)...with very copious hard stool noted and dis-impacted with immediate release of a large amount of hematuria after stool was dis-impacted."A review of the ED critical care note indicated Resident 13 was given intravenous fluids as she "appeared clinically dry" and she was started on intravenous ceftriaxone (antibiotics) because of a UTI. The diagnoses for Resident 13 after transfer to the GACH included acute (sudden) renal (kidney) failure, hyperkalemia (high levels of potassium in the blood), UTI, hematuria, sepsis (a potentially life-threatening complication of an infection), dehydration, rectal impaction. A review of Resident 13's History and Physical (GACH's), dated December 23, 2014, indicated "Patient also noted to have a fecal impaction, now having multiple bowel movements after dis-impaction." Resident 13's bowel was cleared with lactulose (oral liquid laxatives) twice a day.During an interview with Registered Nurse (RN) 1, on January 7, 2015 at 9:15 a.m., when asked if laxatives were given to Resident 13 during her stay in the facility from December 12 to 22, 2014, she stated, "We didn't give it." RN 1 was asked if a licensed nurse had checked Resident 13 for constipation and/or impaction since Resident 13 received Ultram and Percocet (opioid analgesics and may cause constipation). RN 1 stated "I don't know," and that she could not find any documentation a nurse assessed Resident 13 for constipation and impaction.During an interview with the director of nursing (DON), on January 7, 2015 at 10:45 a.m., the DON stated the facility did not have a written policy and procedure on how to address constipation and/or fecal impaction for residents. On January 12, 2014 at 10:30 a.m. during a telephone interview, Family 1 stated he started getting concerned with Resident 13's health status on December 17, 2014 because she was not eating as much. On the 18th, Family 1 stated he noticed Resident 13 was not really conscious and constantly moaned and made "sounds." Family 1 stated he repeatedly asked what was being done and facility reported "they are aware." The next day, which was the 19th, Family 1 stated he told the facility Resident 13 was not getting any liquids and something was wrong with the resident.During the telephone interview, Family 1 stated that on December 20, 2014, he was really concerned because he could see Resident 13 getting worse and he told a licensed nurse that morning that Resident 13's abdomen looked kind of big and he (Family 1) stated, "We have to do something." The licensed nurse, who Family 1 spoke to that morning, stated, "What do you want us to do about it?"The facility failed to provide the fluid intake necessary for proper hydration and prevent complications, such as fecal impaction, for Resident 13 by failing to:1. Reassess the resident for increased risk for dehydration after being diagnosed with urinary tract infection (UTI- infection in the bladder that holds the urine and a trigger for dehydration) and hematuria (blood cells leaking into the urine). 2. Update a care plan to reflect the resident's diagnoses of UTI and hematuria, as the resident?s current health status, for interventions to be developed and implemented in accordance with the facility?s policy and procedure. 3. Implement the facility's policy and procedure to conduct a nutritional assessment when a resident had a change of condition.4. Review the resident's fluid intake and potential for the presence of an acute underlying medical problem after the resident refused the first three (3) consecutive meals in accordance with the facility?s policy and procedure. The resident refused seven (7) meals consecutively without nursing intervention.5. Implement a fluid intake and output recording when the resident?s risk for dehydration increased after the resident had a UTI, to meet the resident's fluid needs in accordance with the facility?s policy and procedure. 6. Assess the resident for complications from dehydration, such as constipation (bowel movements that are hard to pass) to prevent the development of fecal impaction (solid, immobile bulk of human stool or feces that can develop in the rectum as a result of constipation). 7. Implement the resident?s plan of care to monitor for fecal impaction and stool consistency. 8. Administer the medication Milk of Magnesia (MOM, a medication that reduces stomach acid, and increases water in the intestines which may induce defecation) if the resident had no bowel movement for two days as ordered by the physician.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. |
| 970000107 |
York Healthcare & Wellness Centre |
940013285 |
B |
14-Jun-17 |
LOJS11 |
8976 |
F-225
483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must:
(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures.
On 5/9/17 at 9 a.m., an unannounced visit was conducted at the facility to investigate a entity reported incident regarding Resident 1?s physical abuse by a certified nurse assistant 1 (CNA 1) who had used her hand to slap the resident?s face as witnessed by CNA 2 at the facility.
The facility failed to ensure that Resident 1?s allegation of physical abuse was
reported immediately, 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.
A review of Resident 1's record titled, "Face Sheet (admission record)," that indicated Resident 1 was admitted to the facility on XXXXXXX13, and was re-admitted on XXXXXXX15, with diagnoses of hemiplegia (paralysis of one side of the body) of left non-dominant side followed by a stroke (a condition when the blood supply to part of the brain is interrupted, depriving brain tissue of oxygen and nutrients, and causing brain cells to die), Parkinson's disease (a long-term movement disorder that occurs when the brain cells that control movement start to die and cause changes in how you move), and muscle weakness.
A review of Resident 1's record titled, "Admission Assessment," dated 3/20/15, indicated that Resident 1 was alert and did not have behavioral and safety concerns, have any threatening or combative behavior.
A review of Resident 1's record titled, "Minimum Data Set ([MDS], a resident assessment and care screening tool)," dated 2/1/17, indicated that Resident 1 was cognitively (refers to mental abilities or processes) intact. The MDS indicated that Resident 1 did not have disorganized thinking and altered level of consciousness or exhibit abnormal physical and verbal behavioral symptoms directed towards others such as hitting, screaming, kicking, abusing others sexually, disrobing or threatening others.
The MDS indicated Resident 1 required extensive assistance (resident performed part of the activity; staff provided support with bearing weight, at times full staff performance of activity) with one person physical-assist for the following activities of daily living (ADL): bed mobility (how resident moves to and from lying position, turns side to side, and positions body while in bed), transfer (how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position), and toilet use (how resident uses the toilet room, commode, bedpan, or urinal; transfers on/off toilet; cleanses self after elimination; changes pad; and adjust clothes).
A review of the facility's investigation regarding the allegation of physical abuse and dated 4/20/17 at 9 p.m. indicated, that Resident 1 verbalized that he kicked CNA 1 because she was not answering the call light and he needed his diaper to be changed by CNA 1. Resident 1 stated that CNA 1 put her hand on his right cheek. "He (Resident 1) cringed in fear for short time."
A review of the facility's investigation of the allegation of abuse for Resident 1, dated 4/20/17 at 9 p.m., indicated that Licensed Vocational Nurse (LVN 1) stated that Resident 1 kicked CNA 1 and CNA 1 touched his (Resident 1) right cheek (no documented date and time of incident). The investigation indicated LVN 1 stated he did not inform the Administrator and Registered Nurse Supervisor.
On 5/9/17 at 4:40 p.m., during an interview, the Administrator stated facility staff were mandated reporters and allegations of abuse that do not result in serious bodily injury should be reported immediately within 24 hours to Ombudsman, Health Department, and law enforcement.
During a telephone interview on 5/10/17 at 12 p.m., CNA 1 stated she had taken cared of Resident 1 for three years. CNA 1 stated on 4/4/17, around 10:30 p.m., Resident 1's call light was on and CNA 1 went into Resident 1's room. CNA 1 stated that Resident 1 was not aggressive and was quiet. CNA 1 stated that it was her last chance during her shift to change Resident 1's diaper and so she asked Resident 1 if he needed to change his diaper. CNA 1 stated Resident 1 was quiet and agreed to have his diaper changed. CNA 1 stated while she was changing Resident 1's diaper, Resident 1 asked CNA 1 to touch his private parts and CNA 1 told Resident 1, "No" and Resident 1 yelled at CNA 1, "I don't need you because you don't help me." CNA 1 stated Resident 1 tried to hit her. CNA 1 denied slapping Resident 1. CNA 1 stated she notified LVN 1 about the incident and then LVN 1 talked to both Resident 1 and her (CNA 1). CNA 1 stated that indicated that the incident need not be reported to the authorities. CNA 1 stated she returned the following day on 4/5/17 and on 4/10/17 to take care of Resident 1.
During an interview on 5/10/17 at 2:12 p.m., the Director of Nursing (DON) stated LVN 1 should have immediately reported Resident 1's allegation of abuse to the Administrator and law enforcement. DON stated when a staff was made aware of an allegation of staff-to-resident abuse, then the staff should notify the Administrator, who was the abuse coordinator, and immediate supervisor to initiate an investigation. During the investigation, the facility was to remove the perpetrator of abuse from the facility so that the resident was protected. DON stated staff should report allegations of abuse within 24 hours to law enforcement, Health Department, and Ombudsman. DON stated the facility was responsible for ensuring a safe environment for the residents.
According to the facility's policy and procedures titled, "Abuse- Reporting & Investigations," dated November 2016 indicated that, the facility was responsible for protecting the health, safety, and welfare of facility residents by ensuring that all reports of resident abuse and mistreatment are promptly and thoroughly investigated.
The policy also indicated that the facility will report all allegations of abuse as required by law and regulations to the appropriate agencies and the facility will promptly and thoroughly investigates reports of resident abuse and mistreatment. The policy indicated allegations of abuse are to be reported to the Administrator or designated representative immediately and the Administrator or designated representative will initiate an investigation immediately. The policy indicated the Administrator or designated representative will not inhibit facility staff from their mandated reporter obligations. Also, the Administrator or designated representative will provide for a safe environment for the resident as indicated by the situation and if the suspected perpetrator was an employee, remove the employee immediately from the care of the resident (s) and immediately suspend the employee pending the outcome of the investigation in accordance with facilities policies. The Administrator or designated representative will notify law enforcement, LTC Ombudsman, and CDPH Licensing and Certification by telephone immediately or as soon as practicable, and in writing (SOC 341) within twenty-four hours including weekends of all other types of allegations of abuse. The policy indicated employees of this facility who have been accused of resident abuse will be suspended from duty until the results of the investigation have been reviewed by the Administrator.
Failure to ensure that all alleged violations involving abuse, are reported immediately, 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 had a direct or immediate relationship to the health, safety, or security of residents. |
| 970000107 |
York Healthcare & Wellness Centre |
940013286 |
B |
14-Jun-17 |
LOJS11 |
7412 |
F-223
483.12
The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident?s symptoms.
483.12(a) The facility must-
(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion;
Based on interview and record review, the facility failed to ensure that Resident 1 had the right to be free from physical abuse when Resident 1 kicked CNA 1 because she was not answering the call light when he needed to have his diaper changed and CNA 1 subsequently used her opened hand to slap Resident 1 in the face.
As a result, Resident 1 was physically abused by certified nurse assistant 1 (CNA 1) when she slapped the resident?s face that was witnessed by CNA 2.
On 5/9/17 at 9 a.m., an unannounced visit was conducted at the facility to investigate a entity reported incident regarding Resident 1?s physical abuse by a certified nurse assistant 1 (CNA 1) who had used her hand to slap the resident?s face as witnessed by CNA 2 at the facility.
Findings:
A review of Resident 1's record titled, "Face Sheet (admission record)," indicated Resident 1 was admitted to the facility on XXXXXXX13, and was re-admitted on XXXXXXX15, with diagnoses of hemiplegia (paralysis of one side of the body) of left non-dominant side followed by a stroke (a condition when the blood supply to part of the brain is interrupted, depriving brain tissue of oxygen and nutrients, and causing brain cells to die), Parkinson's disease (a long-term movement disorder that occurs when the brain cells that control movement start to die and cause changes in how you move), and muscle weakness.
A review of Resident 1's record titled, "Admission Assessment," dated 3/20/15, indicated that Resident 1 was alert and did not have behavioral and safety concerns, and any threatening or combative behavior.
A review of Resident 1's record titled, "Minimum Data Set ([MDS], a resident assessment and care screening tool)," dated 2/1/17, indicated that Resident 1 was cognitively (refers to mental abilities or processes) intact. The MDS indicated that Resident 1 did not have disorganized thinking and altered level of consciousness or exhibit abnormal physical and verbal behavioral symptoms directed towards others such as hitting, screaming, kicking, abusing others sexually, disrobing or threatening others.
The MDS indicated Resident 1 required extensive assistance (resident performed part of the activity; staff provided support with bearing weight, at times full staff performance of activity) with one person physical-assist for the following activities of daily living (ADL): bed mobility (how resident moves to and from lying position, turns side to side, and positions body while in bed), transfer (how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position), and toilet use (how resident uses the toilet room, commode, bedpan, or urinal; transfers on/off toilet; cleanses self after elimination; changes pad; and adjust clothes).
A review of the facility's investigation regarding the allegation of physical abuse and dated 4/20/17 at 9 p.m. indicated, that Resident 1 verbalized that he kicked CNA 1 because she was not answering the call light and he needed his diaper to be changed by CNA 1. Resident 1 stated that CNA 1 put her hand on his right cheek. "He (Resident 1) cringed in fear for short time."
A review of Resident 1's record titled, "Resident Care Plan," dated 4/21/17, indicated that, an alleged staff slapped Resident 1 on the right side of his face. Resident at risk for psychosocial disturbance/changes secondary to allegation of physical abuse. The goal was for Resident 1 to be free from fear and minimize psychosocial disturbance/changes.
During the investigation on 5/0/17, Resident 1 was no longer in the facility and could not be reached for interview.
During a telephone interview on 5/9/17 at 1:45 p.m., CNA 2 stated that after dinner (could not remember the date and time), she was standing by the doorway of Resident 1's room and observed that CNA 1 was with Resident 1 inside Resident 1's room. CNA 2 stated that Resident 1 was upset and yelling and saying, "Get out! Get out!" at CNA 1 as CNA 1 was trying to change Resident 1's diaper. CNA 2 stated Resident 1 refused to have his diaper changed and kicked CNA 1. CNA 2 stated CNA 1 then used her opened hand to slap Resident 1 in the face. CNA 2 stated after CNA 1 hit Resident 1 in the face, CNA 1 (abuser) reported the incident to the Licensed Vocational Nurse (LVN 1).
During a telephone interview on 5/10/17 at 12 p.m., CNA 1 stated she had taken care of Resident 1 for three years. CNA 1 stated on 4/4/17, around 10:30 p.m., Resident 1's call light was on and CNA 1 went into Resident 1's room. CNA 1 stated that Resident 1 was not aggressive and was quiet. CNA 1 stated that it was her last chance during her shift to change Resident 1's diaper and so she asked Resident 1 if he needed to change his diaper. CNA 1 stated Resident 1 was quiet and agreed to have his diaper changed. CNA 1 stated while she was changing Resident 1's diaper, Resident 1 asked CNA 1 to touch his private parts and CNA 1 told Resident 1, "No" and Resident 1 yelled at CNA 1, "I don't need you because you don't help me." CNA 1 stated Resident 1 tried to hit her. CNA 1 denied slapping Resident 1. CNA 1 stated she notified LVN 1 about the incident and then LVN 1 talked to both Resident 1 and her (CNA 1).
During a telephone interview on 5/10/14 at 2:47 p.m., LVN 1 stated that Resident 1 was overall a nice resident but when the resident did not like the care provided to him then he would express his anger by kicking. LVN 1 stated one day in April (could not remember the date and time), LVN 1 was the charge Nurse for Resident 1 that day. CNA 1 stated that Resident 1 was calm when she (CNA 1) came out of Resident 1's room. CNA 1 reported that Resident 1 kicked her. LVN 1 stated he spoke to Resident 1 and CNA 1, and Resident 1 stated he kicked CNA 1 because CNA 1 was in a rush while completing his ADL care with him. LVN 1 stated that Resident 1 had reported that while CNA 1 was providing care to him, CNA 1 slapped him in the face.
A review of the facility's policy and procedures titled, "Abuse- Prevention Program," dated November 2016 indicated, that the facility was responsible for ensuring the health, safety, and comfort of residents by preventing abuse and mistreatment. The policy indicated that the facility does not condone any form of abuse and develops Facility policies, procedures, training programs, and systems in order to promote an environment free from abuse and mistreatment. The policy indicated 'physical abuse' was defined as hitting, slapping, pinching and/or kicking.
Failure of the facility to ensure that Resident 1 had the right to be free from physical abuse when resident 1 kicked CNA 1 because she was not answering the call light when he needed to have his diaper changed and CNA 1 subsequently used her opened hand to slap Resident 1 in the face had a direct or immediate relationship to the health, safety, or security of residents. |