The findings of the complaint (Intake #s 22122, 24522, 26706 and 28265) health survey conducted 1/20/21 through 2/11/21 are documented in this report. The survey was conducted to determine compliance with 42 CFR Part §483 Requirements for Long Term Care Facilities.
The sample was comprised of 7 current residents. The facility had a census of 21 residents.
Abbreviations possibly used in this document:
ADL: activities of daily living
bid: twice a day
BIMS: Brief Interview for Mental Status
CAA: Care Area Assessment
CBG: capillary blood glucose or
blood sugar
cm: centimeter
CMA: Certified Medication Aide
CNA: Certified Nursing Assistant
CPR: Cardiopulmonary Resuscitation
DNS: Director of Nursing Services
F: Fahrenheit
FRI: Facility Reported Incident
HS or hs: hour of sleep
LPN: Licensed Practical Nurse
MAR: Medication Administration
Record
mcg: microgram
MDS: Minimum Data Set
mg: milligram
ml: milliliters
O2 sats: oxygen saturation in the
blood
OT: Occupational Therapist
PCP: Primary Care Physician
PO: by mouth, orally
PRN: as needed
PT: Physical Therapist
RA: Restorative Aide
RAI: Resident Assessment
Instrument
RD: Registered Dietician
ROM: range of motion
RN: Registered Nurse
RNCM: Registered Nurse Care
Manager
SLP: Speech Language
Pathologist
TAR: Treatment Administration
Record
tid: three times a day
UA: Urinary Analysis
UTI: urinary tract infection
The findings of the revisit complaint health survey (Intake #s 22122, 24522, 26706 and 28265) conducted from 5/11/21 through 5/13/21 are documented in this report. The survey was conducted to determine compliance with 42 CFR Part §483 Requirements for Long Term Care Facilities.
The sample was comprised of 10 current residents and 0 closed records. The facility had a census of 18 residents.
Abbreviations possibly used in this document:
ADL: activities of daily living
bid: twice a day
BIMS: Brief Interview for Mental Status
CAA: Care Area Assessment
CBG: capillary blood glucose or
blood sugar
cm: centimeter
CMA: Certified Medication Aide
CNA: Certified Nursing Assistant
CPR: Cardiopulmonary Resuscitation
DNS: Director of Nursing Services
F: Fahrenheit
FRI: Facility Reported Incident
HS or hs: hour of sleep
LPN: Licensed Practical Nurse
MAR: Medication Administration
Record
mcg: microgram
MDS: Minimum Data Set
mg: milligram
ml: milliliters
O2 sats: oxygen saturation in the
blood
OT: Occupational Therapist
PCP: Primary Care Physician
PO: by mouth, orally
PRN: as needed
PT: Physical Therapist
RA: Restorative Aide
RAI: Resident Assessment
Instrument
RD: Registered Dietician
ROM: range of motion
RN: Registered Nurse
RNCM: Registered Nurse Care
Manager
SLP: Speech Language
Pathologist
TAR: Treatment Administration
Record
tid: three times a day
UA: Urinary Analysis
UTI: urinary tract infection
The findings of the revisit complaint (Intake #s 22122, 24522, 26706, and 28265) health survey conducted 6/22/21 through 6/22/21 are documented in this report. It was determined the facility was in compliance with 42 CFR Part §483 Requirements for Long Term Care Facilities.
Based on observation, interview and record review it was determined the facility failed to protect residents from verbal and mental abuse for 2 of 2 sampled residents (#s 16 and 21) reviewed for abuse and dignity. This failure resulted in psychosocial harm as evidenced by Resident #16's depressed mood and expression of fear and anxiety. Findings include:
The facility's 4/2010 Reporting Abuse to Facility Management policy defined abuse as the "willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish". The policy further defined mental abuse as, but not limited to, humiliation, harassment, threats of punishment or withholding of treatment and services.
1. Resident 16 admitted to the facility in 2016 with diagnoses including dementia and anxiety. The resident was severely cognitively impaired.
A complaint intake dated 5/1/20 indicated Staff 6 (LPN) tipped Resident 16's wheelchair backwards with the resident in it and aggressively told the resident to stay in her/his room. Additionally the complaint intake revealed Staff 6 instructed Witness 1 (Complainant) to withhold juice the resident requested without a medical reason to withhold the juice.
A review of the resident's clinical record did not indicate the resident was on fluid restrictions. The resident's care plan indicated the resident was at risk for dehydration and fluids, including juices, were to be encouraged throughout the day and night
A 5/31/20 progress note revealed the resident made comments that she/he was "so lonely".
An 8/16/20 progress note indicated the resident reported being lonely and asked staff to check on her/him often.
On 9/29/20 a public complaint was received that alleged Staff 6 shoved Resident 16 in her/his wheelchair into her/his room from the doorway.
On 1/20/21 at 1:47 PM Staff 13 (CNA) reported she witnessed verbal abuse by Staff 12 (CMA) towards Resident 16. She further stated she also witnessed Staff 9 (RN) frequently be unkind to Resident 16. She reported the resident was not able to report if someone mistreated her/him.
On 1/20/21 at 1:21 PM Staff 7 (LPN) stated some staff were "more agitated" with Resident 16 than others.
On 1/20/21 at 3:15 PM Resident 16 was observed to propel her/his wheelchair in the hall as Staff 19 (CNA) exited another resident's room carrying a trash bag. Without saying anything to the resident, Staff 19 immediately used her one free hand to turn Resident 16's wheelchair around and pointed it towards her/his room. The resident wheeled her/himself back to her/his room.
On 1/20/21 at 3:25 PM Resident 16 was observed at the entrance to the open med room door and Staff 12 (CMA) stated loudly and in an agitated manner "no! not in here!" to the resident. The resident wheeled her/himself back to her/his room.
On 1/20/21 at 2:07 PM Resident 16 was observed to propel her/his wheelchair to the nurse's station and turned out of sight where day and evening staff were all huddled. From down the hall Staff 12 (CMA) was heard to say in an agitated and loud voice "Oh no, I am not dealing with this today." Immediately following the her statement, Resident 16 exited the area and returned to her/his room.
Observations made of Resident 16 on 1/26/21 between 10:00 AM and 2:00 PM revealed the resident propelled her/his wheelchair through the hall. The resident frequently appeared content to look around and be near staff. The unit was noticeably less restrictive during the day shift than it was during previous evening shift observations. Staff did not restrict Resident 16's movements and the resident was allowed to wander the hall freely and was not instructed to return to her/his room. No observations were made of inappropriate behavior, entering other resident's rooms or attempts to board the elevator.
On 1/26/21 at 11:41 AM Staff 11 (CMA) stated she witnessed Staff 10 (RN) stand at the nurse's station and yell at Resident 16 repeatedly "Get your mask on. Get your mask on" but she never offered to assist her/him to put one on. Staff 11 further reported on 1/22/21 Staff 6 (LPN) pushed Resident 16 to her/his room and once she reached the entrance to her/his room, Staff 6 pushed the resident into the room and let go of the wheelchair after she pushed. She stated Staff 6 did the same thing many times previously and it stopped for a short period of time when she was talked to by management. Staff 11 reported Staff 9 and Staff 12 also frequently yelled at Resident 16 to go to her/his room. She further reported she heard Staff 12 say "I ain't dealing with this today" as soon as she saw Resident 16.
On 1/26/21 at 12:24 PM Staff 20 (CNA) reported concerns related to staff on evening shift who wheeled Resident 16 back to her/his room every time she/he came out. She reported they did it "pretty fast or rough". She further reported the staff on evening shift frequently yelled at the resident to return to her/his room and put her/his mask on.
On 1/26/21 at 1:06 PM Resident 20, who was alert and oriented, stated Resident 16 liked to go around the facility in her/his wheelchair and Staff 6 always yelled at her/him to get back to her/his room. She/he reported Staff 6 talked "real ornery" to Resident 16. Resident 20 further stated she/he witnessed Staff 6 "shove" the resident into to her/his room "really hard". She/he demonstrated a quick forward motion with her/his hands. Resident 20 further stated "that's just not right".
On 1/26/21 at 1:15 PM Staff 16 (CNA) stated during evening shift every time Resident 16 came out of her room Staff 6 and Staff 12 pushed her/him right back into her/his room. She explained they appeared a little over the top at times when they pushed the resident in her/his wheelchair and demonstrated with her arms a forceful forward pushing motion. She stated they were not nice to Resident 16 and they yelled at the resident to go to her/his room and constantly pushed them towards her/his room. Staff 16 described the treatment of Resident 16 by Staff 6 and Staff 12 as both abuse and a lack of dignity. Staff 16 reported the resident seemed more depressed.
On 1/26/21 at 1:55 PM Staff 15 (CNA) reported she witnessed verbal abuse towards Resident 16 from Staff 10.
On 1/27/21 at 12:37 PM Staff 4 (Social Services) reported she witnessed a "complete lack of patience or compassion" from Staff 6 towards the resident. She reported on 8/31/20 Resident 16 was in her/his wheelchair near the nurse's station where she/he liked to sit. She stated Staff 6 walked up to the resident and stood over her/him in a position of power and in a very gruff tone told the resident she/he needed to be "down there" and pointed towards the residents room. Staff 4 reported she then grabbed the wheelchair and pushed the resident towards her/his room. She stated what she observed appeared to be abuse and did not sit right with her.
On 1/27/21 at 1:23 PM Staff 18 (CNA) reported Staff 6 repeatedly took Resident 16 back to her/his room and pushed her/him in a "hateful" way. She demonstrated a hard forward pushing motion with her arms and hands. Staff 18 stated during one incident Staff 6 leaned down and whispered to the resident and the resident began to cry. She reported several times Resident 16 described Staff 6 to her and told her she was "mean". Staff 18 said the resident exhibited different behaviors on Friday and Saturday when Staff 6 worked than on other days.
On 2/1/21 at 9:31 AM Staff 23 (Confidential Staff) reported during the week of 1/18/21 at approximately 3:30 PM Resident 16 told her she/he was scared of the "mean people". She stated the resident told her "they're mean; they're scary" and "it's bad out there". Staff 23 reported the resident held onto her hand and asked her not to leave. She stated the resident appeared scared and it was difficult to leave. Staff 23 reported the evening shift staff were not as patient with Resident 16 and tended to get upset with her/him. She reported Staff 6 and Staff 12 yelled at the resident and pointed down the hallway "like a dog" when they told her/him to go to her/his room. Staff 23 further stated they did not treat the resident like a human being.
On 2/2/21 at 12:02 PM Staff 8 (Housekeeping) recalled an incident when Staff 12 wheeled Resident 16 to her/his room and the resident had her/his feet down on the ground pushing against the movement the whole time Staff 12 pushed the wheelchair. She described another incident when the resident asked Staff 6 for pain medication and Staff 6 yelled at the resident that she/he already had something for pain and told her/him to go back to her/his room. Staff 8 reported approximately two months earlier Staff 6 pushed Resident 16 really hard in her/his wheelchair. She reported another time Staff 6 pushed the resident through the door of her/his room and she put her foot on the back of the wheelchair and held her hands on the door frame to prevent the resident from pushing her/himself back out of the room.
On 2/2/21 at 12:29 PM Staff 24 (Housekeeping) reported staff told her not to allow Resident 16 to touch her because the resident was "really gross". She further stated she witnessed Staff 12 yell at and push the resident roughly in her/his wheelchair.
On 2/2/21 at 1:24 PM Staff 3 (RNCM) stated staff did not report anything to her related to mistreatment of Resident 16. She reported she observed several staff be impatient with the resident and just tell her/him "oh you need to go that way". Staff 3 stated some staff treated the resident with disrespect and there were some staff on evening shift who repeatedly told Resident 16 to go to her/his room. She explained she did not think the staff intended to be mean when they were short with the resident. She reported she reminded the staff to not talk to the resident the way they did.
On 2/2/21 at 2:23 PM a tray table was observed in the doorway of Resident 16's room, placed like a gate. The resident pushed the table out of the way and exited her/his room in her/his wheelchair. Once the resident arrived at the nurse's station, Staff 12 immediately instructed the resident to "go back down the hall" in an agitated tone.
On 2/3/21 at 2:52 PM Staff 1 (Administrator) reported he was aware of concerns related to staff mistreatment of Resident 16. He stated he spoke with the subject staff and they become more calm with the resident. He reported he believed staff now treated the resident with respect.
2. Resident 21 admitted to the facility in 8/2018 with diagnoses including atrial fibrillation and heart failure.
A review of Resident 21's progress notes revealed the following:
*2/1/21 at 11:26 PM - The resident was upset after Staff 2 (DNS) spoke with her/him and "the CNA had to tell the DNS that the resident wanted some privacy twice before the DNS finally stopped. It took the staff some time to calm down the resident."
*2/2/21 at 6:13 PM - The resident reported she/he felt like she/he was targeted. The resident was "very angry at the DNS" and didn't want her in her/his room.
On 2/2/21 at 12:52 PM Resident 21 reported Staff 2 went into her/his room on 2/1/21 and "started in on me" regarding the amount of visitors she/he had outside. The resident stated she/he told Staff 2 she/he felt like she was being picked on, told Staff 2 she/he had enough and motioned for her to leave her/his room. Resident 21 reported Staff 2 would not leave her/his room. The resident further stated she "has it in for me because I talk back to her".
On 2/2/21 at 1:24 PM Staff 3 (RNCM) reported Resident 21 told her she/he felt as if Staff 2 repeatedly targeted and punished her/him.
On 2/2/21 at 5:39 PM Staff 19 (CNA) reported at approximately 8:15 PM on 2/1/21 Staff 2 went into Resident 21's room. Staff 19 stated she stood at the door to the medication room, two doors away from the resident's room with the intent to over hear what was about to occur because she "was kind of ready for it". Staff 19 explained Staff 2 frequently "does this" with the resident. She stated Staff 2 "kind of picks on" Resident 21 so staff were always ready to interject and advocate for the resident. She reported Staff 2 informed the resident she spoke with the resident's daughter and whether the resident liked it or not staff would wear all personal protective equipment (PPE) when they entered her/his room. She further stated Staff 2 also told the resident she/he could not have anymore outside visits. Staff 19 stated the resident became upset and asked Staff 2 to get out of her/his room twice but Staff 2 would not leave. Staff 19 reported she stepped in and told Staff 2 to respect the resident's wishes and leave her/his room.
On 2/3/21 at 12:38 PM Staff 9 (LPN) reported Resident 21 was upset the day following the interaction with Staff 2. She stated the resident told her if she/he could punch somebody in the nose she/he would have done it.
On 2/3/21 at 2:52 PM Staff 1 (Administrator) reported he talked with Resident 21 following the interaction and she/he was upset about the way Staff 2 treated her/him.
On 2/4/21 at 1:26 PM Staff 14 (CNA) reported when Staff 2 went to Resident 21's room on the night of 2/1/21 after 8:00 PM she stood nearby to listen to the interaction. She explained she did so because whenever Staff 2 went into Resident 21's room, she knew she would upset the resident and most staff stood nearby and looked out for the resident. Staff 14 reported during the interaction Staff 2 informed the resident staff would wear all PPE when they entered her/his room although she clarified the resident was not quarantined to her/his room. She stated the resident became upset, told Staff 2 she/he wanted privacy and told her to leave. She further stated Staff 2 did not leave the resident's room after she/he requested and Resident 21 again asked Staff 2 to leave. Staff 14 reported at that point, Staff 19 spoke up and told Staff 2 the resident asked her to leave and she needed to do so. Staff 14 stated it was not out of the ordinary for Staff 2 to treat Resident 21 differently than other residents and frequently spoke to the resident in a mean and controlling tone. She further stated the way Staff 2 treated the resident was mental abuse.
On 2/4/21 at 2:06 PM Witness 6 (Family Member) reported Resident 21 informed her of the interaction with Staff 2 on the evening of 2/1/21 and she/he was very upset about it. She stated the resident stated on previous occasions she/he thought Staff 2 deliberately picked on her/him. She confirmed the resident was fully cognitively intact.
On 2/8/21 at 8:54 AM Staff 6 (LPN) reported Staff 2 approached Resident 21's room on the evening of 2/1/21. She stated she was in the med room two doors away from the resident's room at the time and she chose to stay there so she could hear the interaction. Staff 6 reported other staff also froze and stood nearby because Staff 2 frequently targeted Resident 21 and they had to be ready to advocate for the resident. She stated Staff 2 was inside of the resident's room "just harping" on her/him regarding the resident being placed on enhanced precautions following her/his visit with family. Staff 6 reported Staff 2's voice was raised at Resident 21. She further reported the resident started to yell at Staff 2 to get out of her/his room. According to Staff 6, the resident repeatedly told Staff 2 to get out until Staff 19 intervened and calmly told Staff 2 to leave the resident's room. She stated even after staff intervened, it took a couple of minutes before Staff 2 finally "backed off". Staff 6 reported the resident was visibly upset.
F-600, GImmediate:¿ Upon receipt of survey findings, the facility immediately re-opened the abuse investigations. Staff #6 and staff #12 have been removed from the schedule. Staff #2 no longer works at the facility. ID of Others: ¿ The facility is conducting resident and staff interviews to determine if other residents have been affected by the alleged deficient practice. Corrective action to be taken if and where warranted. System Changes: > The facility staff will receive comprehensive abuse education to include what constitutes abuse, and the abuse reporting requirements.> The Social Service Director (SSD) will initiate random weekly resident/family interviews to assure that no resident feels mistreated of fearful. Results of the interviews will be shared with the NHA immediately if there is a concern voiced by the resident. >The Activity Director will provide residents with information on abuse reporting and resident rights at the next Resident council meeting.> The facility will conduct random daily observations of staff/resident interaction to ensure that no abuse or involuntary seclusion is taking place. On the spot education will be provided as needed, and any events of abuse will be reported to the proper entities immediately. Monitoring:¿ The NHA will review the daily observation for concerns and/or issues and will track and trend effectiveness of interventions¿ The results of the daily observation and the SSD interviews will be reviewed monthly (or sooner as needed) at the QAPI meeting. Changes will be made to the action plan as needed for sustained compliance.
Based on observation, interview and record review it was determined the facility failed to ensure residents were free from involuntary seclusion for 1 of 3 sampled residents (#16) reviewed for abuse. This placed residents at risk for a decreased quality of life. Findings include:
Resident 16 admitted to the facility in 2016 with diagnoses including dementia and anxiety.
A review of the 6/30/20 Annual MDS Assessment revealed the resident exhibited behaviors which included wandering daily. The resident had a BIMS score of 2 which indicated the resident was severely cognitively impaired.
On 5/1/20 an anonymous public complaint was received that alleged facility staff forced residents to stay in their rooms.
A 5/31/20 progress note indicated Resident 16 made comments that she/he was "so lonely".
An 8/6/20 progress note revealed the resident reported being lonely and asked staff to check on her/him often.
A 12/20/20 progress note indicated the resident stated she/he was lonely and wanted to be around staff during evening shift.
Resident 16's current care plan revealed staff should allow the resident to have control over situations as long as it did not endanger self or others. The care plan indicated when the resident wandered into other residents' rooms, staff should redirect the resident to her/his own room. There was nothing in the care plan to indicate the resident could not be out of her/his room.
On 1/20/21 at 1:47 PM Staff 13 (CNA) reported Resident 16 enjoyed being out in the hall and around staff. She stated when the evening shift staff arrived they immediately sent the resident to her/his room.
On 1/20/21 at 3:15 PM Resident 16 was observed in the hall in her/his wheelchair as Staff 19 (CNA) came out of another resident's room carrying a trash bag. Immediately upon seeing Resident 16 and without saying anything, Staff 14 used her free hand to turn the resident's wheelchair around pointed back towards the resident's room. Resident 16 did not have inappropriate behaviors and did not attempt to enter other resident's rooms. The resident did nothing other than be in the hall when she/he was turned around. Resident 16 returned to her/his room.
During observations between 2:00 PM and 4:00 PM on 1/20/21, Staff 9 (RN) and Staff 12 (CMA) frequently instructed Resident 16 to return to her/his room or turned the resident's wheelchair towards her/his room each time the resident was in the hall. The resident did not exhibit inappropriate behaviors or attempt to enter other resident's rooms.
Observations made during evening shift on 1/25/21 revealed Staff 6 (LPN), Staff 12, Staff 14 (CNA) and Staff 19 (CNA) repeatedly instruct Resident 16 to return to her/his room or physically moved the resident in her/his wheelchair to or toward her/his room each time the resident was in the hall. The resident did not behave inappropriately and did not attempt to enter other resident's rooms.
Observations made during day shift on 1/26/21 revealed Resident 16 frequently propelled her/himself back and forth from her/his room to the nurse's station. The resident had no inappropriate behaviors, did not attempt to enter other resident's rooms and appeared content. At no time during the day shift observations did any staff instruct Resident 16 to return to her/his room.
On 1/26/2021 at 11:41 AM Staff 11 (CMA) reported she witnessed multiple staff repeatedly wheel Resident 16 back to her/his room and yell at the resident to go to her/his room. She reported some staff placed a tray table inside the resident's doorway of her/his room so it appeared the resident was locked in the room. Staff 11 stated the resident was able to move the tray table independently.
On 1/26/21 at 1:15 PM Staff 16 (CNA) reported when she worked evening shift, she observed staff push Resident 16 back to her/his room every time the resident came out of her/his room.
On 1/26/21 12:24 PM Staff 20 (CNA) stated she previously worked evening shift and no longer would due to her concerns related to some staff on evening shift who constantly returned Resident 16 to her/his room. She stated the staff pushed the resident back to her/his room every time she/he came out in the hall. Staff 20 further reported the staff also yelled at the resident to go back to her/his room. She stated Staff 2 (DNS) told staff that all of the residents were to stay in their rooms due to Covid-19. She reported it seemed only Resident 16 was told to return to her/his room while other residents who came out in the hall were not stopped. Staff 20 stated she could understand the redirection to her/his room if the resident went into other residents' rooms however the resident was returned to her/his room every time she/he was just in the hall.
On 1/26/21 at 1:55 PM Staff 15 (CNA) reported she saw staff push Resident 16 in her/his wheelchair back to her/his room repeatedly. She stated the facility felt like a prison.
On 1/26/21 at 2:13 PM Staff 19 reported Staff 2 heavily implied to staff they were supposed to keep the residents in or near their rooms.
On 1/27/21 at 11:40 AM Staff 7 (RN) reported staff were instructed by management to not allow residents to sit in the hall or near the nurse's station. She stated many residents liked to sit in the hall and now the residents were confined to their rooms. Staff 7 reported the residents were too isolated.
On 1/27/21 at 1:23 PM Staff 18 (CNA) reported Staff 2 and Staff 6 instructed staff to keep all residents in their rooms. She stated she did not think it was right and did not do so.
On 1/27/21 at 12:37 PM Staff 4 (Social Services) reported Resident 16 was a social butterfly and wanted to be where the action was. She stated on 8/31/20 Resident 16 was in her/his wheelchair by the nurse's station where she/he liked to be and Staff 6 told the resident she/he needed to be "down there" and pointed towards the resident's room. Staff 4 reported she did not understand why Staff 6 did not want the resident to sit there.
On 2/1/21 at 9:45 AM Staff 5 (Activity Director) stated she observed staff frequently tell Resident 16 to go back to her/his room. She reported the facility felt like a prison.
On 2/2/21 at 12:02 PM Staff 21 (Housekeeping) reported multiple staff who worked evenings and weekends constantly told Resident 16 to go to her/his room.
Observations made during evening shift on 2/2/21 revealed the following:
* 2:23 PM A tray table was in the doorway of Resident 16's room like a gate. The resident pushed it out of the way and exited her/his room.
* 2:26 PM Resident 16 propelled her/himself down the hall to the nurse's station. The resident did not behave inappropriately and did not attempt to enter rooms. Staff 12 immediately instructed the resident to "go back down the hall". The resident returned to her/his room.
* 2:30 PM Staff 22 (CNA) placed the tray table back in the resident's doorway once the resident was back in her/his room.
* 3:17 PM A wet floor sign was on the carpeted floor in the middle of the area in front of the nurse's station, placed there with the intention to keep the resident from going in front of the nurse's station.
* 3:20 PM Resident 16 propelled towards the nurse's station again. The resident did not exhibit inappropriate behavior and did not attempt to enter another resident's room. When the resident reached the nurse's station Staff 9 immediately pushed the resident in her/his wheelchair back down the hall towards her/his room. Resident 16 continued to her/his room independently.
* 3:36 PM Resident 16 headed back down the hall and when she/he neared the nurse's station, Staff 19 immediately turned the resident's wheelchair around and pushed her/him back down the hall towards her/his room. Resident 16 continued to her/his room independently.
* 3:42 PM Resident 22 was in the hallway next to the nurse's station talking to another resident who was in their room. Staff did not instruct her/him to go to her/his room.
* 4:01 PM Resident 16 wheeled her/himself past the nurse's station to the end of the hall and turned around with no inappropriate behavior and no attempts to enter another resident's room. Once the resident was near the nurse's station on her/his way back Staff 9 told the resident to go back to her/his room.
* 5:46 PM Staff 19 instructed Staff 22 to place the wet floor sign back in the middle of the carpeted walkway in front of the nurse's station to prevent Resident 16 from entering the area.
* 6:01 PM Resident 16 propelled her/himself to the nurses station and Staff 12 immediately turned the wheelchair around and told the resident to go the other way.
On 2/2/21 at 1:24 PM Staff 3 (RNCM) reported she was told by management the residents were supposed to stay in their rooms as much as possible. She confirmed she witnessed staff instruct Resident 16 to return to her/his room and did not see them do the same with other residents.
F-603, DImmediate: ¿ Upon receipt of survey findings, the facility immediately re-opened the abuse investigations. Staff #6 and staff #12 have been removed from the schedule. Staff #2 no longer works at the facility.ID of Others: ¿ The facility is conducting resident and staff interviews to determine if other residents have been affected by the alleged deficient practice. Corrective action to be taken if and where warranted.System Changes:> The facility staff will receive comprehensive abuse education to include what constitutes abuse, and the abuse reporting requirements.> The Social Service Director (SSD) will initiate random weekly resident/family interviews to assure that no resident feels mistreated of fearful. Results of the interviews will be shared with the NHA immediately if there is a concern voiced by the resident. > The Activity Director will provide residents with information on abuse reporting and resident rights at the next Resident council meeting.> The facility will conduct random daily observations of staff/resident interaction to ensure that no abuse or involuntary seclusion is taking place. On the spot education will be provided as needed, and any events of abuse will be reported to the proper entities immediately. Monitoring: ¿ The NHA will review the daily observations for concerns and/or issues, and will track and trend the effectiveness of interventions¿ The results of the daily observations and the SSD interviews will be reviewed monthly (or sooner as needed) at the QAPI meeting. Changes will be made to the action plan as needed for sustained compliance.
Based on interview and record review it was determined the facility failed to develop and implement written policies related to required abuse training and reporting of abuse for 2 of 2 sampled residents (#s 16 and 21) reviewed for abuse. This failure resulted in psychosocial harm as evidenced by Resident #16's depressed mood and expression of fear and anxiety. Findings include:
The facility's 4/2010 Reporting Abuse to Facility Management policy revealed the following:
- It was the responsibility of employees to promptly report incidents or suspected incidents of resident abuse to facility management.
- To assist with recognition of incidents, abuse was defined as "the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish"; and mental abuse was defined as, but not limited to, "humiliation, harassment, threats of punishment, or withholding of treatment or services".
- All personnel were encouraged to report incidents of resident abuse or suspected incidents of abuse and reports could be made without fear of retaliation from the facility or it's staff.
The facility's 7/2017 Abuse Investigation and Reporting Policy indicated "All reports of resident abuse...mistreatment...shall be promptly reported to local, state and federal agencies...and thoroughly investigated by facility management."
Review of the facility's written policies and procedures related to abuse did not reveal any documentation related to required employee abuse training.
A review of the documentation of staff abuse and behavioral management training indicated only 4 out of 23 direct care staff completed the required annual training.
1. Resident 16 admitted to the facility in 2016 with diagnoses including dementia and anxiety. The resident had a BIMS of 2 which indicated severe cognitive impairment.
A complaint intake dated 5/1/20 indicated Staff 6 (LPN) tipped Resident 16's wheelchair backwards with the resident in it and aggressively told the resident to stay in her/his room. Additionally the complaint intake revealed Staff 6 instructed Witness 1 (Complainant) to withhold juice the resident requested without a medical reason. Witness 1 indicated in the complaint they did not report the concerns to management due to fear of retaliation.
A complaint intake dated 9/29/20 indicated Staff 6 shoved Resident 16 in her/his wheelchair through the door and into her/his room forcefully. The complaint further indicated the behavior had gone on for some time but staff were afraid to report due to fear of retaliation.
One investigation was found related to abuse towards Resident 16. It was completed on 9/26/20 and indicated Staff 6 allegedly transported the resident in an unsafe manner. A review of the investigation revealed:
* There were no descriptions to explain how the wheelchair transport was "unsafe".
* Resident 16 had dementia, was alert to her/his name, recognized family and reported God spoke to her/him; yet the resident was able to deny psychological harm from the incident.
* The resident was asked a series of yes or no questions, none of which were related to the incident cited in the allegation.
* Staff statements documented in the investigation revealed the following:
- Staff 11 (CMA) reported Staff 6 pushed the resident in her/his wheelchair in a manner that she felt was unsafe.
- Staff 6 denied pushing the resident in the wheelchair in a manner that would place the resident at risk for injury.
- Of the four additional interviews with staff, only one of them was interviewed related to the allegation of the unsafe wheelchair transport. The one staff reported she did not witness staff push the resident forcefully in the wheelchair.
On 1/20/21 at 1:21 PM Staff 7 (LPN) stated some staff were agitated towards Resident 16 but did not think the staff's behavior was abuse.
On 1/25/21 at 2:18 PM Staff 14 (CNA) reported she had abuse training in school but did not receive training from the facility.
On 1/25/21 at 4:44 PM Staff 2 (DNS) reported she completed an investigation related to unsafe wheelchair transport in 9/2020 and did not find abuse. She stated the staff person who reported the alleged abuse was upset with Staff 6 which was why she reported the incident. Staff 2 denied any additional allegations of mistreatment towards Resident 16.
On 1/26/21 at 12:24 PM Staff 20 (CNA) stated she reported concerns about evening shift staff yelling at Resident 16 and treating her/him roughly to management. She stated other staff would not report because they were worried about retaliation.
On 1/26/21 at 1:15 PM Staff 16 (CNA) described the way Staff 6 and Staff 12 treated Resident 16 as both abuse and a dignity issue. She stated she reported her concerns to Staff 1 (Administrator). She further stated she probably should have made more of an official statement however she was used to things being swept under the rug by management. Staff 16 stated most of the staff were hesitant to speak up because the staff they reported would "make our worlds tougher".
On 1/26/21 at 1:55 PM Staff 15 (CNA) stated she reported concerns of verbal abuse towards Resident 16 by Staff 10 to management but nothing usually happened when concerns were brought to management. She reported when she advocated for resident's she was disciplined for minor infractions or punished with schedule changes.
On 1/27/21 at 12:26 PM Staff 1 reported the first time he heard of any concerns related to mistreatment towards Resident 16 by Staff 6 was on 9/24/20. He stated at the time Staff 2 (DNS) investigated the incident and she determined abuse did not occur. He reported Staff 2 did not share anything related to the investigation with him besides abuse was ruled out. Staff 1 stated there were no other abuse allegations or investigations related to Resident 16.
On 1/27/21 at 12:37 PM Staff 4 (Social Services) reported she witnessed what she thought was abuse towards Resident 16 and she informed Staff 1 of the incident on 9/1/20. She stated Staff 1 thanked her for letting him know but she did not hear anything more.
On 1/27/21 at 1:23 PM Staff 18 (CNA) stated she reported concerns of mistreatment by Staff 6 towards Resident 16 to management, including Staff 1, and as a result became the target of hostile staff.
On 2/1/21 at 9:31 AM Staff 23 (Confidential Staff) reported one day during the week of 1/18/21 at approximately 3:30 PM Resident 16 told her she/he was scared of the "mean people". She stated the resident told her "they're mean; they're scary" and "it's bad out there". Staff 23 stated the evening shift staff were not as patient with Resident 16 and tended to get upset with her/him. She reported Staff 6 and Staff 12 yelled at the resident and treated the resident "like a dog" when they pointed down the hallway and told her/him to go to her/his room. Staff 23 said Staff 6 and Staff 12 did not treat the resident like a human being. She reported concerns related to staff mistreatment of Resident 16 were brought up multiple times in morning huddle over the last year and nothing was done.
On 2/1/21 at 9:45 AM Staff 5 (Activity Director) reported there was no real abuse training. She stated there were two in-services done related to abuse but the training was not comprehensive.
On 2/2/21 at 12:02 PM Staff 8 (Housekeeping) stated she informed Staff 1 of concerns which she described as verbal and mental abuse towards Resident 16 by Staff 6 and Staff 12 and he told her it would be investigated. She said the same concerns were brought up many times in morning huddle by other staff.
On 2/2/21 at 1:24 PM Staff 3 (RNCM) confirmed concerns related to staff's mistreatment of Resident 16 were brought up in morning huddle but nothing to her knowledge was done.
On 2/3/21 at 2:52 PM Staff 1 (Administrator) confirmed he was aware of the concerns related to the staff mistreatment of Resident 16 because they were brought up during morning huddle. He confirmed he did not investigate or report the concerns as abuse.
Refer to F600 and F603.
2. Resident 21 admitted to the facility in 8/2018 with diagnoses including atrial fibrillation and heart failure.
On 2/2/21 at 12:52 PM Resident 21 reported Staff 2 went into her/his room on 2/1/21 and "started in on me". The resident stated she/he told Staff 2 she/he felt picked on and motioned for her to leave the room. Resident 21 reported Staff 2 would not leave her/his room. The resident further stated Staff 2 "has it in for me" because "I talk back to her".
On 2/2/21 at 5:39 PM Staff 19 (CNA) reported when Staff 2 went into Resident 21's room, she remained near to witness the interaction because Staff 2 frequently "kind of picks on" the resident. She reported on the evening of 2/1/21 the resident became really upset and asked Staff 2 to get out of her/his room twice but Staff 2 would not leave. Staff 19 reported she asked Staff 2 to respect the resident's wishes and leave the room. She said Staff 2 immediately retaliated against her and told her they would have a meeting the following day with Staff 1 (Administrator) due to her insubordination. She stated Staff 2 frequently used threats of discipline against staff who advocated for residents.
On 2/3/21 at 2:20 PM Staff 3 (RNCM) said Resident 21 informed her she/he felt like Staff 2 repeatedly targeted and punished her/him. Staff 3 reported most of the staff witnessed how Staff 2 "riles up" Resident 21. She reported Staff 2 intended to fire Staff 19 because she stepped in during the incident on 2/1/21.
On 2/3/21 at 2:52 PM Staff 1 (Administrator) reported he talked with Resident 21 following the interaction and she/he was really upset about the way she/he was treated by Staff 2.
On 2/4/21 at 1:26 PM Staff 14 (CNA) reported when Staff 2 went into Resident 21's room on the night of 2/1/21 she remained nearby to listen to the interaction because she knew the resident would be upset. She reported after the resident asked Staff 2 to leave her/his room twice with no result, Staff 19 spoke up and told Staff 2 she needed to do as the resident asked. She reported Staff 2 then told Staff 19 she would be disciplined for intervening. Staff 14 reported Staff 19 was in trouble only because she advocated for the resident when Staff 2 was abusive.
On 2/8/21 at 8:54 AM Staff 6 (LPN) reported when Staff 2 approached Resident 21's room on the evening of 2/1/21 she chose to stay in the med room two doors away so she could hear the interaction. She reported Staff 2 was inside the resident's room "just harping" on the resident with a raised voice and when the resident yelled at Staff 2 to leave her/his room she would not leave. Staff 6 reported Staff 19 stepped in and calmly told Staff 2 to leave the resident's room because the resident was visibly upset. She reported Staff 1 frequently wrote staff up for insubordination when they advocated for a resident. Staff 6 reported the facility provided vague training related to abuse and behaviors and it was only provided when the facility received a citation.
Refer to F600.
F-607, GImmediate: ¿ Upon receipt of survey findings, the facility immediately re-opened the abuse investigations. Staff # 6 and staff #12 have been removed from the schedule. Staff #2 no longer works at the facility. Other corrective action will be taken as warranted. ID of Others:¿ All residents have the potential to be affected by the alleged deficient practice.System Changes:¿ The facility has a written policy that includes required annual abuse training. Staff will be educated on the written policy. ¿ Facility staff will be educated on abuse prevention and reporting.¿ The NHA will complete quarterly audits of in-service records to be sure that all staff have received the annual abuse prevention and reporting training. Monitoring:¿ The NHA will bring the results of the abuse training audit to QAPI meeting monthly for committee review for three months and then quarterly to assure sustained compliance with the rule.
Based on observation, interview and record review, it was determined the facility failed to provide an ongoing activity program to support the mental and psychosocial well-being for 1 of 1 sampled resident (#16) reviewed for abuse. This placed residents at risk for social isolation. Findings include:
Resident 16 admitted to the facility in 2016 with diagnoses including dementia and anxiety.
The 12/31/20 Quarterly MDS Assessment revealed the resident wandered daily. The resident had a BIMS score of 2 which indicated severe cognitive impairment.
Resident 16's current care plan revealed socialization time was important to the resident.
Observation of the Activity Calendar posted near the nurse's station revealed the following schedule:
*10:00 AM: "sensory" or "reminisce" alternated each day
*11:00 AM: 1:1
*1:00 PM: alternating activities listed were "boggle", "store", "beading", "reminisce" and "letter writing"
During observations of the facility on 1/20/21, 1/26/21, 1/27/21, 2/2/21 and 2/3/21, no activities were conducted with any residents. 15 out of 20 residents remained in their rooms during all observations.
On 1/20/21 at 1:47 PM Staff 13 (CNA) reported Resident 16 needed attention and she/he was bored.
On 1/26/21 at 11:41 AM Staff 11 (CMA) reported she was not aware of any activities being done with any residents. She stated the residents could not have puzzles or magazines due to the Covid-19 restrictions.
On 1/26/21 at 1:15 PM Staff 16 (CNA) reported there were no activities since 3/2020 when Covid-19 restrictions began. She stated Resident 16 wandered and was bored.
On 1/26/21 at 12:24 PM Staff 20 (CNA) reported there were no activities to keep Resident 16 busy.
On 1/26/21 at 1:06 PM Resident 20 reported Resident 16 was lonely and there was nothing for her/him to do to keep busy. She/he stated there were no activities to her/his knowledge and that was fine because she/he preferred to stay in her/his room. The resident reported Resident 16 was different and needed organized activities.
On 1/26/21 at 1:55 PM Staff 15 (CNA) stated there was nothing for Resident 16 to do because activities were stopped in 3/2020 due to Covid-19 restrictions. She reported the resident liked to throw balls into cups, look at pictures, color and go outside. Staff 15 stated Staff 2 (DNS) instructed staff not to take Resident 16 outside any longer. She stated staff could get activity packets but they did not have time to do the activities with the resident who could not independently do them.
On 1/27/21 at 11:38 AM Staff 13 reported she witnessed Resident 16 have one to one activities sometimes but it was less than one hour and less than once per week.
On 1/27/21 at 11:40 AM Staff 7 (LPN) reported activities were not what they used to be prior to the Covid-19 pandemic. She stated the residents used to have books and puzzles but they were all removed from the unit due to possible cross contamination. Staff 7 reported Resident 16 used to be able to go outside and now she/he cried to go outside. She stated they were told by Staff 2 they could not bring her/him outside anymore due to Covid-19 restrictions.
On 1/27/21 at 12:37 PM Staff 4 (Social Services) reported most of Resident 16's behaviors were due to extreme boredom. She stated the resident was a social butterfly and wanted to be where the action was. Staff 4 reported due to Covid-19 restrictions there was no space available for residents to have activities and maintain social distance. She further reported they wanted to create an activity space in an empty room but it was unknown if that could happen. Staff 4 reported Resident 16 enjoyed the garden and gazebo area outside and staff brought her/him out if they had time.
On 2/1/21 at 9:45 AM Staff 5 (Activity Director) reported Staff 2 told her she could not do any activities with the residents outside of their rooms. She reported she wanted to clear out an empty room so she could do small group activities while she kept the residents socially distanced. She stated she did one to one activities with Resident 16 when she had time and also brought her/him activity packets. She reported unless she stayed with the resident, she/he lost interest in the packets.
On 2/1/21 at 2:10 PM Witness 3 (Complainant) reported Resident 16 was bored because the facility did not offer activities due to Covid-19 restrictions.
On 2/2/21 at 1:24 PM Staff 3 (RNCM) reported Staff 5 wanted to restart activities and talked about it for several months. She stated she was under the impression an empty room would be set up as an activity space but then heard from Staff 1 (Administrator) they were not able to do it. She reported Resident 16 liked to go outside around the gazebo and was not aware Staff 2 told staff they could not take her/him outside any longer. Staff 3 reported Resident 16 needed to be around people and have attention.
On 2/2/21 at 4:06 PM Staff 22 (CNA) reported Resident 16 seemed bored. She stated the resident was always on the move with nowhere to go.
On 2/3/21 at 2:52 PM Staff 1 (Administrator) reported activities were not done as they were prior to Covid-19. He stated one to one activities with all residents were supposed to occur daily but was unsure if they did.
F-679, DImmediate:¿ A facility IDT meeting will be held to discuss and determine resident #16s care needs, and appropriate, effective interventions. The care plan will be updated as warranted.¿ The Activity Director will complete an updated activity evaluation for resident #16 to determine how best to meet the residents activity wants/needs. ID of Others:¿ All residents have the potential to be affected by the alleged deficient practice.¿ The facility is currently under an Executive Order due to COVID-19 and so there are some restrictions on allowable activitiesSystem Changes:¿ The AD will review and adjust the activity calendar to more accurately reflect the current activity offerings for the residents. ¿ The NHA will conduct twice weekly rounds to audit to be sure the activities are being offered per the posted calendar. Monitoring:¿ The results of the NHA activity rounding will be shared at the monthly QAPI meeting for trending and compliance with the rule.
Based on observation, interview and record review it was determined the facility failed to identify a change of condition timely for 1 of 3 sampled residents (#16) reviewed for change of condition. This placed residents at risk for unmet medical needs. Findings include:
Resident 16 admitted to the facility in 2016 with diagnoses including dementia and recurrent urinary tract infections. The resident was severely cognitively impaired.
The resident's care plan area related to the history of dehydration and last reviewed 8/10/20 revealed she/he was at risk for dehydration related to the use of a diuretic (a medication that increases the excretion of water from the body). The care plan instructed staff to assess the resident for signs of dehydration which included a change in mental status.
On 1/26/21 at 12:02 PM Resident 16 was observed bent forward in her/his wheelchair. Upon Staff 1's (Administrator) observation of the resident bent forward, he stated it was odd and he never saw the resident lean like that. Staff 1 was observed to inform Staff 3 (RNCM) and Staff 7 (LPN) of his observations of the resident. Staff 7 informed him the resident had been "off" for about a week.
On 1/26/21 at 12:24 PM Staff 16 (CNA) stated Resident 16 slept more during the last couple of weeks and was "almost like a zombie". She reported she informed the charge nurses.
During observations on 1/26/21 at 12:30 PM Staff 4 (Social Services) brought Resident 16 to the telephone in the hall to speak with her/his family. The resident was unable to hold the telephone and dropped it repeatedly. Staff had to hold the phone for her/him. Resident 16 mumbled incomprehensible words into the phone. When the resident was finished, Staff 4 informed the resident's family member on the phone that the resident seemed extremely tired.
On 1/26/21 at 1:44 PM Resident 16 was again observed in her/his wheelchair bent completely forward over her/his lap.
On 1/27/21 at 11:29 AM Resident 16 was observed in bed lying on her/his right side staring at the wall. Staff 7 entered the room and Staff 20 (CNA) informed her the resident did not seem alright. The resident did not respond to either staff member.
On 1/27/21 at 11:38 AM Staff 13 (CNA) reported Resident 16 had not "been good" for a month. She stated she could tell something was wrong with the resident when she/he did not drink liquids because the resident loved juice.
On 1/27/21 at 11:44 AM Staff 20 reported the resident was "going downhill". She stated the resident normally liked to drink juice and she/he would not drink any. She further stated Resident 16 could not hold a cup.
On 1/27/21 at 11:54 AM Staff 7 (LPN) reported the leaning Resident 16 exhibited the day before was new. She stated the resident usually followed her around asking for juice and today she did not get out of bed. Staff 7 further stated the resident appeared tired and weak yesterday. She reported she spoke with the resident's family member who requested the resident be sent to the hospital.
On 1/27/21 at 12:37 PM Staff 4 (Social Services) reported she usually wrote on a whiteboard for the resident to read and reply but lately she/he did not respond. She stated when she passed the resident in the hall she danced for the resident and she/he usually looked up and smiled. She further stated the resident now only looked down at her feet. Staff 4 reported the resident declined and she never saw the resident keep her/his head lowered like she/he could not lift it.
A review of progress notes from 1/1/21 through 1/26/21 did not reveal any documentation related to a decline or change in condition of Resident 16.
A progress note dated 1/27/21 at 12:45 PM revealed the resident was lethargic and did not respond to verbal commands. The note revealed the resident's family member was contacted who made the decision to send the resident to the hospital.
On 1/27/21 at 1:23 PM Staff 18 (CNA) reported she was aware Resident 16 did not feel good the previous week and she/he sometimes went through periods like that. She stated she noticed that day the resident was much more "out of it" than normal.
A review of the Hospital Discharge Summary dated 1/29/21 revealed Resident 16 was admitted to the hospital for altered mental status and was found to have a urinary tract infection which required intravenous fluid hydration and antibiotics.
On 2/1/21 at 2:10 PM Witness 3 (Complainant) reported on 1/26/21 Resident 16 could not even talk to her on the phone. She stated she called the facility the next day and the resident was unable to come to the phone. Witness 3 reported the resident was finally sent to the hospital at her request where she/he was found to be dehydrated and had a severe urinary tract infection. Witness 3 reported the facility had contacted her on 1/26/21 to discuss moving the resident due to her/his behaviors. She expressed concern that the staff did not recognize the change in the resident as a sign of a UTI. She reported the facility instead focused on stopping the resident's behaviors rather than try to determine the underlying cause.
On 2/3/21 at 2:20 PM Staff 3 (RNCM) reported Resident 16 appeared near baseline after she/he returned from the hospital. She stated the resident was full of energy unlike the weeks prior to the hospitalization.
F-684, DImmediate:¿ Resident #16 was treated and is currently at her baseline health status. ID of Others:¿ All residents have the potential to be affected by the alleged deficient practice. ¿ The Resident Care Manager (RCM) or Designee will complete a nursing eval of current residents to determine if a change of condition is occurring. Follow up as needed. System Changes:¿ The Nursing staff will be educated on identifying a change of resident condition and how to report a change of condition. ¿ Each workday morning the nurse management team will review the 24- hour report and the prior days progress notes for any status change with the residents. Follow up and notification will be completed as needed. ¿ The DNS/RCM will complete random resident observations and/or evals twice weekly for s/sx of a condition change. The DNS/RCM will follow up with any change as warranted. Monitoring:¿ The DNS will bring the results from the random resident observations and progress note reviews to the monthly QAPI meeting for compliance review. Changes will be made to the action plan per the QAPI committee recommendations.
Based on interview and record review it was determined the facility failed to obtain ensure hospice services were implemented in a timely manner for 1 of 3 sampled residents (#103) reviewed for change of condition. This failure placed residents at risk for lack of hospice services. Findings include:
Resident 103 readmitted to the facility in 4/2021 with diagnoses including respiratory failure.
An 4/13/21 progress note indicated a Care Conference was held with facility staff and Resident 103's family members. Hospice services were recommended by the facility and the family agreed to begin hospice services for Resident 103. The physician was contacted and an order for hospice services was requested.
An 4/19/21 progress note indicated no order for hospice services was received yet and a second request was sent to the physician.
A 5/3/21 progress note indicated the facility was still waiting for hospice orders. The physician was contacted again.
A 5/7/21 progress note indicated the physician signed orders for hospice services.
On 5/13/21 at 10:22 AM Staff 3 (RNCM) stated Resident 103's family wanted hospice services and the facility prepared the documentation. Staff 3 stated she sent the information to the physician, but there was no response. Staff 3 stated she "badgered and badgered" the physician until Resident 103 was seen on 5/7/21 and an order for hospice services was obtained.
On 5/13/21 at 11:43 AM Staff 2 (DNS) stated Resident 103's family wanted hospice services for the resident. Staff 2 stated attempts to obtain a physician order for hospice services were not successful "for quite some time." Staff 2 stated Resident 103 was admitted to hospice services on 5/13/21 and indicated one month passed since the family requested hospice services.
Resident #103 is currently under Hospice Care services.All terminal residents have the potential to be affected by the alleged deficient practice.Systemic Changes:The LN staff will be educated on how to complete a Hospice referral.When there is a potential Hospice appropriate resident at the facility, the nurse management team will call Hospice direct (as well as the medical provider), so that Hospice can complete an evaluation for appropriateness of service/need in collaboration with the resident’s medical provider. Any request or referral for Hospice services will be noted on the facility 24 hour report to assure facility timely follow up. The RCM or designee will review/audit the 24 hour report prior to stand-up meeting, and follow up on any Hospice referrals to assure timely resolution. The RCM/designee will bring the results of the audits with timeliness trending to the monthly QAPI meeting for revisions to the action plan as needed.
Based on interview and record review it was determined the facility failed to ensure residents were seen by a physician at least once every 60 days for 2 of 3 residents (#s 16 and 20) reviewed for medications. This placed residents at risk for unmet assessment needs. Findings include:
1. Resident 16 admitted to the facility in 2016 with diagnoses including dementia, history of non-Hodgkin lymphoma, hypertension and osteoporosis. The resident was severely cognitively impaired.
Review of Resident 16's physician visit notes from 1/1/20 to 2/1/20 revealed only two physician visits occurred: on 2/6/20 and 11/30/20. The 11/30/20 visit note indicated the resident should return again in six months.
On 1/27/21 at 11:14 AM Staff 1 (Administrator) reported Resident 16 was not seen by the facility's medical director and instead saw her/his own physician.
On 1/27/21 at 12:37 PM Staff 4 (Social Services) reported she went to the physician appointment with Resident 16 on 11/30/20. She stated the appointment was for a specific gastrointestinal concern and nothing additional was discussed related to medications or behaviors.
On 2/2/21 at 1:24 PM Staff 3 (RNCM) confirmed residents should have physician visits every 60 days and Resident 16 only had two visits in the last year.
2. Resident 20 admitted to the facility in 2019 with diagnoses including diabetes with complications, heart failure, hypertension and atrial fibrillation.
On 2/20/21 a review of all physician visit notes from 1/1/20 to 2/1/21 revealed Resident 20's last physician visit was on 3/12/20, nine months ago.
On 2/2/21 at 1:24 PM Staff 3 (RNCM) confirmed residents should have physician visits every 60 days.
F-712, DImmediate:¿ Resident #16 had an appointment scheduled with the MD on 03/17/2021 and next scheduled appointment 5/12/2021. Resident #20 will have an appointment scheduled with the MD on_02/18/2021 and next scheduled appointment is 04/19/2021. ID of Others: ¿ Medical Records Director (MRD) will audit current resident charts to assure MD visits have occurred within the 60-day timeframe. If there are any missed visits, the SSD will schedule appointments with the provider.System Changes:¿ A review of the MD visit timeliness rule will be completed with the facility management team in order to assure understanding of the federal requirement. ¿ The MRD will conduct routine monthly audits for any MD visits that are due and will provide a list of residents in need of appointments to the SSD so that visits may be scheduled. Monitoring:¿ MRD will bring the MD visit audits and compliance trending to the monthly QAPI meeting for review. Changes to the action plan per committees recommendations.
Based on interview and record review it was determined the facility failed to ensure a full time Director of Nursing was in place and failed to ensure an RN served as the charge nurse for eight consecutive hours, seven days a week for 14 out of 64 days reviewed for staffing coverage. This placed residents at risk for ineffective and uncoordinated nursing services and unmet assessment needs. Findings include:
1. On 1/25/21 at 4:44 PM Staff 2 (DNS) reported she started a new job but came into the facility when needed before and after her new job.
On 2/1/21 at 9:31 AM Staff 5 (Activity Director) reported Staff 2 was technically the facility's DNS even though she did not work there any longer and only came in every once in a while.
On 2/2/21 at 12:52 PM Resident 21 reported it was her/his understanding that Staff 2 quit her job as the DNS however she was still at the facility sometimes and she/he was unsure of her role.
On 2/2/21 at 1:24 PM Staff 3 (RNCM) reported she did not know what the plan was related to the DNS position. She stated Staff 2 still came into the facility at times but she did not know when it would be. Staff 3 reported Staff 2 had another full time job.
On 2/3/21 at 2:52 PM Staff 1 (Administrator) reported Staff 2 was listed as the active DNS however she worked at another job and did not work full time at the facility. He stated they were actively looking to hire a new DNS.
2. The facility's Direct Care Staff Daily Reports from 12/1/20 through 2/2/21, revealed an RN did not work eight consecutive hours on the following days: 12/4/20, 12/5/20, 12/6/20, 12/7/20, 12/9/20, 12/26/20, 12/28/20, 1/3/21, 1/16/21, 1/17/21, 1/18/21, 1/22/21, 1/24/21 and 1/28/21.
On 2/3/21 at 2:52 PM Staff 1 (Administrator) confirmed the RN staffing shortages.
F-727, FImmediate:¿ The new Director of Nursing Services (DNS) began full time employment at the facility on 3/18/21. ¿ An additional charge shift RN has been hired as of 3/18/21. ID of Others:¿ All residents have the potential to be affected by the alleged deficient practice. System Changes:¿ The newly hired DNS is full time and is available to staff and residents. ¿ The facility staffing person will be re-educated on the RN requirement to assure RN coverage is scheduled at least 8 consecutive hours/day 7 days/week per the rule. ¿ During the daily stand- up meeting, the upcoming schedule will be reviewed to assure that the RN coverage is in place to meet the rule. Monitoring:¿ The NHA/DNS will report to the monthly QAPI committee the compliance trending with RN and DNS coverage. ¿ Changes may be made to the action plan based on the QAPI committees recommendations.
Based on observation, interview and record review it was determined the facility failed to ensure a PRN order for an antipsychotic was not in place for more than 14 days, failed to to identify or monitor targeted behaviors for the use of an antipsychotic and failed to have a system in place to determine the efficacy of an antipsychotic and communicate such to the physician for 3 of 3 sampled residents (#s 16, 18 and 19) reviewed for unnecessary medications. This failure resulted in new and prolonged significant change in alertness for Resident 16. Findings include:
1. Resident 16 admitted to the facility in 2016 with diagnoses including dementia and anxiety. The resident was severely cognitively impaired.
Resident 16's Cognitive Loss and Behavioral Symptoms CAA completed on 8/10/20 assessed the resident's behaviors as wandering into other resident's rooms, swearing and striking at staff, especially out of anger when staff attempted to redirect her/him, and digging in the garbage.
Resident 16's current care plan indicated multiple care areas related to behaviors and revealed behaviors were not new:
6/13/17 - Behavioral Symptoms: refusing care and yelling at staff at times. Interventions: approach resident in unhurried and calm manner; resident responds well to smiles; resident enjoys social activities and visiting with friends; reassure resident; when refuses care, re-approach later or offer a different time;
7/18/18 - Behavioral Symptoms: resident to resident verbal and physical altercations. Interventions: allow resident to have control over situations; convey an attitude of acceptance toward resident; support appropriate moods and behaviors;
12/3/18 - Behavioral Symptoms: cursing at staff; inappropriate hand gestures when redirected; striking out at staff; wandering; rummaging through garbage. Interventions: resident's strength was she/he can often be redirected with food; allow resident to have control over situations; avoid over-stimulation; do not engage resident in sensitive conversation when resident uses foul language or body gestures; offer food or fluids; check for other areas of discomfort which may contribute to behaviors
10/2/20 - Behavioral Symptoms: wandering; entering other resident's rooms; exit seeking; removing colostomy bag and disposing of it in inappropriate areas; opening doors to the stairwells. Interventions: allow resident to have control over situations; when resident enters other rooms redirect to her/his room and offer food, fluids and activity; convey an attitude of acceptance; maintain a calm environment and a calm, slow approach; if available have a staff member take resident outside; seat resident where constant or near constant observation is possible; when resident is exit seeking, redirect to her/his room.
10/6/20 - Behavioral Symptoms: refused to wear a mask. Interventions: provide a mask and give reminders; social services and activities will spend 1:1 time each day.
A 10/6/20 fax to the resident's physician from Staff 9 (RN) revealed the resident was an elopement risk and had behaviors which included going into other residents' rooms, touching personal protective equipment (PPE) with unclean hands, combative towards staff and cursed at staff when redirection was attempted. The physician responded with an order for risperidone 0.5 mg every two hours PRN for agitation.
A review of Resident 16's MAR from 10/1/20 through 1/31/21 revealed the order for PRN risperidone remained continuous throughout that time period. The MAR indicated the resident was administered the PRN dose of risperidone 41 times between 10/8/20 and 1/13/21. According to the MAR, the resident received the PRN risperidone for the following reasons:
*increased agitation - 14 times
*going into other residents' rooms - 17 times
*eloping - 4 times
*removing colostomy bag - 1 time
*wandering - 1 time
*throwing feces - 1 time
*attempted to get on elevator - 1 time
*getting into PPE - 1 time
*"inappropriate behavior, refused to wear a mask" - 1 time.
Follow up documentation of the PRN administration of risperidone indicated 15 out of the 41 times the medication was either not effective or no follow up was done.
A review of Resident 16's clinical record did not reveal any documentation the resident's physician directly examined the resident, evaluated her/his use of PRN risperidone or wrote a new order every 14 days.
A 12/18/20 physician order revealed the resident received 1 mg of risperidone at bedtime.
On 12/22/20, just four days after the resident started the scheduled risperidone, a fax to the resident's physician from Staff 2 (DNS) indicated Resident 16 currently received 1 mg of risperidone every night and 0.5 mg of risperidone every two hours PRN yet the resident continued to wander into other residents' rooms, strike out at staff and exit seek. She requested an additional scheduled dose of risperidone for the resident. The physician agreed with the request for an additional 0.5 mg of risperidone scheduled at 2:00 PM.
A review of Resident 16's clinical record revealed no documentation related to the specific behaviors manifested by agitation the risperidone was meant to address.
A review of Resident 16's progress notes from 5/1/20 through 1/31/21 revealed the resident exhibited the same behaviors throughout that time period.
A 1/13/21 progress note for the resident indicated "same behaviors continue risperidone ineffective".
No evidence was found to indicate a behavior monitoring system was in place to determine if the antipsychotic was effective in treating the resident's behaviors.
The FDA Black Box Warning for risperdal indicated the medication was not approved for use by elderly patients with dementia-related psychosis (behaviors that can include agitation or aggressive behavior) and those patients were at an increased risk of death from the use of the medication. The FDA label also revealed adverse side effects including cerebrovascular events such as stroke, somnolence (sleepiness or drowsiness), abdominal pain, dizziness, agitation and akathisia (a movement disorder).
A review of Resident 16's current care plan did not reveal any documentation related to the resident's use of risperidone. A review of the resident's clinical record did not reveal documentation related to the possible side effects of risperidone or what and how the staff should monitor the resident.
A 1/7/21 Pharmacy Consultant Recommendation requested Resident 16's physician to consider a trial reduction of risperidone to 0.5 mg at 2:00 PM and 0.5 mg at bedtime and noted the psychotropic committee reported the resident was overly somnolent in the mornings. Staff 3 documented on the nursing assessment portion of the recommendation that the resident did not exhibit behaviors aside from wandering.
A fax dated 1/25/21 from the resident's physician in response to the Staff 3's assessment on the pharmacy recommendation indicated the physicians response was "I don't know who you are talking to because I am being told otherwise. I have multiple faxes that patient is verbally abusive and have assaulted fellow residents/staff. Do not change!"
A fax communication from Resident 16's physician dated 1/25/21 in response to the pharmacy consultant's notification that risperidone was prescribed for the resident without an adequate indication for use revealed "patient has been assaulting staff and residents" and with risperidone those behaviors have been controlled.
A review of Resident 16's clinical chart did not reveal incident reports related to any assaults indicated in the physician's documentation.
Observations of Resident 16 from 1/20/21 through 1/26/21 revealed the following:
- 1/20/21 1:18 PM the resident was asleep in bed with her/his lunch tray on the bedside table untouched.
- 1/20/21 3:10 PM the resident sat on the edge of her/his bed, rocked back and forth slightly and appeared extremely drowsy.
- 1/25/21 2:03 PM the resident laid in bed on her/his right side and gently rocked back and forth. The resident's eyes were open and stared straight ahead with glazed eyes. She/he did not react to movement in the doorway.
- 1/25/21 3:12 PM the resident remained awake in the same position in her/his bed, with her/his eyes open in a glazed stare.
- 1/25/21 4:27 PM the resident was in her/his wheelchair in her/his room staring at the blank wall with glazed eyes.
- 1/26/21 12:09 PM the resident propelled her/himself up and down the hall bent forward in the wheelchair. She/he appeared withdrawn and did not interact with staff who said hello or stopped to talk to the resident.
- 1/26/21 12:30 PM the resident was unable to hold the telephone while she/he talked with family on the phone in the hall. Her/his words were mumbled and incomprehensible. Staff 3 informed Staff 4 the behavior was a side effect of the risperidone.
On 1/20/21 at 1:21 PM Staff 7 (LPN) reported Resident 16 was more tired and slept most of the day since she/he started the risperidone.
On 1/26/21 at 11:41 AM Staff 11 (CMA) reported the resident seemed overmedicated. She explained the resident was "zoned out" which was not baseline for the resident. Staff 11 stated Resident 16 was usually up and she/he frequently requested food in between meals but now the resident slept all day and ate very little.
On 1/26/21 at 12:02 PM Staff 7 reported she and Staff 3 both faxed Resident 16's physician and requested a decrease in the risperidone due to the resident's decline and the physician would not decrease it.
On 1/26/21 at 12:24 PM Staff 20 (CNA) reported Resident 16 slept more during the last couple of weeks. She stated the resident was "like a zombie".
On 1/26/21 at 1:15 PM 16 (CNA) stated the resident declined and slept more.
On 1/27/21 at 12:37 PM Staff 4 (Social Services) stated she led the monthly psychotropic medication meetings and was not aware of the regulation related to the 14 day limit for PRN anti-psychotic medication orders. She confirmed the resident was not examined by her/his physician related to the use of the PRN risperidone. Staff 4 stated there was not a system to monitor the resident's behaviors or the efficacy of the medication. She further stated she was not aware of specific monitoring for side effects of risperidone. Staff 4 reported the resident was more groggy and slept more since she/he started the medication.
On 1/27/21 at 1:20 PM Staff 7 (LPN) reported Resident 16 continued to exhibit the same behaviors as before the risperidone was started. She explained the resident tried to get into things but staff would just try to redirect. She reported she usually kept the resident near her or another staff member and that intervention was effective. Staff 7 stated she did not agree with the risperidone because she did not believe the resident needed it. She further reported the PRN risperidone was never administered during her shift because they did not have the need to use it. She said only certain staff reported issues with behaviors from Resident 16.
On 1/27/21 at 1:23 PM Staff 18 (CNA) reported she noticed a big difference in Resident 16 since Christmas. She explained the resident was now sleeping more and not her/himself.
A review of Resident 16's hospital discharge dated 1/30/21 revealed the risperidone was discontinued by the hospital physician per Witness 7's request.
On 2/1/21 at 9:45 AM Staff 5 (Activity Director) stated in the last month the resident did not seem like her/himself. She reported Resident 16 was really tired and her/his eyes were glossed over.
On 2/1/21 at 2:10 PM Witness 3 (Complainant) reported she was told the resident was started on the medication because she/he went into other residents' rooms. She stated the resident was likely bored and she did not agree with the use of the medication for that purpose. Witness 3 reported she believed the facility overmedicated the resident and used the medication instead of caring for her/him. She further reported when she visited the resident in 12/2020, the resident just stared and did not look at her. She explained the resident's behavior was odd and much different than when she visited the resident in 8/2020. She stated she was not aware the resident was on the risperidone at that time. Witness 3 reported she was concerned with the withdrawn behavior of Resident 16 so the next day she called and asked staff why she/he seemed so different. She stated staff informed her at that time the resident started taking the antipsychotic which likely explained the changes. Witness 3 reported the resident recently went to the hospital and was found to have a UTI. She further reported the hospital physician informed her the side effects from the risperidone masked the symptoms of the UTI which resulted in the severity of the UTI.
On 2/1/21 at 4:16 PM Witness 7 (Pharmacy Consultant) reported Staff 2 contacted her in December because she wanted to increase Resident 16's scheduled risperidone. She stated her recommendation to Staff 2 at the time was to eliminate the PRN risperidone if she wanted to increase the scheduled dose. She further stated PRN psychoactive medications were meant to stabilize a patient on a short term basis only. Witness 7 stated during the January medication review, she recommended the physician discontinue the PRN as well as decrease the scheduled dose because the resident was overly somnolent.
During observations of the resident on 2/2/21 and 2/3/21 she/he appeared noticeably more alert and bright eyed. The change in the resident was much like she/he was a different person. She/he was observed to look up at and interact with staff verbally.
On 2/2/21 at 1:24 PM Staff 3 (RNCM) reported she was not aware of the regulation related to PRN antipsychotic medication orders. She stated the physician did not assess the resident related to the use of the risperidone and the PRN order was continuous rather than renewed every 14 days. Staff 3 confirmed the clinical record did not provide documentation of the specific behaviors the PRN risperidone was targeted to manage. She further confirmed there was no behavior monitoring in place. Staff 3 confirmed the care plan was not updated to include antipsychotic medication use or monitoring. Staff 3 reported she did not witness any behaviors which would warrant the use of an antipsychotic. She confirmed the resident's behaviors documented in the progress notes remained unchanged since the risperidone started and indicated the medication was not effective to manage the resident's behaviors. Staff 3 further stated Resident 16's risperidone order was unnecessary and was used as a convenience for staff more than anything else. She stated the resident became obtunded (lessened interest in environment, slowed response to stimulus and increased drowsiness). She further stated when Resident 16 went to the hospital and a UTI was diagnosed, the risperidone was discontinued altogether and as a result the resident was more like her/himself again. Staff 3 reported she faxed the resident's physician to request the risperidone be reduced or discontinued and informed the physician of the resident's somnolence since she/he started the medication. She stated the physician indicated other nurses in the facility reported otherwise and declined to decrease or discontinue the risperidone. Staff 3 stated the staff who faxed the physician were not involved in the psychotropic meetings and did not understand the regulations related to the medications and should not have interfered with the physician communication related to the medication.
2. Resident 18 admitted to the facility in 9/2018 with diagnoses including dementia, depressive episodes and anxiety.
The 12/20/20 Quarterly MDS Assessment revealed the resident had a BIMS score of 13 which indicated she/he was alert and oriented. The assessment revealed the resident received antipsychotic, antianxiety and antidepressant medications daily.
A review of Resident 18's 1/2021 MAR revealed the resident received the following scheduled psychotropic medications:
*olanzapine (an antipsychotic) daily for behaviors of hitting/kicking
*fluoxetine (an antidepressant) daily for depressive disorder
*lorazepam (an antianxiety) daily for anxiety
A review of the resident's clinical record did not indicate any monitoring was done for behaviors, including hitting, kicking or behavioral manifestations of depression and anxiety to determine the effectiveness of the medications.
On 2/21/21 at 1:24 PM Staff 3 (RNCM) confirmed there was no behavior monitoring in place.
3. Resident 19 admitted to the facility in 6/2019 with diagnoses including bipolar disorder and dementia.
The 11/15/20 Quarterly MDS Assessment indicated the resident was fully alert and oriented and exhibited verbal behaviors and rejection of care one to three days per week. The assessment revealed the resident received an antipsychotic daily.
A 10/27/20 fax sent to the resident's physician by Staff 9 (RN) indicated the prescribed Seroquel (an antipsychotic) was no longer effective and the resident was still combative, "actually hitting and kicking the staff". Staff 9 requested an order for Depakote (an anticonvulsant also used to treat psychiatric conditions) which the physician provided.
A review of Resident 19's 1/2021 MAR revealed the resident received both the Seroquel and Depakote twice daily.
A review of the resident's clinical record revealed no monitoring of the resident's behaviors to determine the effectiveness of the medications.
On 2/21/21 at 1:24 PM Staff 3 (RNCM) confirmed there was no behavior monitoring in place.
F-758, GImmediate:¿ Facility will request a pharmacy review of medication for recommendations. ¿ Residents #16, #18, and #19 will have behavior tracking forms initiated to monitor for behaviors and effectiveness of interventions. ID of Others:¿ The facility will audit the records of residents receiving psychoactive medications for behavior monitoring. Changes will be made to care plans and monitors as warranted. System Changes:¿ Members of the behavior committee will be educated on the requirements under F-758 to include the need for behavior monitoring as well as the requirement re: PRN anti-psychotic usage. ¿ The facility will initiate the use of a behavior monitoring system to capture trends in resident behaviors and responses to interventions and medications used. ¿ The nursing staff will be educated on the proper use of the monitoring tool. ¿ The behavior monitoring tools will be reviewed monthly at a minimum by the behavior committee¿ The behavior committee will track and trend the resident behaviors and use the data to determine the effectiveness of interventions and medications used. Monitoring:¿ The Behavior committee will report trending of behaviors and medication usage at the monthly QAPI meeting.¿ The QAPI committee may make changes to the action plan based on findings in order to assure that compliance with the rule is sustained.
Based on interview and record review it was determined the facility failed to ensure appropriate indications for use of antipsychotic medication for 1 of 3 sampled residents (#18) reviewed for unnecessary medication. This placed residents at risk for adverse side effects of antipsychotic medication. Findings include:
Resident 18 admitted to the facility in 2018 and had a diagnosis of dementia with behavioral disturbance.
The resident's 9/20/20 Psychotropic Medication Use CAA indicated the resident had a diagnosis of "Psychosis" and received Zyprexa (antipsychotic medication also known as olanzapine) for psychosis.
A review of the resident's record revealed Resident 18 did not have a diagnosis of psychotic disorder, schizophrenia or "psychosis."
Resident 18's 5/2021 MAR indicated an order for olanzapine dated 10/23/20. The medication was to be administered daily for behaviors including hitting/kicking and agitation. The associated diagnosis was restlessness and agitation.
A 5/3/21 communication to the physician indicated "Pharmacy is requesting a Risk vs Benefit for olanzapine" for Resident 18. The physician's response was to discontinue the olanzapine.
The 5/2021 MAR indicated the order was discontinued on 5/3/21 and then resumed on 5/7/21 with an associated diagnosis of "Psychosis."
Progress Notes on 5/5/21 indicated Resident 18 was cooperative, had no behaviors and had no adverse side effects of the medication change.
A 5/6/21 at 1:13 AM progress note indicated Resident 18 did not have any adverse side effects and no behaviors were seen.
Progress notes dated 5/6/21 at 1:05 PM and 1:08 PM by Staff 4 (LPN) indicate Resident 18 had no behaviors or adverse side effects from the medication change.
A 5/6/21 communication to the physician sent at 2:20 PM (20 minutes after shift change), written by Staff 6 (RN) indicated Resident 18 did not feel well, tried to throw her/himself out of the wheelchair, was aggressive and combative and indicated the resident felt like she/he was touching an electric fence. The communication indicated a diagnosis of "Psychosis" and asked the physician to reconsider the order to discontinue the olanzapine. The physician indicated to reinstate the medication and the order was noted by Staff 6 at 4:30 PM.
Progress notes dated 5/7/21 at 1:24 AM and 10:41 AM indicated Resident 18 had no adverse side effects and no behaviors prior to receiving olanzapine again on 5/7/21.
Behavior tracking records from 5/3/21 through 5/7/21 indicated Resident 18 had no behaviors.
No evidence was found in the resident's clinical record to indicate interventions were attempted to assist Resident 18 with behaviors prior to restarting the olanzapine.
On 5/13/21 at 10:51 AM Staff 4 stated Resident 18 did not have behaviors or side effects from discontinuing the olanzapine when she worked with Resident 18 on 5/6/21.
On 5/13/21 at 11:19 AM Staff 6 stated Resident 18's behaviors returned almost immediately when the olanzapine was discontinued. Staff 6 stated Resident 18 previously had aggressive tendencies which the olanzapine helped. When asked about Resident 18's behaviors on 5/6/21 which prompted the physician communication, Staff 6 stated Resident 18 threw a bedside table but was not hitting or kicking. Staff 6 acknowledged the lack of documentation for the behaviors she reported to the physician.
During interviews with Staff 2 (DNS) and Staff 3 (RNCM) on 5/13/21 both staff indicated Resident 18 did not have behaviors when the olanzapine was discontinued. The staff indicated the physician was contacted because they were concerned Resident 18's behaviors would return as the medication was discontinued abruptly instead of gradually. Staff 2 acknowledged the discrepancies between the rationales for resuming the medication and the lack of an assessment to indication appropriate use of antipsychotic medication for a resident with dementia.
Resident #18 continues to receive Olanzapine 5mg per MD order. The indication for use will be clarified by the MD.Any resident who receives antipsychotic medication has the potential to be affected by the alleged deficient practice. The facility will audit residents with antipsychotic medication to assure there is an appropriate indication for usage. Corrections to be made as warrantedSystemic Changes:The psychotropic/behavior committee will meet monthly and review residents receiving antipsychotic medications for appropriate indications for usage. The committee will contact the provider to request appropriate indications as needed.The RCM/designee will use a tickler file to follow up with provider to assure indications for use are obtained timely.Monitoring:The RCM/designee will bring results and trending of psychotropic committee recommendations/requests sent to providers, to the facility monthly QAPI meeting for review, and may change the action plan based on findings and committee recommendations.
The findings of the licensure and complaint (Intake #s 22122, 24522, 26706 and 28265) health survey conducted 1/20/21 through 2/11/21 are documented in this report. The survey was conducted to determine compliance with OAR 411 Divisions 85 through 89. For additional information refer to the Form CMS 2567 dated 2/11/21.
The sample was comprised of 7 current residents. The facility had a census of 21 residents.
The findings of the licensure and health complaint revisit survey conducted 5/11/21 through 5/13/21 are documented in this report. The survey was conducted to determine compliance with OAR 411 Divisions 85 through 89. For additional information refer to the Form CMS 2567 dated 5/13/21.
The sample was comprised of 10 current residents and 0 closed records. The facility had a census of 18 residents.
Abbreviations possibly used in this document:
ADL: activities of daily living
bid: twice a day
BIMS: Brief Interview for Mental Status
CAA: Care Area Assessment
CBG: capillary blood glucose or
blood sugar
cm: centimeter
CMA: Certified Medication Aide
CNA: Certified Nursing Assistant
CPR: Cardiopulmonary Resuscitation
DNS: Director of Nursing Services
F: Fahrenheit
FRI: Facility Reported Incident
HS or hs: hour of sleep
LPN: Licensed Practical Nurse
MAR: Medication Administration
Record
mcg: microgram
MDS: Minimum Data Set
mg: milligram
ml: milliliters
O2 sats: oxygen saturation in the
blood
OT: Occupational Therapist
PCP: Primary Care Physician
PO: by mouth, orally
PRN: as needed
PT: Physical Therapist
RA: Restorative Aide
RAI: Resident Assessment
Instrument
RD: Registered Dietician
ROM: range of motion
RN: Registered Nurse
RNCM: Registered Nurse Care
Manager
SLP: Speech Language
Pathologist
TAR: Treatment Administration
Record
tid: three times a day
UA: Urinary Analysis
UTI: urinary tract infection
The findings of the health complaint revisit survey (Intake #s 22122, 24522, 26706, and 28265) conducted on 6/22/21 are documented in this report. The facility was found to be in substantial compliance with OAR 411 Divisions 85 through 89.
Based on interview and record review it was determined the facility failed to ensure minimum CNA staff to resident ratios were maintained for 26 of 64 days reviewed for minimum CNA staffing. This placed residents at risk for delayed or lack of care. Findings include:
Review of Direct Care Staff Daily Reports revealed inadequate CNA staffing for 26 of 64 days as follows:
12/2020: 17 days (seven day shifts and 17 evening shifts)
1/2021: seven days (all evening shifts)
2/1/21 and 2/2/21: two days (both evening shifts)
On 2/3/21 at 2:52 PM Staff 1 (Administrator) acknowledged the facility did not meet the minimum CNA to resident staffing ratios from 12/1/20 through 2/2/21.
O.A.R. M183, FThe facility currently employs 12 full time Aides and 5 part time Aides to cover the staffing shifts. The facility also has access to agency staff as needed. The facility schedules C.N.A.s in advance to be sure there are the correct amount of people on shift to meet the staffing ratio and resident care needs. At times, there are unforeseen situations, such as sick employees, or staff accidents, that result in the inability to cover the vacant shift. During those times, the management team, LN, and CMA pitch in to help assure that the resident care needs are met during the short shift. The facility continues to recruit for Aides. The facility will consider the following options to assist in meeting staffing needs:1. Offer a bonus to pick up when the shift is short2. The use of sign-on bonus as a recruitment tool3. Placing the Aides on a 4 on 2 off rotation (30 day would be be given to the SEIU and the CNAs before such action)4. Contact the local C.N.A. training center for potential candidates5. Use of the N.A. Emergency Waiver to recruit and fast track N.A.s to work on the floor6. Advertise on Indeed and any local recruitment venues for Aides.
******************************
OAR 411-085-0360 Abuse
Refer to F600, F603 and F607
******************************
OAR 411-086-0230 Activity Services
Refer to F679
******************************
OAR 411-086-0110 Nursing Services: Resident Care
Refer to F684
******************************
OAR 411-086-0200 Physician Services
Refer to F712
******************************
OAR 411-086-0100 Nursing Services: Staffing
Refer to F727
******************************
OAR 411-086-0140 Nursing Services: Problem Resolution & Preventive Care
Refer to F758
******************************
******************************
OAR 411-086-0110 Nursing Services: Resident Care
Refer to F684
******************************
OAR 411-086-0140 Nursing Services: Problem Resolution & Preventive Care
Refer to F758
******************************
