The findings of the complaint (Intake# 48400) health survey conducted 2/22/24 through 2/23/24 are documented in this report. The survey was conducted to determine compliance with 42 CFR Part ยง483 Requirements for Long Term Care Facilities.
The sample was comprised of 10 current residents and 1 closed records. The facility had a census of 48 residents.
The facility was found to be in an Immediate Jeopardy (IJ) situation in the area of:
483.25 Quality of Care
On 2/23/24 at 2:45 PM the Administrator was notified the immediacy was removed based on onsite verification that the IJ removal plan was implemented. Following the removal of the immediacy, noncompliance remained at isolated with no actual harm with potential for more than minimal harm that is not IJ.
The facility was found to be providing Substandard Quality of Care in the area of:
483.25 Quality of Care
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
CDC: Centers for Disease Control and Prevention
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
IP: Infection Preventionist
LPN: Licensed Practical Nurse
MAR: Medication Administration Record
mcg: microgram
MDS: Minimum Data Set
mg: milligram
ml: milliliters
NA: Nursing Assistant
NP: Nurse Practitioner
O2 sats: oxygen saturation in the blood
OT: Occupational Therapist
PCP: Primary Care Physician
PO: by mouth, orally
PPE: Personal Protective Equipment
PRN: as needed
PT: Physical Therapist
RA: Restorative Aide
RAI: Resident Assessment Instrument
RD: Registered Dietitian
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# 48400) health survey conducted 4/5/24 are documented in this report. The survey was conducted to verify correction of the deficiencies noted from the survey dated 2/23/24. These deficiencies have been corrected, effective 2/28/24.
Based on observation, interview and record review it was determined the facility failed to ensure the resident environment was free from accident hazards for 1 of 1 sampled resident (#199) reviewed for accidental injury. This failure, determined to be an Immediate Jeopardy (IJ) situation, resulted in Resident 199 sustaining third degree burns requiring acute care intervention when her/his foot sustained prolonged contact with an electric baseboard heater. Findings include:
Resident 199 admitted to the facility with hospice services on 1/12/24 with diagnoses including congestive heart failure and dementia.
An Admission MDS dated 1/18/24 revealed Resident 199 had a BIMS score of three, which indicated the resident had severe cognitive impairment. The Admission MDS indicated Resident 199 had upper and lower extremity ROM impairment on one side, she/he required total assistance with bed mobility, and sitting to lying on the side of the bed required maximum assistance (helper does more than half the effort).
A review of Resident 199's 2/19/24 care plan and progress note revealed no safety assessment regarding the resident's safety in her/his room relative to the electric baseboard heater.
A public complaint was received on 2/20/24 which alleged Resident 199 was sent to the hospital with third degree burns (full-thickness burn that destroys the outer layer of skin and the entire layer beneath) on her/his right foot sustained from an electric baseboard heater at the facility.
On 2/22/24 at 10:29 AM Witness 2 (Complainant) stated Resident 199 was sent to the hospital at approximately 6:35 AM on 2/19/24. The resident had a rapid heart rate, was in severe pain and had a large burn on her/his right foot. Witness 2 stated the facility reported Resident 199 sustained the burn from a heater, and the resident was monitored for safety every two hours. However, given the severity of the injury, it appeared to be the result of prolonged low-temperature heat exposure. Witness 2 stated Resident 199's toes were black and dry, and the bottom of her/his right foot resembled leather with an indentation across the mid-section of her/his foot that the facility could not explain.
On 2/22/24 at 11:23 AM Staff 16 (LPN) stated she was called by Staff 7 (CNA) immediately to Resident 199's room at approximately 4:45 AM on 2/19/24. Staff 16 stated Resident 199 was laying on her/his back because Staff 7 moved the resident's right foot off the baseboard heater. Staff 16 stated the resident's right foot appeared to be bluish and purplish in the area of her/his 3rd, 4th, and 5th toes from the tip of the toes extending to the arch of the foot; top and bottom of the foot were discolored. Staff 16 stated she immediately assessed Resident 199 and she called 911 to send the resident to the hospital. Staff 16 stated Resident 199 did not appear to be in distress and was calm.
On 2/22/24 at 11:39 AM Staff 7 (CNA) stated she was assigned to Resident 199 and checked on her/him about two hours per the care plan. Staff 7 stated at approximately 3:30 AM on 2/19/24 Resident 199 had her/his feet dangling off the bed close to the baseboard heater. Staff 7 stated Resident 199's feet were fine and not discolored, they were warm to the touch, but appeared normal in color. Staff 7 stated she repositioned Resident 199's feet back into the bed and moved the bed away approximately 18 inches away from the baseboard heater. Staff 7 returned the bed back to the low position (close to the floor) because she/he was a fall risk. Staff 7 stated she returned at approximately 5:15 AM on 2/19/24 to check on Resident 199 before the end of her shift and found her/his right foot on the baseboard heater and her/his right toes were darkened and discolored. Staff 7 stated she immediately removed Resident 199's right foot from the heater and yelled for Staff 16.
During an observation of Resident 199's room on 2/22/24 at 10:50 AM the thermostat for the electric baseboard heater, located on the long wall next to the first hanging TV closest to the door, was set at 70 degrees F. Resident 199's bed was located by the window, there was blue tape approximately 13-inches away from the baseboard heater placed by the facility after the incident to mark a safe distance from the baseboard heater and the bed was approximately two inches away from the blue tape. The bed when in the low position was approximately 14 inches tall and baseboard heater was approximately six inches tall and extended 72-inches in length. The baseboard heater featured a metal casing on the top, front and sides, with an approximately 1.5-inch opening at the front from which hot air emanated to warm the room. The metal casing was hot to the touch.
A review of Resident 199's 2/19/24 hospital admission note revealed the resident sustained third degree burns to her/his right foot. The hospital notes indicated significant injury "necrotic (dead tissue) of fourth and fifth toes, third degree burn to plantar (bottom of the foot) surface of foot that looks older than stated ...has associated blistering and dryness of right foot." The top of Resident 199's right foot appeared to have dark purple discoloration from mid-foot towards the toes which appeared "dark purple with aspects of black." The plantar surface appeared to be "dark purple to brown discoloration with dry skin with texture of leather" and a linear indentation from the arch of the foot to the right 5th toe on the plantar surface. The hospital concluded based on their assessment a full thickness or third degree burn to the right foot from prolonged heat exposure.
On 2/22/24 at 11:39 AM Staff 7 stated she found Resident 199 several times attempting to put her/his feet on or in the baseboard heater. Staff 7 stated the week prior she reported to Staff 18 (RN) that Resident 199 sat at the edge of her/his bed and, while wearing socks, placed her/his feet on and in the baseboard heater. Staff 7 stated she moved Resident 199 away from the heater and moved the bed and repositioned the resident.
On 2/22/24 at 12:45 PM Staff 18 (RN) stated she recalled Staff 7 reported to her Resident 199 was found sitting at the edge of the bed putting her/his feet with socks on in the baseboard heater. Staff 18 stated she asked Staff 7 to move Resident 199's bed away from the baseboard heater and Staff 18 assessed the resident's skin to ensure it was intact. Staff 18 stated she did not document the incident or her assessment. Staff 18 stated at the end of her shift she informed the oncoming nurse, Staff 19 (LPN), of the incident.
On 2/22/24 at 12:56 PM Staff 19 stated she did not recall any incidents of Resident 199 putting her/his feet on or in the baseboard heater. Staff 19 did not recall Staff 18 giving her report of the incident or assessment.
On 2/22/24 at 2:01 PM Staff 21 (Maintenance Director) observed Resident 199's room with the surveyor. The thermostat was set at 90 degrees F. Staff 21 confirmed he placed the blue tape on the floor but did not recall if there was tape on the floor prior to the incident. Staff 21 agreed the metal casing on the baseboard heater was hot to the touch and used a temperature gun to check the temperature of the top of the baseboard heater which was 145 degrees F, and the hot air emitting was 144 degrees F. Staff 21 stated the baseboard heater was operating as intended. Staff 21 stated the blue tape was a visual reminder for the staff to keep residents and items out of that area because the baseboard heater gets hot enough to melt items. Staff 21 stated he conducted staff in-services and presented melted items that were in or too close to the baseboard heaters.
On 2/23/24 at 10:52 AM Staff 14 (CNA) stated, prior to the incident of 2/19/24, she found Resident 199 several times facing the window with her/his feet on the wall above the heater. Staff 14 was educated and repositioned Resident 199 away for the baseboard heater.
On 2/23/34 at 1:33 PM Staff 15 (CNA) stated she recalled the charge nurse told her when she was the assigned to Resident 199 to ensure she/he did not place her/his feet on the baseboard heater. Staff 15 stated the facility provided in-services not to place items on or near the baseboard heaters because staff were shown pillows and linen that were burned from contact with the baseboard heaters.
On 2/22/24 at 6:45 PM, the facility administrative staff, including Staff 2 (Assistant Administrator) and Staff 3 (DNS), were notified of the (IJ) situation and an immediacy removal plan was requested.
On 2/22/24 at 8:22 PM the facility submitted an acceptable immediacy removal plan to address the IJ situation.
The immediacy removal plan included the following:
1. Resident 199 was no longer in the facility.
2. All baseboard heaters would be turned off and replaced with a safe alternative.
3. Staff would check room temperature every two hours to verify each room was at a comfortable temperature.
The immediacy was removed on 2/23/24 based on onsite verification of the removal plan.
Resident #199 is no longer a resident at the facility.NHA/Designee completed Baseline audit of all baseboard heaters in resident rooms. Baseboard heaters were turned off 2/22/24 and room temperatures were monitored for continued comfort while baseboard heaters were being replaced. Identified baseboard heaters were removed and replaced with cadet heaters that are mounted three quarters up the wall from the floor out of resident reach by the end of day 2/27/24.NHA/Designee provided education to staff initiated 2/19/24 related to keeping items outside the blue taped areas surrounding the baseboard heaters to prevent getting too close to the heater as well as facility policy related to Accidents, Hazards and Supervision. NHA/Designee will conduct an audit of room temperatures that have the new cadet heaters installed to verify they are providing a comfortable environment. Audits will be conducted weekly for 4 weeks, then monthly for 2 months.Audit trends will be reported to facility QAPI X 3 months for review and further recommendations.
The findings of the licensure and complaint (Intake # 48400) health survey 2/22/24 through 2/23/24 are documented in this report. The survey was conducted to determine compliance with OAR 411 - 85 through 89. For additional information refer to the Form CMS 2567 dated 2/23/24.
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
CDC: Centers for Disease Control and Prevention
cm: centimeter
CMA: Certified Medication Aide
CNA: Certified Nursing Assistant
CPR: Cardiopulmonary Resuscitation
DNS/DON: Director of Nursing Services
F: Fahrenheit
FRI: Facility Reported Incident
HS or hs: hour of sleep
IP: Infection Preventionist
LPN: Licensed Practical Nurse
MAR: Medication Administration Record
mcg: microgram
MDS: Minimum Data Set
mg: milligram
ml: milliliters
NA: Nursing Assistant
NP: Nurse Practitioner
O2 sats: oxygen saturation in the blood
OT: Occupational Therapist
PCP: Primary Care Physician
PO: by mouth, orally
PPE: Personal Protective Equipment
PRN: as needed
PT: Physical Therapist
RA: Restorative Aide
RAI: Resident Assessment Instrument
RD: Registered Dietitian
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 complaint (intake #48400) revisit health survey conducted 4/5/24 are documented in this report. The facility was found to be in substantial compliance with OAR 411-70 and 85 through 89.
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OAR 411-086-0140 Nursing Services: Problem Resolution and Preventive Care
Refer to F689
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