Based on interview and record review, it was determined the facility failed to ensure residents were assessed by an RN in accordance with their conditions, findings documented, and interventions developed and implemented as a result of the assessment for 1 of 2 sampled residents (#3) reviewed who experienced significant changes of condition. Findings include, but are not limited to:
Resident 3 was admitted to the facility on 9/12/18 with diagnoses of right lung removal as an infant, congestive heart failure and malnutrition.
The clinical record revealed the following changes during a hospital stay from 10/26/20-11/24/20:
*Stage two pressure ulcer (open wound) to the coccyx;
*A reopening of a previous PEG tube stoma;
*Continuing chronic stasis ulcer on the right lower extremity;
*Significant change in mobility, toileting, and ability to prepare meals;
*A change in dosages of three cardiac medications including a previously stable blood thinner; and
*Advancing from PRN oxygen use to continuous oxygen use.
These issues constituted a significant change of condition and required an RN assessment. There was no documented evidence of a thorough RN assessment completed and no interventions developed or implemented as a result of the RN assessment.
The need to ensure a facility RN assessment was completed for Resident 3's significant changes of condition, to include findings documented and interventions developed and implemented as a result of the assessment was discussed with Staff 1 (Administrator/Owner) and Staff 2 (RCC) on 12/2/20 at 11:00 am. They acknowledged the findings.
Administrator will notify facility RN when residents have a significant change in condition to ensure that a timely RN assessment is completed for changes of condition. Administrator will further communicate, as previously noted, with our RN consultant company Voorhies and Associates to ensure that an alternate RN is available for assessment of Significant changes in condition. Our facility RN was out of town for Thanksgiving and d/t covid we could not secure a replacement RN until following week. Home Health RN had seen resident twice before our facility RN return. This administrator has discussed option of remote RN assessment in situation of Covid or absence of our routine RN. Administrator and RN consultant company will continue to communicate to ensure that a timely RN assessment is completed for Signficant changes of condition. This system will be monitored ongoing by Administrator, Nursing Consultant and assigned facility RN.
Based on interview and record review, it was determined the facility failed to ensure a resident who self-administered medications was evaluated at least quarterly to ensure they were safe to do so, for 1 of 1 sampled resident (#3) who self-administered medications. Findings include, but are not limited to:
Resident 3 was admitted to the facility on 9/12/18 with diagnoses of right lung removal as an infant, congestive heart failure and malnutrition.
Review of the resident's 10/22/20 signed physician orders and the November 2020 MAR indicated the resident had an order to self-administer the Ethacrynic acid (diuretic) and Dilatiazem (cardiac medication). The facility administered all other medications for the resident.
There was no documented evidence a self-medication evaluation had been completed by the facility.
The need to ensure a quarterly self-medication administration evaluation was completed for each resident who wished to self-administer medications was discussed with Staff 1 (Administrator/Owner) and Staff 2 (RCC) on 12/2/20 at 11:00 am. They acknowledged the findings.
Administrator has added quarterly review of residents that self medicate to the RN check list of duties to ensure that the check list will provide ongoing guidance to complete self medication assessments on residents as needed. This is also added to our quarterly service plan check list to prompt medication aides to refer back to RN and Administrator when a resident is self medicating any component of their med profile in addition to having doctors orders on file. Protocol will guide RN to schedule calendar reminders, possibly in quickmar, for quarterly assessments ongoing. Administrator, facility staff and RN will monitor to ensure they are completed. Our EMAR system does include an assessment for use. Administrator and Facility RN will provide ongoing monitoring of this system as it will be in our weekly meeting list.
Based on observation, interview and record review, it was determined the facility failed to ensure a supportive device with potentially restraining qualities was assessed thoroughly by an RN, PT or OT prior to use for 1 of 1 sampled resident (# 4) who had a half-length side rail on their bed. Findings include, but are not limited to:
Resident 4 was admitted to the facility in 9/2020 with diagnoses including left sided hemiparesis.
During an observation on 12/1/20 at 11:50 am, Resident 4's bed had a 1/2 length side rail in the up position, on the resident's left side, opposite the wall. The side rail was loose.
There was no documented evidence a side rail assessment had been completed by an RN, PT or OT which included:
*Informing the resident of the risks and benefits associated with the device;
*The facility documented other less restrictive alternatives evaluated prior to the use of the device;
*The facility had instructed caregivers on the correct use and precautions related to the use of the device; and
*Documenting the use of the side rail on the service plan.
During an interview with Staff 8 (Universal Worker/MA) on 12/1/20 at 12:30 pm, she stated the use of the side rail had not been assessed nor was it on the service plan. Staff 8 was informed the side rail was loose and she stated she would tighten the device.
Facility Administrator and Facility RN will monitor presence and use of supportie devices with restraining qualities to ensure that assessments are completed prior to use of any of these devices. This includes ensuring that all staff are trained ongoing that NO supportive device is to be in place without an RN assessment and detailed instructions as to its use by resident and support staff. Administrator was not aware that this bed rail was in use confirming that more staff training and awareness is needed. Training of supportive device policies are being re written and included in new hire training as well as ongoing to explain the necessary steps needed to approve such a device .
Based on observation, interview and record review, it was determined the facility failed to ensure their re-licensure survey plan of correction was implemented and satisfied the Department. Findings include but are not limited to:
Refer to C 260 and C 270.
Administrator submitted a plan of correction for review of the Division. Administrator alledges to have a plan of correction to achieve compliance by 1/16/21
