The findings of the complaint health survey (Intake# 26925) conducted 10/21/20 through 10/29/20 are documented in this report. The survey was conducted to determine compliance with 42 CFR Part §483 Requirements for Long Term Care Facilities. The facility was found to be in an Immediate Jeopardy and substandard quality of care situation in the areas of:
CFR 483.21 Comprehensive Resident Centered Care Plans
CFR 483.25 Quality of Care
The sample was comprised of one current resident and four closed records. The facility had a census of 48 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 # 26925) conducted 1/12/21 through 1/13/21 are documented in this report. The facility was found to be in substantial compliance with requirements for Long Term Care Facilities, 42 CFR Part 483.
Based on observation, interview and record review it was determined the facility failed to ensure licensed staff provided care and services according to professional standards of practice and licensure requirements for 6 of 6 licensed nurses (#s 3, 5, 7, 8, 10, and 16) related to a resident's change of condition. Staff failed to identify, comprehensively assess and intervene timely for an acute change in a resident's condition for 1 of 3 sampled residents (#1) reviewed for change of condition. This failure, determined to be an immediate jeopardy situation, resulted in a delay of identification and assessment of symptoms and a delay in emergent treatment for Resident 1's left frontoparietal infarct (stroke) and NSTEMI (heart attack). As a result, Resident 1 was hospitalized, placed on hospice care and passed away on 10/21/20. Findings include:
Oregon State Board of Nursing Scope of Practice Standards for Licensed Practical Nurses (OAR 851-045-0050) indicated the following:
2. Standards related to the Licensed Practical Nurse's responsibility for nursing practice implementation.
a. Conduct and document initial and ongoing focused nursing assessments of the health status of clients by:
A. Collecting objective and subjective data from observations, examinations, interviews, and written records in an accurate and timely manner as appropriate to the client's health care needs and context of care;
B. Distinguishing abnormal from normal data, sorting, selecting, recording, and reporting the data;
D. Anticipating and recognizing changes or potential changes in client status; identifying signs and symptoms of deviation from current health status;
d. Implement the plan of care by:
B. Documenting nursing interventions and responses to care in an accurate, timely, thorough, and clear manner.
e. Evaluating client responses to nursing interventions and progress toward desired outcomes.
A. Outcome data shall be used as a basis for reassessing the plan of care and modifying nursing interventions; and
B. Outcome data shall be collected, documented and communicated to appropriate members of the healthcare team.
Oregon State Board of Nursing Scope of Practice Standards for Registered Nurses (OAR 851-045-0060) indicated the following:
2. Standards related to the Registered Nurse's responsibility for nursing practice implementation.
a. Conduct and document initial and ongoing comprehensive and focused nursing assessments of the health status of clients by:
A. Collecting objective and subjective data from observations, examinations, interviews, and written records in an accurate and timely manner as appropriate to the client's health care needs and context of care;
B. Distinguishing abnormal from normal data, sorting, selecting, recording, analyzing, synthesizing and reporting the data;
D. Anticipating and recognizing changes or potential changes in client status; identifying signs and symptoms of deviation from current health status;
d. Implement the plan of care by:
B. Documenting nursing interventions and responses to care in an accurate, timely, thorough, and clear manner.
e. Evaluating client responses to nursing interventions and progress toward desired outcomes.
A. Outcome data shall be used as a basis for reassessing the plan of care and modifying nursing interventions; and
B. Outcome data shall be collected, documented and communicated to appropriate members of the healthcare team.
Conduct Derogatory to the Standards of Nursing (OAR 851-045-0070) indicated the following:
1. Conduct related to the client's safety and integrity:
b. Failing to take action to preserve or promote the client's safety based on nursing assessment and judgement.
3. Conduct related to communication:
b. Incomplete recordkeeping regarding client care; including but not limited to, failure to document care given or other information important to the client's care;
h. Failing to communicate information regarding the client's status to members of the health care team (physician, nurse practitioner, nursing supervisor, nurse co-worker) in an ongoing and timely manner;
4. Conduct related to achieving and maintaining clinical competency:
b. Failing to conform to the essential standards of acceptable and prevailing nursing practice.
Resident 1 admitted to the facility in 11/2019 with diagnoses including atrial fibrillation (irregular heart beat) and peripheral vascular disease (a blood circulation disorder).
Resident 1's 11/25/19 Admission MDS and 8/27/20 Quarterly MDS Section C: Cognitive Patterns and Section G: Functional Status assessed the resident with BIMS 15 (cognitively intact), supervision to extensive assist for ADLs and no impairments to either shoulder, elbow, wrist or hand.
A progress note written by Staff 5 (LPN) dated 10/16/20 at 11:20 AM indicated "Resident was sent out to the hospital after exhibiting symptoms such as anomic aphasia [difficulty expressing words] and an inability to use the right arm. Resident also complained of slight chest pains. VS [vital signs] 114/86, 88, 97.3, 18 and 97%."
No other assessments such as facial symmetry, change in mental status or vision changes were noted. No additional details such as onset time of symptoms were documented.
Resident 1's 10/16/20 Hospital Admission History and Physical indicated Resident 1 was admitted to the hospital for right upper extremity weakness. The records indicated "the patient states her/his right upper extremity has been weak for about 36 hours while her/his residence noticed it today and called 9-1-1. When asked when her/his symptoms of right upper paralysis started, she/he relayed the afternoon of 10/15/20. She/he stated she/he believes that it progressed to its right upper flaccid (soft, limp, weak) state over the day on 10/15/20." The physical exam assessed Resident 1's extremities as "exception flaccid paralysis of the right upper extremity from the shoulder." The diagnostic studies revealed ataxia (loss of coordination of the muscles) and stroke suspected.
Resident 1's 10/20/20 Nursing Facility Transfer Orders indicated the discharge diagnosis was an acute ischemic stroke and hospice care was ordered.
On 10/20/20 at 4:50 PM Witness 1 (Complainant) stated on 10/16/20 he responded to an emergent call to the facility. Witness 1 stated Staff 5 (LPN) reported Resident 1 was exhibiting symptoms of a stroke, had intermittent dysphasia (impairment of the ability to communicate) and altered mental status since since Wednesday 10/14/20. Upon arrival to the facility, Witness 1 stated Resident 1 was alert, understood what was going on and her/his right arm was completely flaccid. Witness 1 stated Resident 1 reported she/he was unable to use her/his right arm since Wednesday 10/14/20 night.
A progress note dated 10/20/20 at 5:17 PM indicated Resident 1 was readmitted to the facility on hospice level of care.
On 10/21/20 during the time of survey, no observations of Resident 1 were conducted due to end of life cares. Resident 1 passed away.
On 10/21/20 at 12:06 PM and 12:18 PM Staff 4 (CNA) and Staff 6 (CNA) stated prior to hospitalization and readmit to the facility, Resident 1 was alert, oriented, talkative and able to use her/his right arm to grasp and pull on the bedrail for repositioning. Staff 6 stated since Resident 1 returned to the facility the prior evening, she/he was not responsive.
On 10/21/20 at 12:30 PM Staff 5 (LPN) stated he arrived to work on Friday morning 10/16/20 and Staff 16 (RN) reported Resident 1 "hadn't been right the last two nights. She/he was having trouble rolling." Staff 5 stated he checked on Resident 1 that morning at an unspecified time and the resident could not use her/his right arm, it was completely flaccid and swollen and the resident was having trouble speaking. Staff 5 stated he told Staff 3 (RNCM) he thought Resident 1 had a stroke. Staff 5 stated Resident 1's vital signs were good and he called the doctor. Staff 5 stated Resident 1 later complained of chest pain and the doctor had not called back by the time Resident 1 was sent out.
Staff 5 failed to call 9-1-1 immediately after identifying signs and symptoms of a stroke such as right arm flaccidity and trouble speaking.
On 10/22/20 at 9:33 AM Staff 7 (LPN) stated she worked on Thursday evening 10/15/20 (one day after the first symptoms were identified). Staff 7 (LPN) stated Staff 3 (RNCM) told her Resident 1 had right arm weakness. Staff 7 stated between 4:00 PM and 5:00 PM she checked Resident 1's capillary refill (color return to the finger or fingernail after applying pressure) and it was "good," the resident's hand was "warm and she/he had feeling" and the resident had no pain. Staff 7 stated Resident 1 was unable to lift her/his right arm at all and this was unusual. Staff 7 stated she reported this finding to Staff 3 (RNCM). Staff 7 stated later in the shift, Staff 15 (CNA) reported Resident 1 was unable to use her/his right arm. Staff 7 stated she obtained a "full set of vital signs" and called the on-call physician. The physician ordered blood tests.
A review of Resident 1's health record revealed no documentation of vital signs the evening of 10/15/20 and no other assessments such as facial symmetry, change in mental status, vision changes, body symmetry, and grip strength.
Staff 7 failed to call 9-1-1 immediately after identifying signs and symptoms of a stroke such as new onset right arm weakness and/or paralysis.
On 10/22/20 at 12:00 PM Staff 8 (RN) stated she was assigned to Resident 1 for the day shift Thursday 10/15/20 (one day after the first symptoms were identified). Staff 8 stated Resident 1 was screaming and refusing "everything" which was unusual. Staff 8 stated at the beginning of her shift, Staff 18 (CNA) reported Resident 1 was unable to use her/his right arm at all. Staff 8 stated she told Staff 3 (RNCM). Staff 8 stated she was unable to assess Resident 1 related to Resident 1's increased distress, screaming and refusals.
A review of Resident 1's health record for day shift Thursday 10/15/20 revealed no documentation of Resident 1's inability to use her/his right arm, the resident's unusual behavior and refusals. There was no documentation of an assessment or attempts to assess the resident. There was no documentation noting Resident 1's change of condition or notification to the physician, RNCM or family.
Staff 8 failed to further investigate and assess Resident 1's new onset right arm weakness, failed to notify the physician and failed to call 9-1-1 immediately related to signs and symptoms of a stroke.
On 10/22/20 at 1:06 PM Staff 11(CNA) stated on Friday 10/16/20 morning she reported to Staff 5 (LPN) Resident 1 was unable to move half her/his body and could not use her/his right arm at all. Staff 11 stated Staff 5 responded he already knew, had called the doctor and was waiting for Staff 3 (RNCM) to arrive. Staff 11 stated later in the shift, she reminded Staff 5 again about Resident 1's change in condition.
Staff 5 failed to call 9-1-1 immediately after report of Resident 1's signs and symptoms of a stroke including inability to move half her/his body and inability to use her/his right arm.
On 10/23/20 at 5:13 AM Staff 16 (LPN) stated on Thursday 10/15/20 night shift a CNA and Staff 7 (LPN) told him Resident 1's "mood was changed" and she/he was unable to use her/his right arm and hand. Staff 16 stated he was unable to complete an assessment but stated he could see Resident 1's arm was not moving and thought it was "just muscle stiffness." Staff 16 stated he also noticed the resident had a "complete mood change."
A review of Resident 1's health record for 10/15/20 night shift revealed no documentation of an assessment to include vital signs, facial symmetry, change in mental status, vision changes, body symmetry and grip strength.
Staff 16 failed to call 9-1-1 immediately after report of Resident 1's signs and symptoms of a stroke including change in mental status and new onset right arm paralysis.
On 10/23/20 at 11:00 AM Staff 10 (LPN) stated she was assigned to Resident 1 on Wednesday evening shift 10/14/20 (date of identification of symptoms). Staff 10 stated Resident 1 refused cares and medications and complained of feeling weak which was unusual. Staff 10 stated when she saw Resident 1, she/he was holding onto her/his right hand and the resident complained her/his right hand and whole body felt weak. Staff 10 stated she checked Resident 1's capillary refill and massaged her/his hand. Staff 10 stated Resident 1's vital signs were "fine."
A review of Resident 1's health record for 10/14/20 evening shift revealed no documentation of further assessments to include vital signs, facial symmetry, change in mental status, body symmetry and grip strength.
Staff 10 failed to complete a comprehensive assessment related to Resident 1's change of condition and failed to call 9-1-1 immediately after Resident 1's signs and symptoms of a stroke including new onset weakness.
On 10/23/20 at 12:33 PM Staff 18 (CNA) stated she worked with Resident 1 from Wednesday 10/14/20 night shift through the morning of Thursday 10/15/20. Staff 18 stated at approximately 1:30 AM, she told Staff 16 (LPN) Resident 1 was unable to use her/his right arm and wouldn't talk or laugh as usual. Staff 18 stated she also reported Resident 1's change of condition to the oncoming Staff 8 (RN) and Staff 9 (CMA).
A review of Resident 1's health record for 10/14/20 through 10/15/20 night shift revealed no vital signs and no assessments to include facial symmetry, change in mental status and grip strength.
Staff 16 failed to conduct a comprehensive assessment of Resident 1and failed to call 9-1-1 immediately after notification of Resident 1's signs and symptoms of a stroke including new onset right arm/hand paralysis and change in mental status.
On 10/27/20 at 10:55 AM Staff 3 (RNCM) stated the process for identifying and reporting a resident's change in condition was to have staff "run it by her" in order to discuss next steps. If the situation was emergent, Staff 3 expected nursing staff to notify the physician. Staff 3 stated she talked to Resident 1 on Thursday 10/15/20 around 5:00 PM and Resident 1's cognition was fine. Staff 3 stated around 5:15 PM or so, (one day after onset of symptoms were identified) Staff 7 (LPN) reported to her Resident 1 could not move her/his arm. Staff 3 stated she went in "very briefly" and saw Resident 1 and did not conduct a physical assessment but she could see Resident 1 was unable to move her/his right arm. Staff 3 stated Resident 1 was speaking and she/he seemed tired. Staff 3 stated she directed Staff 7 to call the physician, obtain a capillary blood glucose level and get vital signs.
A review of Resident 1's health record for 10/15/20 evening revealed no vital signs, no blood glucose level and no evidence of a physical assessment to include facial symmetry, body symmetry and grip strength.
Staff 3 failed to conduct a physical assessment, failed to follow up on Resident 1's change in condition and right arm paralysis and failed to call 9-1-1 immediately after Resident 1 was observed with new onset right arm paralysis.
On 10/27/20 at 11:44 AM findings of this investigation were reviewed with Staff 2 (DNS). Staff 2 stated there were practical things the nursing staff should have done better. Staff 2 stated she expected staff to conduct full assessments, document their findings, make notes and record vital signs. Staff 2 stated nursing staff should have placed Resident 1 on alert to ensure shift to shift communication regarding Resident 1's change of condition and supervisors should have been notified. Staff 2 stated if a resident was exhibiting signs and symptoms of a stroke, staff should conduct a full assessment of arms, legs, eyes and movement and then call 9-1-1.
On 10/27/20 at 4:10 PM Staff 1 (Administrator) and Staff 2 were informed of the immediate jeopardy (IJ) situation, IJ templates were provided and an immediate IJ removal plan was requested.
On 10/27/20 at 6:55 PM the facility submitted a removal plan which was accepted by the surveyor.
The IJ Removal Plan indicated the facility would implement the following actions:
- Immediate evaluation of all residents in the facility conducted by the nursing management team to determine if any other residents have been affected;
- Education on identifying a change of condition, intervening timely and adding residents with noted changes on alert monitoring;
- Education to include e-interact tool for change of condition, stop and watch and SBAR;
- Full investigation initiated of this incident to include a root cause analysis.
On 10/27/20 at 7:12 PM Staff 1 was observed gathering staff for an in-service and Staff 2 was observed conducting resident assessments.
On 10/28/20 from 11:35 AM through 3:54 PM interviews were conducted with Staff 3 (RNCM), Staff 4 (CNA), Staff 6 (CNA), Staff 7 (LPN), Staff 9 (CMA), Staff 10 (LPN), Staff 11 (CNA), Staff 12 (RN), Staff 13 (Agency CNA), Staff 14 (LPN), Staff 15 (CNA), Staff 17 (RN), Staff 20 (CNA), Staff 21 (LPN), Staff 22 (CNA). Staff verified they received training and education related to identifying, documenting, monitoring, reporting, notifying and responding to residents' change of condition.
On 10/28/20 at 4:00 PM Staff 1 provided documentation of completed assessments of all residents in the facility and stated there were no residents who were negatively affected. Staff 1 provided verification that licensed nursing staff received the required training and education.
On 10/29/20 at 1:20 PM Staff 1 and Staff 2 verified all elements of the IJ removal plan were completed.
This Plan of Correction is prepared and submitted as required by law. By submitting this Plan of Correction, EmpRes Hillsboro Health and Rehabilitation does not admit that the deficiencies listed on the CMS Form 2567L exist, nor does the Facility admit to any statements, findings, facts or conclusions that form the basis for the alleged deficiencies. The Facility reserves the right to challenge in legal proceedings, all deficiencies, statements, findings, facts and conclusions that form the basis for the deficiency. F 658 Services Provided Meet Professional StandardsCFR(s): 483.21(b)(3)(i)Resident Specific:Resident #1 no longer resides at the center.Other Residents:The Director of Nursing (DNS) and/or designee has reviewed other residents to ensure licensed staff provide care and services according to professional standards of practice and licensure requirements related to resident change of condition, including identification, comprehensive assessment and timely intervention for an acute change in resident condition, in order to avoid placing the resident as risk for not receiving emergent treatment. Facility Systems:Facility licensed staff have been re-educated on providing care and services according to professional standards of practice and licensure requirements related to resident change of condition, including identification, comprehensive assessment and timely intervention for an acute change in resident condition, in order to avoid placing the resident as risk for not receiving emergent treatment. Monitor:The DNS and/or designee will monitor resident condition to ensure licensed staff provide care and services according to professional standards of practice and licensure requirements related to resident change of condition, including identification, comprehensive assessment and timely intervention for an acute change in resident condition, in order to avoid placing the resident as risk for not receiving emergent treatment through observations to validate compliance a minimum of 5 times weekly for four weeks and weekly for 2 months. Any concerns identified will be addressed immediately, additional education provided and counseling if appropriate. Monitoring results will be presented by the DNS and/or designee at the monthly Performance Improvement meeting. Monitoring results and system components will be reviewed by the Performance Improvement Team for 3 months and periodically thereafter, with subsequent recommendations developed and implemented as deemed necessary. Date of Compliance: December 3, 2020Person Responsible: Director of Nursing and/or designee.
Based on observation, interview and record review it was determined the facility failed to identify, comprehensively assess and intervene timely for an acute change in a resident's condition for 1 of 3 sampled residents (#1) reviewed for change of condition. This failure, determined to be an immediate jeopardy situation, resulted in a delay of identification and assessment of symptoms and a delay in emergent treatment for Resident 1's left frontoparietal infarct (stroke) and NSTEMI (heart attack). As a result, Resident 1 was hospitalized, placed on Hospice Care and passed away on 10/21/20. This placed all residents at risk for unidentified change of condition, delay of treatment and serious harm and/or death. Findings include:
The American Stroke Association advised to use the letters in "FAST" to identify stroke symptoms:
- Facial drooping (does one side droop or is it numb? Ask the person to smile. Is it lopsided or uneven?)
- Arm weakness (Is one arm weak or numb? Ask the person to raise both arms. Does one arm drift downward?)
- Speech difficulty (Is speech slurred or jumbled? Is the person unable to speak or hard to understand? Ask the person to repeat a simple sentence)
- Time (Call 9-1-1 immediately)
The American Stroke Association advised if someone shows any of these symptoms, even if the symptoms go away, call 9-1-1 or emergency medical services immediately. Receiving timely stroke treatment is an important and critical step to recovery and survival. Immediate treatment may minimize the long-term effects of stroke and even prevent death.
Resident 1 admitted to the facility in 11/2019 with diagnoses including atrial fibrillation (irregular heart beat) and peripheral vascular disease (a blood circulation disorder).
Resident 1's 11/25/19 Admission MDS and 8/27/20 Quarterly MDS Section C: Cognitive Patterns and Section G: Functional Status assessed the resident with BIMS 15 (cognitively intact), supervision to extensive assist for ADLs and no impairments to either shoulder, elbow, wrist or hand.
A progress note written by Staff 5 (LPN) dated 10/16/20 at 11:20 AM indicated "Resident was sent out to the hospital after exhibiting symptoms such as anomic aphasia [difficulty expressing words] and an inability to use the right arm. Resident also complained of slight chest pains. VS [vital signs] 114/86, 88, 97.3, 18 and 97%."
No other assessments such as facial symmetry, change in mental status or vision changes were noted. No additional details such as onset time of symptoms were documented.
Resident 1's 10/16/20 Hospital Admission History and Physical indicated Resident 1 was admitted to the hospital for right upper extremity weakness. The records indicated "the patient states her/his right upper extremity has been weak for about 36 hours while her/his [facility] noticed it today and called 911. When asked when her/his symptoms of right upper paralysis started, she/he relayed the afternoon of 10/15/20. She/he stated she/he believes that it progressed to its right upper flaccid (soft, limp, weak) state over the day on 10/15/20." The physical exam assessed Resident 1's extremities as "exception flaccid paralysis of the right upper extremity from the shoulder." The diagnostic studies revealed ataxia (loss of coordination of the muscles) and stroke suspected.
Resident 1's 10/20/20 Nursing Facility Transfer Orders indicated the hospital discharge diagnosis was an acute ischemic stroke and hospice care was ordered.
On 10/20/20 at 4:50 PM Witness 1 (Complainant) stated on 10/16/20 he responded to an emergent call to the facility. Witness 1 stated Staff 5 (LPN) reported Resident 1 was exhibiting symptoms of a stroke, had intermittent dysphasia (impairment of the ability to communicate) and altered mental status since since Wednesday 10/14/20. Upon arrival to the facility, Witness 1 stated Resident 1 was alert, understood what was going on and her/his right arm was completely flaccid. Witness 1 stated Resident 1 reported she/he was unable to use her/his right arm since Wednesday 10/14/20 night.
Resident 1's health record indicated on 10/20/20 at 5:17 PM Resident 1 was readmitted to the facility on hospice level of care.
On 10/21/20 during the time of survey, no observations of Resident 1 were conducted due to end of life cares. Resident 1 passed away.
On 10/21/20 at 12:06 PM and 12:18 PM Staff 4 (CNA) and Staff 6 (CNA) stated prior to hospitalization and readmit to the facility, Resident 1 was alert, oriented, talkative and able to use her/his right arm to grasp and pull on the bedrail for repositioning. Staff 6 stated since Resident 1 returned to the facility the prior evening, she/he was not responsive.
On 10/21/20 at 12:30 PM Staff 5 (LPN) stated he arrived to work on Friday morning 10/16/20 (six nursing shifts after onset of symptoms) and Staff 16 (RN) reported Resident 1 "hadn't been right the last two nights. She/he was having trouble rolling." Staff 5 stated he checked on Resident 1 that morning at an unspecified time and the resident could not use her/his right arm, it was completely flaccid and swollen and the resident was having trouble speaking. Staff 5 stated he told Staff 3 (RNCM) he thought Resident 1 had a stroke. Staff 5 stated Resident 1's vital signs were good and he called the doctor. Staff 5 stated Resident 1 later complained of chest pain and the doctor had not called back by the time Resident 1 was sent out.
On 10/22/20 at 9:33 AM Staff 7 (LPN) stated she worked the evening shift Thursday 10/15/20 (fourth nursing shifts after onset of symptoms). Staff 7 (LPN) stated Staff 3 (RNCM) told her Resident 1 had right arm weakness. Staff 7 stated between 4:00 PM and 5:00 PM she checked Resident 1's capillary refill (color return to the finger or fingernail after applying pressure) and it was "good," "the resident's hand was warm and she/he had feeling" and the resident had no pain. Staff 7 stated Resident 1 was unable to lift her/his right arm at all and this was unusual. Staff 7 stated she reported this finding to Staff 3 (RNCM). Staff 7 stated later in the shift, Staff 15 (CNA) reported Resident 1 was was unable to use her/his right arm. Staff 7 stated she obtained a "full set of vital signs" and called the on-call physician. The physician ordered blood tests.
On 10/22/20 at 12:00 PM Staff 8 (RN) stated she was assigned to Resident 1 for the day shift Thursday 10/15/20 (third nursing shift after onset of symptoms) Staff 8 stated Resident 1 was screaming and refusing "everything" which was unusual. Staff 8 stated at the beginning of her shift, Staff 18 (CNA) reported Resident 1 was unable to use her/his right arm at all. Staff 8 stated she told Staff 3 (RNCM). Staff 8 stated she was unable to assess Resident 1 related to Resident 1's increased distress, screaming and refusals.
On 10/22/20 at 1:06 PM Staff 11 (CNA) stated on Friday 10/16/20 morning (sixth nursing shift after onset of symptoms) she reported to Staff 5 (LPN) Resident 1 was unable to move half her/his body and could not use her/his right arm at all. Staff 11 stated Staff 5 responded he already knew, had called the doctor and was waiting for Staff 3 (RNCM) to arrive. Staff 11 stated later in the shift, she reminded Staff 5 again about Resident 1's change in condition.
On 10/23/20 at 5:13 AM Staff 16 (LPN) stated on Thursday 10/15/20 night shift (fifth nursing shift after onset of symptoms) a CNA and Staff 7 (LPN) told him Resident 1's "mood was changed" and the resident was unable to use her/his right arm and hand. Staff 16 stated he was unable to complete an assessment, the resident had a "complete mood change" and the resident's arm was not moving. Staff 16 stated he thought Resident 1's change of condition was just muscle stiffness.
On 10/23/20 at 11:00 AM Staff 10 (LPN) stated she was assigned to Resident 1 on Wednesday evening shift 10/14/20 (first nursing shift; onset of symptoms). Staff 10 stated Resident 1 refused cares and medications and complained of feeling weak which was unusual. Staff 10 stated when she saw Resident 1, she/he was holding onto her/his right hand and the resident complained her/his hand and her/his whole body felt weak. Staff 10 stated she checked Resident 1's capillary refill and massaged her/his hand. Staff 10 stated Resident 1's vital signs were "fine."
On 10/23/20 at 12:33 PM Staff 18 (CNA) stated she worked with Resident 1 from Wednesday 10/14/20 night shift through the morning of Thursday 10/15/20. Staff 18 stated at approximately 1:30 AM, she told Staff 16 (LPN) Resident 1 was unable to use her/his right arm and wouldn't talk or laugh as usual. Staff 18 stated she also reported Resident 1's change of condition to the oncoming Staff 8 (RN) and Staff 9 (CMA).
On 10/27/20 at 10:55 AM Staff 3 (RNCM) stated the process for identifying and reporting a resident's change in condition was to have staff "run it by her" in order to discuss next steps. If the situation was emergent, Staff 3 expected nursing staff to notify the physician. Staff 3 stated she talked to Resident 1 on Thursday 10/15/20 around 5:00 PM and Resident 1's cognition was "fine." Staff 3 stated around 5:15 PM or so, Staff 7 (LPN) reported to her Resident 1 could not move her/his arm. Staff 3 stated she went in to Resident 1's room "very briefly" and saw Resident 1. Staff 3 stated she did not conduct a physical assessment but she could see Resident 1 was unable to move her/his right arm. Staff 3 stated Resident 1 was speaking and she/he seemed tired. Staff 3 stated she directed Staff 7 to call the physician, obtain a capillary blood glucose level and get vital signs.
On 10/27/20 at 11:44 AM findings of this investigation were reviewed with Staff 2 (DNS). Staff 2 stated there were practical things the nursing staff should have done better. Staff 2 stated she expected staff to conduct full assessments, document their findings, make notes and record vital signs. Staff 2 stated nursing staff should have placed Resident 1 on alert to ensure shift to shift communication regarding Resident 1's change of condition and supervisors should have been notified. Staff 2 stated if a resident was exhibiting signs and symptoms of a stroke, staff should conduct a full assessment of arms, legs, eyes and movement and then call 9-1-1.
Review of Resident 1's health record revealed lack of evidence to support the facility identified, comprehensively assessed and intervened timely related to Resident 1's acute change of condition as evidenced by the following:
- Staff failed to call 9-1-1 immediately after Resident 1 exhibited signs and symptoms of a stroke such as new onset right arm weakness, flaccidity and paralysis, trouble speaking and change in mental status;
- Staff failed to further investigate, assess and reassess reports and observations of Resident 1's changes of condition;
- Staff failed to document identified changes and interventions related to Resident 1's changes in condition.
- Resident 1's Vital Signs Report revealed an incomplete set of vital signs were documented on 10/14/20 at 7:13 AM; the vital signs did not include Resident 1's blood pressure, pulse or respirations. No vital signs were documented again until 10/15/20 at 7:21 AM (three nursing shifts after onset of symptoms). No vital signs were documented in correspondence with reports of changes in condition on 10/14/20 evening shift, 10/14/20 night shift, 10/15/20 evening shift and 10/15/20 night shift. No other vital signs were documented until 10/16/20 at 11:20 AM, the day Resident 1 was sent to the hospital.
On 10/27/20 at 4:10 PM Staff 1 (Administrator) and Staff 2 (DNS) were informed of the immediate jeopardy (IJ) situation related to the facility's failure to identify, assess and intervene timely to Resident 1's changes of condition. IJ templates were provided and an immediate IJ removal plan was requested.
On 10/27/20 at 6:55 PM the facility submitted a removal plan which was accepted by the surveyor.
The IJ Removal Plan indicated the facility would implement the following actions:
- Immediate evaluation of all residents in the facility conducted by the nursing management team to determine if any other residents have been affected;
- Education on identifying a change of condition, intervening timely and adding residents with noted changes on alert monitoring;
- Education to include e-interact tool for change of condition, stop and watch and SBAR;
- Full investigation initiated of this incident to include a root cause analysis.
On 10/27/20 at 7:12 PM Staff 1 was observed gathering staff for an in-service and Staff 2 was observed conducting resident assessments.
On 10/28/20 from 11:35 AM through 3:54 PM interviews were conducted with Staff 3 (RNCM), Staff 4 (CNA), Staff 6 (CNA), Staff 7 (LPN), Staff 9 (CMA), Staff 10 (LPN), Staff 11 (CNA), Staff 12 (RN), Staff 13 (Agency CNA), Staff 14 (LPN), Staff 15 (CNA), Staff 17 (RN), Staff 20 (CNA), Staff 21 (LPN), Staff 22 (CNA). Staff verified they received training and education related to identifying, documenting, monitoring, reporting, notifying and responding to residents' change of condition.
On 10/28/20 at 4:00 PM Staff 1 provided documentation of completed assessments of all residents in the facility and stated there were no residents who were negatively affected. Staff 1 provided verification that licensed nursing staff received the required training and education.
On 10/29/20 at 1:20 PM Staff 1 and Staff 2 verified all elements of the IJ removal plan were completed.
Root-Cause Analysis conducted including involvement of ID Team, QAPI Committee and the Governing Body. Findings and intervention plan was reviewed in QAPI Committee meeting on October 30, 2020.F 684 – Quality of CareCFR(s): 483.25Resident Specific:Resident #1 no longer resides at the center.Other Residents:The Director of Nursing (DNS) and/or designee has reviewed other residents to ensure identification, comprehensive assessment and timely intervention for acute change in resident condition occurs in order to avoid placing residents at risk for unidentified change of condition, delay in emergent treatment and serious harm/death. Facility Systems:Facility staff have been re-educated on ensuring identification, comprehensive assessment and timely intervention for acute change in resident condition occurs in order to avoid placing residents at risk for unidentified change of condition, delay in emergent treatment and serious harm/death. Monitor:The DNS and/or designee will monitor resident condition to ensure identification, comprehensive assessment and timely intervention for acute change in condition occurs in order to avoid placing residents at risk for unidentified change of condition, delay in emergent treatment and serious harm/death through observations to validate compliance a minimum of 5 times weekly for four weeks and monthly for 2 months. Any concerns identified will be addressed immediately, additional education provided and counseling if appropriate. Monitoring results will be presented by the DNS and/or designee at the monthly Performance Improvement meeting. Monitoring results and system components will be reviewed by the Performance Improvement Team for 3 months and periodically thereafter, with subsequent recommendations developed and implemented as deemed necessary. Date of Compliance: December 03, 2020Person Responsible: Director of Nursing and/or designee.
The findings of the complaint (Intake # 26925) health survey conducted 10/21/20 through 10/29/20 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 10/29/20.
The findings of the health complaint revisit survey (Intake # 26925) conducted 1/12/21 through 1/13/21 are documented in this report. The facility was found to be in substantial compliance with requirements for the OARs 411 Division 85 through 89.
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OAR 411-086-0110 Nursing Services: Resident Care
Refer to F658 and F684
