The findings of the complaint (Intake # 27641) health survey conducted 3/3/21 through 3/11/21 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 19 current residents. The facility had a census of 113 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 #27641) survey conducted 5/18/21 through 5/19/21 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 ensure residents were free from physical abuse for 2 of 8 sampled residents (#s 1 and 2) reviewed for abuse. This placed residents at risk for abuse. Findings include:
The undated facility Abuse and Neglect policy indicated staff will assist to identify, correct and intervene in situations in which abuse, neglect and/or misappropriation of resident property is more likely to occur. Identification of residents and/or situations may include:
4. Identify residents with conditions or behavior problems that would increase their risk of abuse from the staff or other residents.
Resident 1 admitted to the facility in 4/2020 with diagnoses including dementia and anxiety.
The 10/21/20 Significant Change MDS indicated the resident had a BIMS of 3 (severe cognitive impairment). The MDS did not indicate any behaviors for Resident 1.
The 6/15/20 care plan indicated Resident 1 got upset when she/he would see [Resident 2] head for Resident 1's room or the door to Resident 1's room was open.
Resident 1's progress notes revealed a history of behaviors and near altercations with other residents including:
-11/24/20 Resident 1 got upset with Resident 6. Resident 1 was in her/his wheelchair and approached Resident 6 and attempted to kick at Resident 6. The two residents were separated and assessed.
-2/1/21 indicated Resident 1 was witnessed to be shouting at Resident 2 for being near Resident 1's room and was also witnessed to be mocking Resident 7. Will continue to monitor.
-2/4/21 physical aggression was initiated by Resident 1 toward Resident 2. Monitor for behavior and mood changes. There was no physical contact that occurred. Resident 1 accused Resident 2 of going into her/his room, which did not happen.
-2/11/21 progress note indicated Resident 1 was on alert monitoring and starting to show aggression toward Resident 2 when Resident 2 went into another resident's room. Resident 2 was assisted out of the area.
-2/13/21 another resident was outside Resident 1's room and moved a chair, which caused Resident 1 to get angry. Both residents were separated and the other resident was redirected away from Resident 1's room.
-2/18/21 progress note indicated Resident 1 became angry with Resident 8 and stated "[Resident 8] is staring at me and better knock it off or I will make [her/him]". Continued throughout the morning needed to re-direct Resident 1 away from residents.
-2/20/21 Resident 1 was observed to try to grab the back of Resident 8's shirt when Resident 8 got to close to Resident 1's room. Resident 1 stated that was her/his room and Resident 8 was not allowed in. The residents were separated from each other and Resident 1 was showed to her/his room. Resident 8 was not attempting to enter Resident 1's room.
-2/20/21 that afternoon Resident 1 tried to help Resident 7 put on her/his shoe Resident 1 got mad and tried to hit Resident 7 with a coffee cup. The residents were separated right away. Resident 1 also got angry when Resident 8 was around Resident 1. Resident 1 needed re-direction away from other residents.
-3/3/21 Resident 1 told Resident 2 "I'm going to hit you" in a happy voice when Resident 2 got too close to Resident 1. Resident 2 was assisted out of the area.
On 3/3/21 at 1:04 PM Resident 1 was observed in the HKC (locked memory care) unit dining room sitting at a table talking to a resident. Another resident came up to Resident 1's table two times and was in very close proximity. Resident 1 did not react to the resident. Staff were observed assisting other residents with eating.
Resident 2 admitted to the facility in 2019 with diagnoses including Alzheimer's disease and aphasia (loss of ability to understand or express speech, caused by brain damage).
The 2/13/21 Annual MDS indicated Resident 2 had a BIMS of 5 (severe cognitive impairment).
The 2/13/21 Cognitive Loss/Dementia CAA indicated Resident 2 had poor safety judgment and invaded other resident's space and had been involved in resident to resident altercations. The note indicated staff direct Resident 2 away from other residents who may get annoyed by her/him.
a. The 9/12/20 incident report indicated a CNA witnessed Resident 2 punch Resident 1's right arm in the dining room and no bruise or injury was noted and Resident 1 stated she/he was fine.
Resident 1's 9/14/20 care plan indicated to redirect Resident 2 away from Resident 1 at the first sign of escalation of behaviors such as screaming, loud talking or if Resident 2 attempts to go into Resident 1's room.
b. The 12/10/20 physical incident report indicated Resident 1 grabbed Resident 2's arm to pull her/him out of a different resident's room which agitated Resident 2 and they began yelling. Staff separated Resident 1 and Resident 2. No injuries were noted and staff were reminded to monitor both residents closely to prevent another incident. No abuse intended and interventions are in place to prevent reoccurrence of this event.
Resident 1's 12/10/20 care plan indicated to separate Resident 1 and Resident 2 immediately if observed to be getting close to each other. Resident 1 can be protective of other residents and not allow Resident 2 to enter other rooms. Re-assure Resident 1 that Resident 2 does not mean to harm other residents.
c. The 12/12/20 physical incident report indicated Resident 2 entered Resident 1's unoccupied room. Resident 1 followed Resident 2, grabbed Resident 2's right arm, and attempted to pull Resident 2 out of the room. Resident 2 then struck Resident 1 on the back with her/his fist. The note indicated residents were separated and no injuries were noted. The note further indicated no abuse intended and interventions were in place to prevent reoccurrence of the event.
The 12/12/20 incident report did not indicate if the care plan was followed or what interventions were in place to prevent further incidents.
d. The 1/28/21 fall report indicated Staff 7 (LPN) overheard Resident 1 and Resident 2 yelling at each other. Before the nurse could get to them Resident 2 walked backwards and fell on the floor into a sitting position in front of Resident 2's room. Resident 2 was upset, walking around the hallway all night and was agitated. The residents were separated and no injuries were noted. The note indicated no abuse or neglect suspected and no changes to Resident 2's care plan needed.
e. The 2/5/21 physical incident report indicated Resident 2 was headed to Resident 1's room. Resident 1 tried to stop Resident 2 verbally. Resident 2 did not respond to Resident 1. Resident 1 pulled Resident 2 by the back of the resident's sweater to stop her/him, which caused Resident 2 to fall to the floor. During the fall Resident 2 hit her/his elbow on the wall and sustained two abrasions. The residents were separated and Resident 2 continued to walk around. The note indicated care plans were updated to redirect Resident 1 and Resident 2 away from each other, stop signs were in place on Resident 1's room, and a change in room assignments would be planned to keep residents away from each other. The note indicated the event was physical abuse initiated by Resident 1.
f. The 2/10/21 physical incident report indicated Resident 1 and Resident 2 were in the dining room and Resident 1 told Resident 2 to "go to your own table" and as Resident 2 turned away Resident 1 slapped Resident 2's bottom. Resident 2 turned around and made "boxing actions" toward Resident 1 but did not make physical contact. The note indicated the residents were separated and Resident 1 would be moved to a room away from Resident 2. Resident 1 and Resident 2's rooms were noted to still be next to each other. The note indicated care plans were updated and "staffs attempt to separate these residents as much as possible." The note further indicated the physical abuse was initiated by Resident 1.
The 2/10/21 nursing note indicated Staff 3 (RNCM) spoke to Resident 1's representative about a room change due to Resident 2 "triggering" Resident 1's anxiety. The note indicated room change was to take place on 2/11/21.
Resident 1's 2/10/21 care plan indicated "attempt to put distance between [Resident 1] and [Resident 2]" and indicated both residents were independently mobile and could get in each others' path.
Resident 1's 2/11/21 care plan indicated she/he moved rooms across the unit from Resident 2's room.
On 3/3/21 at 1:17 PM Staff 3 (RNCM) acknowledged Resident 1 had multiple incidents with Resident 2, as well as other residents. Staff 3 stated Resident 1 recently changed rooms due to her/him being possessive of her/his room and stated Resident 1's medications were recently adjusted for behaviors.
On 3/5/21 at 1:53 PM Staff 2 (DNS) acknowledged the identified incidents between Resident 1 and Resident 2. Staff 2 stated the intervention to prevent incidents between Resident 1 and Resident 2 was to monitor Resident 1 and prevent her/him from getting close to other residents. Staff 2 stated the intervention was "hard to do consistently", especially when staff had to go into other resident rooms for cares. Staff 2 further stated many residents on the HKC (locked memory care) unit required two-person assistance with transfers, which decreased supervision in common areas.
Refer to F725
F600Resident 1 A comprehensive behavioral assessment is being conducted using CAAs 8 (mood) and 9 (behavior) as guides; and the care plan will be updated with possible new interventions. A mental health consult is being considered.Resident 2 - A comprehensive behavioral assessment is being conducted using CAAs 8 (mood) and 9 (behavior) as guides; and the care plan will be updated with possible new interventions. A mental health consult is being considered.All residents will be considered at risk related to aggressive behaviors. We are conducting assessments on all residents identified with aggressive behaviors in order to implement more specific interventions. Until the behavioral assessments are completed, we have implemented increased supervision by all staff, including activity, managerial and nursing staff during those times where care staff are busy in rooms performing care in order to mitigate the possibility of resident to resident behaviors. Please also see our action plan for F725.Nursing staff managers are being educated on abuse utilizing the Federal Interpretive Guidelines by an outside consultant prior to compliance date. In addition, we are updating our investigative processes to include more specific trending of events and more timely and aggressive action plans. Our outside consultant is providing our nursing staff managers with education on the steps to a comprehensive and thorough investigation prior to compliance date. A performance team approach will be utilized to assist with the investigative processes to obtain more voices in developing a prevention plan for all resident-to-resident behaviors.Our quality goal / measure is to prevent all avoidable resident-to-resident incidents. All incidents are tracked and trended with each incident and then monthly. We will review as a team all resident-to-resident behaviors at our daily meeting, to ensure the newly implemented investigative process is being followed and to ensure nursing management staff understand abuse definitions.The Administrator and the Director of Nursing are responsible.
Based on observation, interview, and record review it was determined the facility failed to provide sufficient nursing staff to ensure residents attained or maintained their highest practicable level of well-being for 1 of 1 unit reviewed (HKC, memory care) for staffing. This placed residents at risk for abuse. Findings include:
The undated facility Abuse and Neglect policy indicated facility staff will assist to identify, correct and intervene in situations in which abuse, neglect and/or misappropriation of resident property is more likely to occur. Identification of residents and/or situations may include:
2. Sufficient qualified staff to meet the needs of the resident.
Review of resident care plans indicated the following:
-Residents 7, 11, 12, 13, 14, 15, 16, and 17 required two-person staff assistance with transfers.
-Residents 1, 2, 6, 7, 9, 10, 13, 18, and 19 were monitored for behaviors related to resident to resident altercations.
-Residents 2, 3, 6, 7, 8, 9, 10, 13, 17, 18, and 19 were monitored for behaviors related to wandering.
On 3/3/21 at 10:43 AM Staff 10 (RN) stated there were three CNAs that worked day shift in the HKC unit and "a lot of times" there was just one staff on the floor monitoring residents for behaviors.
On 3/3/21 at 12:57 PM three CNAs, a nurse, and Staff 5 (Activities) were observed in the locked HKC (memory care unit). Two CNAs assisted residents in the dining area with eating and one CNA was observed in a resident room assisting the resident with eating. A nurse was observed passing medications in the dining area. Staff 5 was observed outside of the dining area setting up an activity.
The 3/3/21 and 3/4/21 Staffing Schedule indicated on evening shift one nurse and two CNAs were scheduled and one other CNA was scheduled from 5 PM until 9 PM in the HKC. For night shift, two CNAs and one nurse were scheduled to work in the HKC unit. The 3/3/21 census indicated there were 19 residents in the HKC unit.
On 3/3/21 at 1:17 PM Staff 3 (RNCM) acknowledged she stayed past her scheduled shift to assist staff with the dinner meal and during the day assisted staff with resident transfers. Staff 3 acknowledged multiple residents had behaviors that required monitoring and staff redirection.
On 3/3/21 at 1:32 PM Staff 11 (RN) stated the memory care unit would benefit from another staff member to monitor residents as there were many residents who required two-person cares and transfers and had behaviors.
On 3/4/21 at 11:11 AM Staff 7 (LPN) stated on night shift, the only time she felt there were not enough staff to monitor residents was when she was passing medications and CNAs were assisting residents in their rooms. Staff 7 further stated if CNAs were in a resident room doing a two-person transfer she waited to go into resident rooms until the CNAs were finished so someone would be out on the floor watching residents.
On 3/4/21 at 2:56 PM Staff 16 (CNA) stated the facility was understaffed in the HKC unit due to resident acuity. Staff 16 stated many residents in the unit had fluctuating "sundowning" behaviors during evening shift and that shift had less staff than day shift. Staff 16 stated the dinner meal was difficult due to only two CNAs assigned during the meal. Staff 16 further stated during evening shift the nurse assisted CNAs with resident cares.
On 3/5/21 at 9:03 AM Staff 15 (CNA) stated on evening shift at times there were two CNAs assigned to work the HKC unit with 20 residents. Staff 15 stated a third CNA would sometimes be assigned to work evenings from 5 PM until 9 PM, which helped with resident cares. Staff 15 stated staff were able to complete resident cares, but it could be difficult, and staff had to "scramble" until 5 PM due to less staff. During dinner, activity staff would sometimes assist with passing meal trays, but the HKC did not always have an activity staff person available. Staff 15 stated when CNAs were assisting residents in their rooms then the nurse would be at the medication cart monitoring residents. Staff 15 stated there were six or seven residents who required two-person staff transfers, which left only the nurse to monitor residents.
On 3/5/21 at 1:53 PM Staff 2 (DNS) stated the facility had staffing difficulty "every day." Staff 2 stated intervention to monitor residents to prevent incidents was "hard to do consistently" on the HKC (memory care) unit, especially when staff had to go into resident rooms to provide cares. Staff 2 further stated many residents on the HKC unit required two-person transfers, which decreased supervision in common areas.
On 3/11/21 at 1:10 PM Staff 3 (RNCM) stated all 19 residents on the HKC unit had wandering behaviors. She stated Residents 2, 8, and 9 wandered into other resident rooms. Staff 3 stated nine residents (Residents 7, 9, 11, 12, 13, 14, 15, 16, and 17) required two-person staff assistance for transfers. Staff 3 stated 10 residents were monitored for behaviors related to resident-resident incidents (Residents 1, 2, 6, 7, 8, 9, 10, 13, 18, and 19).
Refer F600.
F725Residents 7, 11, 12, 13, 14, 15, 16 and 17 – We are assessing each resident transfer status with the assistance of physical therapy and updating plans of care as needed.Residents 1, 2, 6, 7, 9, 10, 13, 18 and 19 – We are conducting a comprehensive behavioral assessment using CAA’s 8 (mood) and 9 (behavior) as guides; and the care plan will be updated with possible new interventions to prevent aggressive behaviors and resident-to-resident altercations. A mental health consult is being considered.Residents 2, 3, 6, 7, 8, 9, 10, 13, 17 and 19 - We are conducting a comprehensive behavioral assessment using CAA’s 8 (mood) and 9 (behavior) as guides; and the care plan will be updated with possible new interventions to assist with wandering and increased supervision. A mental health consult is being considered.All residents with increased acuity needs related to care, mobility and behaviors are being identified and assessed so an appropriate staffing plan can be developed.We are implementing a plan to further assess resident and staffing needs that includes the following:• We are examining staff shift (Licensed Nurse and CNA) routines and assignments to determine where staffing needs are increased and then examining current staffing for change in shift routines and/or increasing staff at certain times.• Assess mobility needs of residents currently receiving 2-person transfers in collaboration with physical therapy to determine if 2-persons are truly needed for services being provided while maintaining resident safety. This may result in some policy and procedure revisions with the assistance of therapy.• Assess care needs (ADL and Mobility needs) of high acuity residents and determine if these residents continue to require care in a secured unit. We will then discuss with families the possibility of relocating some residents in other areas of the facility.• Reassess behavioral needs of all residents with significant behaviors that are not easily altered with current behavioral interventions. This will include reviewing our current process for review of behaviors and psychotropic medications.• Developing a process for more specific review of potential admissions to this unit by examining the capability and capacity of staff to care for the potential admission as compared to other residents residing on the unit.• An action plan will be developed and implemented based on the above information prior to compliance date.The above plan will be developed and reviewed by a team, then implemented prior to compliance date. Based on the plan, staffing will be reexamined with each admission, discharge, and significant change of condition in the secured unit. The Administrator and the Director of Nursing are responsible.
The findings of the complaint (Intake # 27641) health survey conducted 3/3/21 through 3/11/21 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 3/11/21.
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 Dietitian
ROM: range of motion
RN: Registered Nurse
RNCM: Registered Nurse Care Manager
SA: State Agency
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 #27641) revisit survey conducted from 5/18/21 through 5/19/21 are documented in this report. The facility was found to be in substantial compliance with OARs 411 - 85 through 89.
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OAR 411-085-0360 Abuse
Refer to F600
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OAR 411-086-0100 Nursing Services: Staffing
Refer to F725
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