The findings of the complaint (Intake #s 25725 and 27709) health survey conducted 1/13/21 through 2/1/21 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 4 current residents and 2 closed records. The facility had a census of 30 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 25725 and 27709) health survey conducted 3/24/21 through 3/26/21 are documented in this report. The facility was found to be in substantial 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 administer the correct medications for 1 of 3 sampled residents (#5) reviewed for safe medication administration. Resident 3 experience unmanaged pain for a prolonged period. Findings include:
Resident 5 admitted to the facility in 11/2020 with diagnoses including cancer, chronic pain syndrome and received hospice (end of life) care.
A physician's order on 11/13/20 directed staff to apply a 100 mcg Fentanyl patch (pain medication) transdermally (applied to the skin) every 72 hours related to cancer and pain.
A 11/2020 MAR instructed staff to place a 100 mcg Fentanyl patch transdermally every 72 hours related to cancer and pain. Additionally, two nurses were required to observe the removal of the old patch, placement of the new patch and document disposal via the narcotic log book. Two staff were to date and sign the new patch when applied and remove the old patch per schedule.
A 11/21/20 Medication Error Report revealed the following error on 11/21/20:
-A 25 mcg Fentanyl patch was placed on Resident 5 at 12:36 PM instead of a 100 mcg Fentanyl patch.
-The wrong dosage was discovered on 11/21/20 at 10:15 PM and the correct 100 mcg Fentanyl patch was placed on Resident 5.
- Staff 12 (LPN) an agency nurse asked Staff 8 (RN) if she needed a second nurse for visual placement and dose check of the Fentanyl patch prior to placing on Resident 5 and Staff 8 replied to go ahead because she did not have time.
-The impact of the error on the resident included Resident 5 being very painful all evening.
Random observations on 1/13/21 through 1/14/21 revealed Resident 5 asleep in bed, lying on her/his side, with a nasal cannula and an oxygen concentrator running. Resident 5 was not interviewable and was asleep in bed anytime time observations and interviews were attempted.
On 1/14/21 at 1:25 PM Staff 8 indicated she recalled the medication error related to Resident 5, however did not believe she worked that day.
On 1/14/21 at 2:44 PM Staff 7 (LPN) stated she worked the evening shift on 11/21/20 and recalled Resident 5 was more painful than usual, she/he was agitated, grimacing and kept trying to get up out of bed. Staff 7 stated the resident was administered additional Dilaudid (a narcotic pain medication for moderate to severe pain) every two hours. Staff 7 stated CNA staff reported throughout the entire evening shift that anytime they attempted to move Resident 5 in bed she/he would "scream ouch, ouch, grimace and wince." Staff 7 stated the Dilaudid could only be administered every two hours and CNA staff reported to her that Resident 5 continued to struggle with pain in between the two hour window of Diludid administration. Staff 7 stated she and Staff 14 (LPN) discovered the medication error during shift change when they were counting the narcotics. Staff 7 and Staff 14 assessed Resident 5 and discovered a 25 mcg Fentanyl patch was on the resident's back instead of a 100 mcg Fentanyl patch. Staff 7 stated the 25 mcg patches were taped up and were not to be used and were delivered by hospice by mistake. Staff 7 stated two nurses were to be present to verify the correct Fentanyl patches being placed, the old Fentanyl patch being removed, two signatures on the new patch and both nurses were to sign the narcotic log. Staff 7 stated this did not occur during the day shift on 11/21/21 and Resident 5 was more painful than usual the entire evening shift due to the incorrect Fentanyl patch; a period of approximately nine and a half hours until the error was discovered.
On 1/15/21 at 9:53 AM Staff 11 (Pharmacist Consultant) stated Resident 5's medication error related to the reduction of the Fentanyl patch could impart the resident's pain level because Resident 5 could develop a tolerance and dependence upon the 100 mcg Fentanyl patch.
On 1/25/21 at 2:36 PM Staff 12 stated she did not work in the building often, however she worked on 11/21/21 on day shift. She vaguely remembered placing a Fentanyl patch on Resident 5. Staff 12 stated because she did not work regularly in the building she asked Staff 8 if she needed to have a witness prior to applying the Fentanyl patch and Staff 8 replied there was nothing special regarding placement of the Fentanyl patch. Staff 12 stated she removed the old Fentanyl patch and replaced with a new one and dispose of the old patch. Staff 8 stated she did not recall the 25 mcg Fentanyl patches being taped up, but she recalled them being in a box and she pulled out a single Fentanyl patch. Staff 12 stated she applied the patch to Resident 5 and signed and dated the Fentanyl patch. Staff 12 further stated she did not recall if Resident 5 was painful or not.
In an interview on 1/14/21 at 2:15 PM and 1/25/21 at 1:45 PM Staff 2 (DNS) stated she was aware of the medication error on 11/21/20 and Resident 5 being more painful than usual during evening shift. Staff 2 stated she expected two nurses to witness when Fentanyl patches were being applied to ensure the correct dosage, application and disposal of the Fentanyl patch was. Staff 2 stated the 25 mcg Fentanyl patches were delivered by hospice, which was the wrong dose for Resident 5. The 25 mcg Fentanyl patches should have been destroyed and not in the medication cart, however they were taped up and placed in the narcotic drawer. Staff 2 stated due to the lower dosage being placed on Resident 5 she/he was painful the entire evening until the error was discovered at the end of evening shift change by Staff 7 and Staff 14.
1. Resident #5 received correct dose of Fentanyl patch and the incorrect dosage patches were removed from the cart and destroyed.2. Medication carts were inspected to determine there were no incorrect Fentanyl doses on the carts for any additional residents and any incorrect doses were clearly labeled to be destroyed. 3. Education will be provided to licensed nurses/Medication aides on the correct steps to ensure old Fentanyl doses are removed and the correct dosage applied. This training will include the requirement to clearly label any incorrect fentanyl patch doses stored in narcotic drawer until destroyed.4. DNS/Designee will monitor narcotic books and Fentanyl dosages available on Medication carts 3x a week x 1 month to ensure residents are receiving correct dose of Fentanyl and to confirm that nursing department is following the correct steps in the administration and destruction of Fentanyl patches. DNS/Designee will report to QAPI x 3 months and then as indicated.
2. Resident 2 was admitted to the facility on 12/16/20 and discharged on 12/17/20 with diagnoses including recovery from recent neck and back surgery, chronic pain and anxiety.
On 1/13/21 at 12:33 PM Resident 2 stated the one meal received during her/his short stay at the facility was not palatable and was served at room temperature in a Styrofoam container.
On 1/14/21 at 12:10 PM a sample lunch tray was provided to survey staff. Each meal was served in a Styrofoam container. The meals included a regular texture meal, a pureed texture meal and two mechanical soft textures (foods requiring less chewing) levels 2 and 3. All meals were barely warm. The food was bland and the pureed meat and carrots were watery.
On 1/14/21 at 12:23 PM Staff 1 (Administrator) agreed there were temperature issues with the identified meals. Staff 1 stated the facility started to utilize Styrofoam containers for all residents due to the recent outbreak of COVID 19. He confirmed the food was bland to taste, the pureed meat and carrots were watery and the pureed meat and carrots should have been smoother and thicker in texture.
3. Resident 3 was admitted to the facility in July 2020 with diagnoses including cancer and malnutrition.
In an Interdisciplinary Care Conference dated 11/2/20 the resident and Witness 3 (Family) stated the food was often over-seasoned and the resident's diet was for soft foods but the vegetables were often not cooked soft enough and were crunchy in texture.
On 1/28/21 at 12:25 PM Witness 3 stated Resident 3 reported some meals were inedible and the food temperature was frequently cool.
On 1/14/21 at 12:10 PM a sample lunch tray was provided to survey staff. Each meal was served in a Styrofoam container. The meals included a regular texture meal, a pureed texture meal and two mechanical soft textures (foods requiring less chewing) levels 2 and 3. All meals were barely warm. The food was bland and the pureed meat and carrots were watery.
On 1/14/21 at 12:23 PM Staff 1 (Administrator) agreed there were temperature issues with the identified meals. Staff 1 stated the facility started to utilize Styrofoam containers for all residents due to the recent outbreak of COVID 19. He confirmed the food was bland to taste, the pureed meat and carrots were watery and the pureed meat and carrots should have been smoother and thicker in texture.
Based on observation, interview and record review it was determined the facility failed to ensure proper flavor, food textures and food temperatures were maintained for food trays served from 1 of 1 facility kitchen reviewed for food service. This placed residents at risk for food that was not palatable, safe or appetizing. Findings include:
1. On 7/27/20 a public complaint was received and indicated food served at the facility was cold.
On 1/13/21 at 10:02 AM Resident 1 (Complainant) indicated she/he was served food which was cold and most of the time not at an appropriate temperature. Resident 1 stated one night she/he was served cold hot dogs. Resident 1 stated she/he spoke to staff on multiple occasions however, the food continued to be served cold and did not taste good.
On 1/13/21 at 3:19 PM Resident 4 stated the food was served warm, not hot. The resident indicated she/he ate the meals however, the food in general was not desirable.
On 1/14/21 at 12:10 PM a sample lunch tray was provided to survey staff and each meal were served in a Styrofoam container. An example of each of the meals provided to residents for the lunch meal was included. The meals included a regular texture meal, a pureed texture meal and two mechanical soft textures (foods requiring less chewing) levels 2 and 3. All meals were tasted and were barely' warm but not hot. The food was bland and the pureed meat and carrots were watery.
On 1/14/21 at 12:23 PM Staff 1 (Administrator) agreed there were temperature issues with the identified meals. Staff 1 stated the facility started to utilize Styrofoam containers for all residents due to the recent outbreak of COVID 19. The food was bland to taste and the pureed meat and carrots were watery. Staff 1 indicated the pureed meat and carrots should have been smoother and thicker in texture.
1. Styrofoam products were immediately removed from service to improve temperatures of food served. Immediate education was given to cook on duty for proper procedure for preparing the different levels of dysphagia diet. 2. Meal temperatures were conducted for room trays to determine improvement and appropriate temperatures delivered to residents in their rooms. 3. Education will be conducted with nursing and dietary department on communication and steps to follow to ensure meal trays are delivered at appropriate temperatures. Dietary staff will attend in-service training for Dysphagia diet levels and appropriate procedures for creating each level of altered texture. 4. Dietary Manager will monitor food temperatures; to include meal trays delivered to rooms, 3x a week x 2 months and report to QAPI as indicated.
2. Resident 3 was admitted to the facility in July 2020 with diagnoses including cancer, an ostomy and malnutrition.
In an Interdisciplinary Care Conference dated 11/2/20 the resident and her/his family stated there was a problem with the dietary manager. Resident 3 stated she/he communicated exactly what foods she/he preferred but it was "never correct". The resident stated she/he could not have pork because it made her/him feel sick but was given pork multiple times.
Resident 3's Diet Profile dated 11/20/20 indicated Resident 3 was allergic to pork and did not like pork.
On 1/15/21 at 9:34 AM Staff 5 (Dietary Manager) stated he did not always review residents' food preferences to ensure they were honored and followed. Staff 5 further stated the kitchen staff were to work together to ensure preferences were followed but human error could occur.
On 1/21/21 at 1:00 PM Staff 1 (Administrator) agreed there was a breakdown in the system regarding following and honoring residents' food preferences.
On 1/28/21 at 12:25 PM Witness 3 (Family) stated Resident 3 was allergic to pork products but received bacon a few weeks ago, which was not the first time. She further stated Staff 5 did not always honor Resident 3's food preferences.
Based on interview and record review it was determined the facility failed to ensure a residents' food preferences were honored for 2 of 3 (#s 1 and 3) sampled residents reviewed for food. This placed residents at risk for food preferences not being honored. Findings include:
1. Resident 1 was admitted to the facility in 7/2020 with diagnoses including diabetes.
On 1/13/21 at 10:02 AM Resident 1 (Complainant) indicated she/he was diabetic and the facility often delivered him desserts, such as cake, and she/he specifically asked for no desserts with her/his meals. Resident 1 stated the facility provided meals which were high in carbohydrates (such as sugar, pasta and potatoes). Resident 1 indicated the facility did not have sugar free syrup and she/he was told it was due to COVID. Resident 1 stated she/he spoke with numerous staff regarding her/his preferences, however she/he continued to be served items she/he did not want, liked or ask for.
The 7/10/20 Interdisciplinary Care Conference under the Dietary Summary section revealed Resident 1 was on a diabetic diet and the resident's preferences were two scrambled eggs and toast for breakfast and a sandwich with extra protein (either extra meat or a cheese stick) for lunch. The kitchen was to avoid the following: corn, broccoli, all fruit, all desserts and any items high in sugar and excessive carbohydrates.
The 7/14/20 Nutrition Assessment completed by the Staff 6 (Registered Dietician) revealed Resident 1 was on a diabetic and heart healthy diet. The resident was to avoid additional salt and the kitchen staff were to honor Resident 1's wishes. The resident did not want brown sugar, liked Splenda (a sugar substitute) in her/his coffee, no dessert, no sugar free juices, liked milk with meals and fruit with lunch and dinner.
The 7/15/20 Dietary Profile revealed Resident 1 was on a diabetic and heart healthy diet. Resident 1 liked scrambled eggs and toast for breakfast, meat sandwiches for lunch with no sides but with extra protein. The resident disliked the menu as it was not consistent with her/his preferences. Accommodations had been made. Resident 1 refused food if it was late and if the food order was wrong.
On 1/14/21 at 2:32 PM Staff 7 (LPN) stated Resident 1 was dissatisfied about the food because she/he was diabetic and did not feel the facility had enough choices or alternatives for her/his diabetic diet. Resident 1 was able to state her/his needs and let staff know when she/he received something which should not have been served.
On 1/15/21 at 9:34 AM Staff 5 (Dietary Manager) indicated Resident 1 was a diabetic and particular about her/his food preferences. The resident did not want any sugary items with her/his meals and if the order was incorrect, she/he would refuse to eat the meal. Staff 5 stated he was unaware Resident 1 did not want any desserts. Staff 5 indicated at times the facility had difficulty with food items being delivered due to the global pandemic. When asked how he ensured nutrition assessments were being implemented, preferences being honored and followed Staff 5 stated he did not always review the Nutrition Assessments and that information came from the nursing staff. When asked how he ensured a diabetic diet was followed Staff 5 stated the menu they utilized indicated not to serve a starch or dessert. Staff 5 further stated the kitchen staff should work together to ensure this was followed however, human error could occur.
On 1/21/21 at 1:00 PM Staff 1 (Administrator) agreed there was a break-down in the system regarding diabetic diets and residents preferences.
On 1/25/21 at 2:14 PM Staff 6 stated she completed a nutrition assessment within seven days of Resident 1's admission to the facility. Staff 6 stated the assessment was communicated to the team, which included Staff 1, Staff 2 (DNS), Staff 17 (RNCM), Staff 18 (LPN/Resident Care Manager) and Staff 5. Staff 6 stated Resident 1 had specific preferences. Resident 1 was a diabetic and on a low sodium diet. Resident 1 wanted fruit and no desserts. Staff 6 stated they had a dietary manager report to which Staff 5 had access to ensure preferences and recommendations being addressed. Staff 6 was not aware Resident 1 was receiving desserts with her/his meals.
1. Identified residents # 1 food preferences were immediately reviewed to determine kitchen staff able to identify and deliver resident meals following her preferences and dietary restrictions, including diabetic offerings. Resident # 3 food allergies were reviewed to determine dietary staff able to determine and follow accurately resident’s allergies to avoid serving.2. An audit was conducted of tray cards to determine they were accurate for textures, food preferences and intolerances, allergies, and dietary restrictions such as diabetes. 3. Education will be conducted with dietary department on communication steps to follow on food preferences and restrictions, allergies, food texture, and proper seasoning and cooking of vegetables to ensure meals are appealing, palliative, and properly portioned. Review will be conducted with nursing dept. to read meal tray cards to determine served meal is accurate. 4. Dietary Manager/Designee will monitor meals to determine that meals are appealing and palliative, appropriate textures, meals follow allergy identification and dietary restrictions, honor preferences, and food is properly seasoned with proper cooking of vegetables 3x a week x 2 months and report to QAPI as indicated
The findings of the complaint (Intake #s 25725 and 27709) health survey conducted 1/13/21 through 2/1/21 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 2/1/21.
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 revisit complaint (intake #s 25725 and 27709) health survey conducted 3/24/21 through 3/26/21 are documented in this report. The facility was found to be in substantial compliance with OAR 411 - 85 through 89.
OAR-411-086-0110 Nursing Services: Resident Care
Refer to F760
*****
OAR-411-086-0250 Dietary Services
Refer to F804, F806
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