Alliance Health at West Acres

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About Alliance Health at West Acres

Alliance Health at West Acres is a non-profit, 138 -bed Medicare/Medicaid certified skilled nursing facility that provides services to the residents of Brockton, Stoughton, Abington, East Bridgewater, Whitman, Holbrook, Randolph, Easton, Bridgewater, Rockland, and the other towns in and surrounding Plymouth County, Massachusetts.

Alliance Health at West Acres
804 Pleasant St,
Brockton, MA 02301

Phone: (508) 583-6000
Website: http://www.alliancehhs.org/Skilled-Nursing-Rehab-Brockton-MA

CMS Star Quality Rating

The Centers for Medicare and Medicaid (CMS) rates all nursing homes that accept medicare or medicaid benefits. CMS created a 5 Star Quality Rating System—1 star is the lowest rating and 5 stars is the highest—that look at three areas.

As of 2018, Alliance Health at West Acres in Brockton, Massachusetts received a rating of 4 out of 5 stars.

Performance Area Rating
Overall Rating 4 out of 5 (Above Average)
State Health Inspections 3 out of 5 (Average)
Staffing 4 out of 5 (Above Average)
Quality Measures 4 out of 5 (Above Average)

Fines Against Alliance Health at West Acres

The Federal Government has not fined Alliance Health at West Acres in the last 3 years.

Fines and Penalties

Our Nursing Home Accident Lawyers inspected government records and discovered Alliance Health at West Acres committed the following offenses:

Failed to let the resident refuse treatment or refuse to take part in an experiment and formulate advance directives.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to ensure for one Resident (#1) out of a total sample of 20 residents, that his/her right to formulate the Advanced Directive for a DNR (Do Not Resuscitate) status was exercised.

Findings include:

Resident #1 was admitted to the facility in 9/2016 with [DIAGNOSES REDACTED]. A review of the most recent Quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated the Resident had short and long term memory deficits and was assessed as being severely impaired in his/her decision making. The MDS indicated the Resident did not have a Health Care Proxy (HCP) and that the medical record had no supporting documentation that he/she had consented for any Advance Directives (including a DNR).

Record review indicated Resident #1 had completed a HCP on 12/25/00. Review of the HCP form indicated that the Resident had outlined his/her advance directives on the form. The Resident directed that no [MEDICAL CONDITION] of . any blood types be given and that . he/she did not want his/her life to be prolonged regarding end of life matters.

Review of the medical record the physician indicated the Resident was a full code and that the Resident did not want blood [MEDICAL CONDITION] (this did not match the Resident’s documented advance directives).

On 11/21/16, the Resident’s physician certified that the Resident was no longer able to understand the nature, extent, or probable consequences of any proposed treatment, was unable to make a rational evaluation of any proposed treatment and was no longer capable of effectively communicating his/her decisions. The physician indicated that the Resident’s HC agent was notified that the HCP was invoked. Subsequent and further review failed to indicate that the physician’s decision to invoke the HCP was changed. Review of the clinical record indicated inconsistencies in the medical plan of care for advance directives.

The care plan for advance directives dated as reviewed on 6/19/17 indicated the Resident was a full code, was not to be transferred to the hospital (DNH) and that the HCP had been deactivated on 10/18/16. In addition, the Interdisciplinary Team Meeting Record indicated that the Advance Directives were reviewed on 6/19/17 and that a MOLST (Massachusetts Medical Orders for Life-Sustaining Treatment) Form/Orders was in place. The plan of care failed to indicate that the Resident did not want blood transfusion or that he/she wanted to be a DNR.

During interview on 7/18/17 at 10:00 A.M., the Resident’s advance directives were reviewed with Unit Manager (UM) #1. The UM reviewed the Resident’s HCP form and said that this was the first time he had seen that the form outlined specific advance directives. He said he had not realized that the Resident had indicated he/she wanted to be a DNR. He said he was aware of the Resident’s refusal of blood [MEDICAL CONDITION]. He reviewed the form and said that after reading the form he agreed that the form indicated the Resident’s wanted his/her advance directives to include a DNR. The UM reviewed the care plan and said that he thought that there was a MOLST form completed and did not know about the DNH, but that he would look into it. UM #1 said that the Resident’s HCP was invoked and that the Family had wanted the Resident to be a Full Code.

During discussion with the Director of Nurses on 7/20/17 at 3:00 P.M., she said the Resident was his/her own person and that the staff met with the Resident who said that he/she wanted to be a Full Code and no blood [MEDICAL CONDITION]. The Director said that the Facility’s Social Worker met with the Resident and had the Resident complete a MOLST form. The Director was unaware that the physician had invoked the HCP on 11/21/16, because the Resident was no longer able to understand the nature, extent, or probable consequences of any proposed treatment, was unable to make a rational evaluation of any proposed treatment and was no longer capable of effectively communicating his/her decisions.

Failed to immediately tell the resident, the resident's doctor and a family member of the resident of situations (injury/decline/room, etc.) that affect the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews the Facility failed to notify the physician of a high blood sugar (BS) on three occasions for one Resident (#17) out of a total sample of 20 Residents.

Findings include:

Resident #17 was admitted to the Facility in 6/2017 and had [DIAGNOSES REDACTED]. Review of Resident #17’s admission Minimum Data Assessment (MDS) assessment dated [DATE], indicated that Resident #17 scored 15 out of 15 on a Brief Interview for Mental Status (BIMS) indicating he/she was cognitively intact. Review of the physician’s telephone order dated 7/1/17 indicated that Resident #17 was to receive the the following order for sliding scale insulin: Regular Insulin Humalin four times a day as follows:

200-250 2 units
251-300 4 units
301-350 6 units
351-400 8 units
401-450 10 units

If BS is greater than 450 call the physician. Review of the Sliding Scale Insulin record for July 2017, indicated the following:

* On 7/1/17 at 4:30 P.M. Resident #17 had a BS of 531.
* On 7/1/17 at 9:00 P.M. Resident #17 had a BS of 550.
* On 7/2/17 at 4:30 P.M. Resident #17 had a BS of 481.

Review of Resident #17’s nurse’s note dated 7/1/17 for the 3:00 P.M. to 11:00 P.M. shift indicated that the physician was not notified of Resident #17’s BS of 531 at 4:30 P.M. or Resident #17’s BS of 550 at 9:00 P.M.

Review of Resident #17’s nurse’s note dated 7/2/17 for the 3:00 P.M. to 11:00 P.M. shift indicated that the physician was not notified of Resident #17’s BS of 481 at 4:30 P.M. Review of Resident #17’s nurse’s note dated 7/7/17 for the 3:00 P.M. to 11:00 P.M. shift indicated that the physician was not notified of Resident #17’s BS of 481 at 4:30 P.M. The Surveyor interviewed the Director of Nurses (DON) at 1:30 P.M. on 7/20/17. The DON said she had nothing to add to the inconsistent documentation regarding the Sliding Scale Insulin. The DON said there is no order to administer Insulin for a BS greater than 450. The Surveyor interviewed the DON by phone at 12:15 P.M. on 7/21/17. The DON said she reached out to the pharmacy today and the pharmacy said they only dispensed Humalog Insulin for Resident #17. The DON said she put a call out to the physician regarding what kind of Insulin the Resident should be receiving, Humalin (as ordered) or Humalog (as administrated), however, there was no return from the physician yet. The DON said there was no clarification of Resident #17’s Insulin prior to the Surveyor identifying the discrepancy in Insulin ordered for Resident #17 vs. the Insulin that was administered.

Failed to make sure each resident receives an accurate assessment by a qualified health professional.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to ensure that all sections of the Resident’s Minimum Data Set (MDS) assessments, were comprehensive and complete to accurately reflect the Resident’s status for 1 Resident (#1) of 20 sampled Residents.

Findings include:

For Resident #1, the facility failed to accurately complete the quarterly MDS assessment with a reference date of 6/6/17 for advance directives. Resident # 1 was admitted to the facility in 9/2016 with [DIAGNOSES REDACTED]. Review of the medical record indicated the Resident had a Health Care Proxy, designating an agent and an alternate. In addition, the Resident signed that he/she wanted to be a Do Not Resuscitate and refused any and all types of blood [MEDICAL CONDITION]. The record indicated the Health Care Proxy was invoked on 11/21/17. Review of the section of the MDS for advance directives, indicated that the Resident did not have a Health Care Proxy, therefore it was not invoked and had no specific advance directives.

On 7/18/17 at 10:00 A.M., the information was shared with the Unit Manager (#1).

Failed to develop a complete care plan that meets all of a resident's needs, with timetables and actions that can be measured.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, medical record review and staff interviews, the Facility failed to develop an individualized activity care plan for one Resident (#3), from a total sample of 20 Residents. The Facility failed to develop an individualized care plan to meet the needs of the Resident who was severely cognitively impaired, legally blind, aphasic, wore a seat belt restraint for safety, understood only Portuguese and had episodes of agitation and fidgeting with his/her restraint and feeding tube. The activity care plan did not indicate measurable objectives or timetables.

Findings include:

Resident #3 was admitted to the Facility in 8/2015 with the following pertinent Diagnoses: [REDACTED].

Resident #3 is non-verbal and only understands Portuguese. The Surveyor observed Resident #3 throughout survey (7/13, 7/14 and 7/18/17). The Resident was observed in only 2 activities (and not listed on activity preference list or calendar) through-out survey, and only following Surveyor inquiries about limited and non-individualized activities.

Review of the annual Minimum Data Sets (MDS) assessment for 6/17 indicated that Resident #3 is cognitively impaired (with a Brief Interview Mental Status score of 3/15) and is non-verbal, severely vision impaired, incontinent of bowel/bladder, wears a buckle seatbelt restraint for safety and is completely dependent on staff for all activities of daily living.

Review of the Resident Activity Admission Assessment indicated the following quarterly summary: involved in activities daily attends mass and observes activities on the unit and family is in daily, if not often. An activity preference listed (A-S) indicated only 2 preferences- (L) Music-Green Day and (M) Religious Involvement.

Review of the Activities Care Plan (target date of 9/2017) indicated the following approaches:

* arrange visits by volunteers (no indication that a calendar of visits was initiated).
* provide 3-4 1:1 sessions with resident per week (*no description of services provided and no goals for treatment)
* provide adaptive equipment to facilitate participation in activities; items that he/she can tinker with
* provide materials of interest to reduce agitation
* The care plan does not indicate a specific list of options for materials which are appropriate for the Resident’s physical and cognitive deficits.

On 7/18/17 at 10:30 A.M. Surveyor #1 interviewed the Activity Director (AD). The AD said that sometimes the Resident listens to music on his/her Pandora radio with his/her cell phone. The Surveyor asked about tactile stimulation to reduce fidgeting and possible falls. The AD showed the Surveyor a tactile board (located in a cupboard of the dining room). The Surveyor said that the tactile board was never observed during survey and staff said that the board was too heavy for the Resident and often threw it. The AD said that she would follow-up on this. After Surveyor inquiry, the AD said that she would reach out to various community programs for the blind and cognitively impaired so that the Resident could listen to tapes in his/her own language. On 7/21/17 at 12:00 P.M., Surveyor #2 conducted a follow-up interview with the AD. The AD said that the Resident’s activity care plan did not say enough and that she needed to revise it.

Failed to make sure services provided by the nursing facility meet professional standards of quality.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the Facility failed to meet professional standards of clinical practice, for 5 sampled Residents (#6, #7, #11, #14 and #17) out of a total sample of 20 Residents.

Findings include:

Standard reference: Standard of Practice Reference: Pursuant to Massachusetts General Law (M.G.L.), chapter 112, individuals are given the designation of registered nurse and practical nurse which includes the responsibility to provide nursing care. Pursuant to the Code of Massachusetts Regulation (CMR) 244, Rules and Regulations 3.02 and 3.04 define the responsibilities and functions of a registered nurse and Practical nurse respectively. The regulations stipulate that both the registered nurse and practical nurse bear full responsibility for systematically assessing health status and recording the related health data. They also stipulate that both the registered nurse and practical nurse incorporate into the plan of care, and implement prescribed medical regimens. The rules and regulations 9.03 define standards of Conduct for Nurses where it is stipulated that a nurse licensed by the Board shall engage in the practice of nursing in accordance with accepted standards of practice.

A. Reconciliation Policy indicated the facility will obtain and document a complete list of the resident’s current medications upon the resident’s admission to the nursing facility. The policy documents that when a resident/patient is admitted to the facility the list of medications ordered upon admission must be compared and reconciled with the list of medications the resident/patient is taking prior to the facility. The policy indicated the medication reconciliation form will be completed upon admission, check the medication listed on the referral from the hospital with the resident, ask the resident of any other medications taking at home. The nurse will then contact the physician regarding potential discrepancies identified during the medication reconciliation assessment as warranted. The policy noted that any discrepancies or changes found between resident medication lists will be clarified in an order and noted on the Medication Reconciliation form.

1. For Resident #7, the facility failed to follow the Facility’s policy and procedure for medication reconciliation on admission, which resulted in inaccurately transcribing the sliding scale insulin, by listing all the current medications not the discrepancies (per procedure and policy). Resident #7 was admitted ,[DATE] after a hospitalization for a surgical repair of a femur fracture. A review of the hospital discharge summary dated 7/10/17 indicated the Resident had other [DIAGNOSES REDACTED]. The hospital discharge summary medications for discharge indicated the Resident was to have a fingerstick blood glucose test pre meals and at HS (Hour of sleep) and was to receive [MEDICATION NAME]based on the results of the glucose test. The hospital medications indicated the Resident was to have insulin administered from two separate sliding scales insulins, one scale for the 3 meals and another sliding scale for HS.

A review of the admission physician’s orders [REDACTED]. The medical record had no information of the separate HS sliding scale insulin orders from the hospital. A review of the medication reconciliation form, dated 7/11/17, had no documentation of the two insulin sliding scale discrepancy and incorrectly listed the current medications. There was no documentation in the medical progress notes or the nurses’ notes that indicated a review and discussion of the two different sliding scales. During interview and record review on 7/18/17 at 10:10 A.M., Unit Manager #1 said the evening (HS) was not in the current orders and could not explain how the two sliding scales were reconciled on admission.

During interview on 7/18/17 at 11:00 A.M., the Director of Nurses said,it is more confusing having two scales for residents ad families, we only use one here. She added that the facility has had some patients with two but most have one. Surveyor #3 asked if there was a policy for residents using only one sliding scale insulin. At 11:30 A.M. the Director of Nurses said the policy does not say anything about residents only having one sliding scale and at 1:40 P.M. the Director presented the Resident’s medication reconciliation form and said it was not done correctly and there was no information of reviewing the two sliding scale insulins.

2. For Resident #14, (a) the facility failed to reconcile the medications upon admission for the sliding scale insulin and did not complete a medication reconciliation form for the insulins, as outlined in the Facility’s policy and procedure for medication reconciliation; (b) and for Resident #14, the Facility failed to obtain the physician’s orders [REDACTED]. Resident #14 was admitted ,[DATE] following a hospitalization for monomorphic [MEDICAL CONDITIONS], moderate [DIAGNOSES REDACTED], [MEDICAL CONDITION] flutter and additionally [DIAGNOSES REDACTED].

(a) The facility failed to reconcile the medications upon admission for the sliding scale insulin and did not complete a medication reconciliation form for the insulins. Review of the hospital discharge summary medications dated 7/11/17 for discharge. indicated the Resident was to have a fingerstick blood glucose test pre meals and at HS (Hour of sleep) and was to receive [MEDICATION NAME]based on the results of the glucose test. The hospital medications indicated the Resident was to have insulin administered from two separate sliding scales insulins, one scale for the 3 meals and another sliding scale for HS.

A review of the admission physician’s orders [REDACTED]. The medical record had no information of the separate HS sliding scale insulin orders from the hospital. The medical record had no medication reconciliation form to review. There was no documentation in the medical progress notes or the nurses’ notes that indicated a review and discussion of the two different sliding scales.

(b) The facility failed to obtain the physician’s orders [REDACTED]. The MAR (Medication Administration Record) for the sliding scale insulin at 9:00 P.M. noted this was discontinued on 7/18/17, but the record had no written physician’s orders [REDACTED].M. Interview on 7/20/17 at 8:45 A.M., Unit Manager #1 said he did not know about the order and would look into it. Interview and record review on 7/20/17 at 11:15 A.M., the Director of Nurses said the [MEDICATION NAME] at 9:00 P.M. was stopped but could not find the physician’s orders [REDACTED].>3. For Resident #11, the facility failed to follow a physician’s orders [REDACTED]. For 34 days the Resident did not receive the dosage of the antidepressant medication [MEDICATION NAME] as the physician had ordered. Resident #11 is a long term care resident with multiple [DIAGNOSES REDACTED]. A review of the last Minimum Data Set (MDS) quarterly assessment dated [DATE] indicated the Resident’s mood as feels tired and had not exhibited any behaviors. The assessment was unchanged from the initial MDS assessment dated [DATE] and assessed the Resident as not ambulating ad requiring extensive assistance for dressing and hygiene. The Resident had no weight loss and no symptoms of pain. A review of the telephone physician’s orders [REDACTED]. (milligrams) by mouth every day. A review of the MAR (Medication Administration Record) for 6/2017 and 7/2017 indicated the Resident did not receive the 15 mg. of [MEDICATION NAME] but received 10 mg. The Resident received the wrong dose of the antidepressant medications for 34 days from 6/1/17 – 7/14/17.

During interview and record review on 7/14/17 at 11:30 A.M., Unit Manager #3 said it looks like an error, there was a new order ([MEDICATION NAME] 15 mg) transcribed to the physician’s orders [REDACTED]. Surveyor #3 and Unit Manager #3 then went to the medication cart and saw the medication card for the [MEDICATION NAME] and it had the wrong dose of 10 mg on the medication card. The UM said she would contact the physician and inform him of the wrong dose administered for the [MEDICATION NAME].

4. For Resident #17, the Facility failed to follow the medical plan of care for medication administration of sliding scale Regular Insulin Humalin with parameters. Resident #17 was admitted to the Facility in 6/2017 and had [DIAGNOSES REDACTED]. Review of Resident #17’s admission Minimum Data Assessment (MDS) assessment dated [DATE], indicated that Resident #17 scored 15 out of 15 on a Brief Interview for Mental Status (BIMS) indicating he/she was cognitively intact.

Review of the physician’s telephone order dated 7/1/17 indicated that Resident #17 was to receive the following order: Regular Insulin Humalin four times a day as follows.
200-250 2 units
251-300 4 units
301-350 6 units
351-400 8 units
401-450 10 units If BS is greater than 450 call physician.

Review of the Sliding Scale Insulin record for July 2017, indicated that on 5 occasions Humalin Insulin was administered not within the parameters indicated by the physician’s orders [REDACTED].>* On 7/1/17 at 4:30 P.M., Resident #17 had a blood sugar (BS) of 531 and Humalog Insulin 10 units was administered. The was no order to administer Insulin for a BS greater than 450.

* On 7/2/17 at 9:00 P.M., Resident #17 had a BS of 550 and Humalog Insulin 10 units was administered. The was no order to administer Insulin for a BS greater than 450.

* On 7/7/17 at 11:30 A.M., Resident #17 had a BS of 486 and Humalog Insulin 10 units was administered. The was no order to administer Insulin for a BS greater than 450.

* On 7/15/17 at 4:30 A.M., Resident #17 had a BS of 588 and Humalog Insulin 10 units was administered. The was no order to administer Insulin for a BS greater than 450.

The Surveyor interviewed the Director of Nurses (DON) at 1:30 P.M. on 7/20/17. The DON said she had nothing to add to the inconsistent documentation regarding the Sliding Scale Insulin. The DON said there is no order to administer Insulin for a BS greater than 450. The Surveyor interviewed the DON by telephone at 12:15 P.M. on 7/21/17. The DON said Resident #17’s physician’s orders [REDACTED].

5. For Resident #6, who had a complex medical history and multiple hospitalization s, (a) the facility failed to ensure that the licensed nurses transcribed, edit and reconciled medications following hospitalization s and/or when obtaining telephone orders for change in condition; and (b) failed to follow procedures for a low blood sugar. Resident #6 had been admitted to the facility in 5/2013 and had [DIAGNOSES REDACTED]. The Resident goes out of the facility to a [MEDICAL TREATMENT] clinic three times a week, Tuesdays, Thursday and Saturdays (leaves at 4:00 P.M. and returns at 9:00 P.M.) for [MEDICAL TREATMENT]. A Quarterly Minimum Data Set (MDS) assessment, dated 5/23/17, indicated Resident #6 scored an 11 out of 15 on his Brief Interview of Mental Status, indicating the Resident was able to understand, be understood and had minimal difficulty with his/her memory. The MDS indicated the Resident required extensive assistance in ambulation, transfers, dressing and bathing.

(a) Review of the medical record indicated the Resident goes out of the facility to a [MEDICAL TREATMENT] clinic three times a week, Tuesdays, Thursday and Saturdays (leaves at 4:00 P.M. and returns at 9:00 P.M.) for [MEDICAL TREATMENT]. Review of the 5/2017, 6/2017 and 7/2017 physician orders [REDACTED]. [MEDICATION NAME] is used to control serum phosphorus levels in people with [MEDICAL CONDITION] who are on [MEDICAL TREATMENT]. [MEDICATION NAME] binds to phosphorus in the foods you eat so your body doesn’t absorb as much and therefore, needs to be taken with meals per the manufacturer’s specifications. The physician order [REDACTED]., 12:00 P.M. and 5:00 P.M. on days the Resident does not go to [MEDICAL TREATMENT] and on days the Resident goes to [MEDICAL TREATMENT] the third dose was to be administered at 9:00 P.M.

The medical record indicated the Resident was hospitalized from [DATE] through 5/16/17. Upon return the [MEDICATION NAME] was transcribed to be administered three times daily and then changed to 4 times daily, adding an additional dose at 9:00 P.M. The licensed nursing staff signed that the medication was administered four times daily including the 5:00 P.M. dose, despite the Resident being at [MEDICAL TREATMENT] three times a week at the time. The 6/2017 MAR, indicated from 6/1/17 through a hospitalization on [DATE], the [MEDICATION NAME] was being administered 4 times daily, including the 5:00 P.M. dose on [MEDICAL TREATMENT] days. Upon readmission on 6/21/17, the medication was transcribed to three daily and the order allowed for the medication to not be administered on [MEDICAL TREATMENT] days.

The record indicated that on 6/23/17, the Resident was re-hospitalized and upon readmission on 7/1/17, the [MEDICATION NAME] order was transcribed to three times per day daily at meals. The licensed staff indicated they administered the medication at 5:00 P.M. daily, despite the Resident not being in the facility for 3 days during the week at this time.

In addition, the physician ordered the Resident’s blood sugars checked four times daily, prior to meals and at hour of sleep (6:30 A.M., 11:30 A.M., 5:00 P.M. and 9:00 P.M.) and sliding scale insulin was to be administered according to the blood sugar level. According to the 5/2017, 6/2017 and 7/2017 MARs, the licensed staff documented that they obtain blood sugars at 5:00 P.M. despite the Resident not being in the building 3 days a week (leaving at 4:00 P.M.).

Further review of the hospital discharge summary dated 7/1/17 indicated due to the Resident’s brittle diabetes the sliding scale insulin should include a fingerstick blood glucose test pre meals and at HS (Hour of sleep) and was to receive [MEDICATION NAME]based on the results of the glucose test. The hospital medications indicated the Resident was to have insulin administered from two separate sliding scales insulin’s, one scale for the 3 meals and another sliding scale for HS. A review of the admission physician’s orders [REDACTED]. The medical record had no information of the separate HS sliding scale insulin orders from the hospital. A review of the medication reconciliation form, dated 7/1/17, had no documentation of the [MEDICATION NAME] or the two insulin sliding scale discrepancy and incorrectly listed the current medications. There was no documentation in the medical progress notes or the nurses’ notes that indicated a review and discussion of the two different sliding scales and/or any other discrepancies.

During interview with Unit Manager #1 on 7/17/17 at 12:15 P.M., she said she knew that the Resident was to have the [MEDICATION NAME] three times daily and was aware of the significance of taking it with meals. The Unit Manager reviewed the medications and MARs, as well as the physician orders. She said while she was reviewing the documents that according to the medical record that the licensed staff were signing they had administered and obtained blood sugars on the days the Resident was not in the building. She said that she did not believe the medication and blood sugars were being provided at [MEDICAL TREATMENT], but would look into it. The Unit Manager said that she was aware of problems with reconciliation of medications upon readmission. She showed the Surveyor several reconciliation forms including the form completed on the Resident’s readmission on 7/1/17. The change in [MEDICATION NAME] from four days daily to three times daily was no included on the form. In addition, the insulin was not included and an additional medication that the Resident had been on prior to the hospitalization of 6/23/17 was not reconciled with the admission orders [REDACTED]. The Unit Manager said that she would look into the discrepancies. No additional information was despite repeated request by the Surveyor for additional information from the Unit Manager, Director of Nurses and Clinical Coordinator on 7/20/17.

(b) On 5/5/17, the nurse’s note indicated the Resident’s blood sugar at 2:30 P.M. was 31. According to the physician orders [REDACTED]. According to facility policy and procedures the nursing staff are to follow procedures for low blood sugars ([DIAGNOSES REDACTED]) and/or a physician’s orders [REDACTED]. The facility policy indicates the nurse is to recheck the blood sugar if less than 70 and either follow physician orders [REDACTED]. The physician is to be notified and the fingerstick is to be rechecked in 15 minutes, if the resident remains hypoglycemic, the nurse is to repeat the treatment and notify the physician. The nursing staff were to document in nurses notes all actions, assessments and resident/physician response, the Resident was to be monitored for 24 hours, looking for signs of response to intervention. According to the MAR for 5/2017 and the nurse’s note for 5/5/17, the Resident was administered the first dose of glucose gel and a recheck of the blood sugar was 41. The nurse documented she administered the glucose gel a second time, however she did not indicate she notified the physician. The nurse then documented the Resident was noted to be lethargic and responded minimally to voice and touch, she then documented she administered a third dose of glucose gel. In addition, the nurse signed the MAR indicated [REDACTED]. The nurse documented the Resident blood sugar was obtained and at 5:00 P.M. was 122. She said she notified the next shift, not the physician.

During interview with the Director of Nurses on 7/20/17 at 9:10 A.M., the Director reviewed the documentation and agreed that the nurse should have notified the physician when the blood sugar had not increased following the first administration of the glucose gel and not administered any additional glucose after the second dose until the nurse spoke with the physician.

Failed to provide care by qualified persons according to each resident's written plan of care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the Facility failed to follow the physician’s order and the written plan of care for a cardiac pacemaker for 1 Resident (#6) out of a total sample of 20 Residents.

Findings include:

Resident #6 had been admitted to the facility in 5/2013 and had [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS) assessment, dated 5/23/17, indicated Resident #6 scored an 11 out of 15 on his Brief Interview of Mental Status, indicating the Resident was able to understand, be understood and had minimal difficulty with his/her memory. The MDS indicated the Resident required extensive assistance in ambulation, transfers, dressing and bathing. Review of the medical record indicated that the Resident had a cardiac pacemaker. The record contained information on the type and make of the pacemaker. The pacemaker had been inserted on 7/18/11 and according to the medical record the last last pacemaker check had been completed on 8/3/15.

Review of 2017 physician’s orders indicated that Resident #6’s pacemaker was to be maintained and checked every 6 months. Review of the care plan for cardiovascular status, initiated on 3/29/16 and updated on 5/25/17, indicated that the Resident had a pacemaker and it was to be maintained according to physician’s orders. Further review of the medical record failed to indicate that Resident #6 had either been seen by his/her cardiologist or that the cardiac pacemaker function had been tested since 8/3/15. Unit Manager #1 was interviewed on 7/17/17 at 12:30 P.M. and on 7/20/17 at 12:45 P.M., she said she did not know when the last time the pacemaker had been checked. She said during both interviews she was looking into it and would be calling the cardiologist and the pacemaker company for information. The Unit Manager provided no additional information.

Failed to make sure that the nursing home area is free from accident hazards and risks and provides supervision to prevent avoidable accidents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and interviews, the Facility failed to ensure for 1 Resident (#6), who was assessed at high risk for falls, was provided appropriate and effective interventions to prevent and/or minimize falls. The total sample was 20 Residents.

Findings include:

Resident #6 had been admitted to the facility in 5/2013 and had [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS) assessment, dated 5/23/17, indicated Resident #6 scored an 11 out of 15 on his Brief Interview of Mental Status, indicating the Resident was able to understand, be understood and had minimal difficulty with his/her memory. The MDS indicated the Resident required extensive assistance in ambulation, transfers, dressing and bathing. The physician order [REDACTED]. Review of the Facility policies related to falls, incident reporting, fall risks, Fall Prevention Program indicated that a fall assessment and incident report are to be completed.

The Fall Prevention Program indicates the following: Policy statement – To minimize resident falls through systematic and appropriate implementation of individualized interventions.

– To utilize Resident related data to determine which residents are at risks.
– To re-assess and re-evaluate any resident who experiences a fall. Fall Risk assessment
– To be completed on admission, quarterly, annually, with any significant change of status and after a fall to determine Resident-at-Risk.
– Residents who score High on the Fall Assessment will have a Fall Risk care plan developed, implemented and revised as necessary.

Resident #6’s individualized care plan for falls, dated as initiated on 3/29/16 and last reviewed on 5/25/17, indicated Resident #6 was at high risk for falls due to medical diagnoses, medications, dialysis and history of falls. The falls goal was to be free from injury if a fall occurs. The falls care plan included multiple interventions to prevent falls and many of the interventions had been initiated on 3/29/17. The interventions included: encourage resident to change positions slowly, encourage use of environmental devices, encouraged wearing of eyeglasses, keep bed in low position with brakes on, keep call light within reach, keep personal items within reach, leave night light on in room, maintain floor is free of hazards, provided assistance in toileting, provide proper footwear, provided resident with safety devices/appliances, remind the Resident to ask for assistance, teach safety measures, bed and chair alarms/sensors, fall mat on right side of bed, scoop mattress and keep remote control on a clip on the bed. Review of the Resident Care Kardex, used by the Certified Nursing Assistance (CNA) for care included the floor mat, scoop mattress, padded side rails, keep control on siderail and encourage the use of reacher.

Record review indicated, from 1/11/17 through 5/31/17, the Resident had 5 falls. The Resident had the following falls;

– On 1/11/17 at 6:10 A.M., the Resident had an unwitnessed fall. The Resident stated that he/she had no recall of how he/she got on floor. The Resident had no injury and the staff implemented bed alarms, fall mat, re-educated the Resident to use call light and added a scoop mattress.

– On 4/28/17, the Resident had 2 falls, the first fall was at 12:00 P.M. The Resident fell while trying to get from his/her bed to wheelchair. The Resident had no injury and staff educated the Resident to ask for help.

– The second fall occurred at 11:15 P.M., the Resident was found on the floor and reported he/she was trying to get out of bed. The Resident was transferred to the hospital and found with mental status changes and sent to the emergency room and later returned on 4/30/17. There was no change to the care plan.

– On 5/8/17 at 7:25 P.M., the Resident was found on the floor and reported he/she was looking for wheelchair. The Resident was transferred to the hospital with mental status changes. There were no changes to the care plan.

– On 5/31/17 at 8:20 A.M., the Resident was found on the floor near his/her bed. The Resident indicated that he/she was attempting to get into bed. The Resident had no injury and there was no change to his/her care plan.

Review of the 5 Facility’s Accident/Incident Report and Investigation Form (for falls) for each of the incidents failed to indicate if the devices including the scoop mattress, alarms and sensors were in place. The incidents indicated the Resident was either found on the floor or was heard yelling for help. No new interventions were identified and implemented following the 1/11/17. Furthermore, the Resident was observed on 7/17/17 at 8:20 A.M., in room and in bed. No alarms or sensors were observed on the bed or wheelchair. There was no mat on the right side of the bed and the mattress was not scooped. In addition, side rails were not padded and the call bell was on the floor. The Resident was lying on his/her right side and had restless body movement. The Resident was observed in wheelchair sleeping during the observation period and no alarms or sensors were heard or observed Observation for this day was from 8:20 A.M. through 10:30 A.M. The Surveyor shared observations with Unit Manager #1.

During observation of the Resident’s room on 7/20/17 at 10:00 A.M. and at 10:20 A.M. with the Clinical Coordinator, the interventions outlined on the Resident’s plan of care to prevent falls could not be located. The Clinical Coordinator stated that maybe the interventions had been discontinued. The Surveyor and Coordinator reviewed the Care Kardex and the record. The plan of care indicated that alarms/sensors, mats, and a scooped mattress were to be implemented to prevent and minimize falls. The Coordinator could not explain why the interventions were not being implemented and agreed the Resident was considered high risk for falls.

Failed to keep accurate, complete and organized clinical records on each resident that meet professional standards

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the Facility failed to accurately maintain medical records for 2 sampled residents (#14 and #6) out of a total sample of 20 residents.

Findings include:

1. For Resident #14, the facility failed to accurately document insulin administration on the Medication Administration Record. Resident #14 was admitted in 7/2017 following a hospitalization for monomorphic [MEDICAL CONDITIONS], moderate [DIAGNOSES REDACTED], [MEDICAL CONDITION] flutter and additionally [DIAGNOSES REDACTED]. A review of the medication record for 7/2017 indicated from 7/11/17 – 7/20/17 the record had two missing initials and fingerstick glucose results for 7/16/17 at 6:30 A.M. and 7/19/17 at 4:30 P.M. The medication record for the 9:00 P.M. insulin dose on 7/17/17 and 7/18/17 indicated the Resident had two glucose test and two insulin administration for this time. Interview and review on 7/20/17 at 11:15 A.M., the Director of Nurses said there were no nurse’s notes for 7/17/17 and 7/18/17 and would review with the staff.

2. For Resident #6, the medical record failed to contain evidence that a recommendation for 1 to 1 psychotherapy was provided. Resident #6 was admitted to the facility in 5/2013 and had [DIAGNOSES REDACTED]. During record review on 7/17/17, the psychiatric consultant had assessed the Resident on 5/17/17. The psychiatric consultant recommended Resident #6 receive 1 to 1 psychotherapy for emotional support. Review of the medical record (including the overflow files) failed to indicate the recommendation had been followed up on. During interviews with the Facility Staff, the Staff were unaware of the recommendation and were unaware if the Resident had been assessed and/or had received the 1 to 1 psychotherapy. Unit Manager #1 was interviewed on 7/17/17 at 12:30 P.M. and on 7/20/17 at 12:45 P.M., she said she did not know about the recommendation made by the consultant on 5/17/17 and was unaware if the 1 to 1 had been provided. She said during both interviews she was looking into it.

On 7/20/17 at 10:10 A.M., Social Worker #1 said that he was unaware of the recommendation and that the psychiatric service provider would have arranged the 1 to 1 psychotherapy for the Resident. He said he would check to see if they had. Both the Director of Nurses and Nursing Coordinator were made aware on 7/20/17 at 10:30 A.M. Post Survey exit from the Facility (exit 7/20/17), the Director of Nurses notified the Surveyor on 7/21/17, via email, that she had been in contact with the consulting 1 to 1 therapist. The Director said that the therapist had a copy of her assessment and forwarded it to the Facility. The assessment dated [DATE] indicated that she recommended medication management not 1 to 1 psychotherapy.

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Sources:

Medicare Nursing Home Profiles and Reports – Alliance Health at West Acres

Inspection Report for Alliance Health at West Acres – 07/20/2017

Page Last Updated: May 14, 2018