Senior Abuse Law

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the Facility failed to obtain a signed consent for 1 Resident (#4) of 6 sampled Residents receiving anti-psychotic medications, from a total of 21 sampled Residents.

Findings include:

Resident #4 was admitted to the facility in 04/2015 with the following Diagnoses:

Review of Minimum Data Set ((MDS) dated [DATE], indicated that the Resident was severely cognitively impaired and had a Brief Interview for Mental Status (BIMS) score of 5 of 15 (unable to complete interview) score. The Resident Health Care Proxy (HCP) was invoked.

Review of the medical record on 1/27/17 indicated that an Informed Consent Form for [MEDICATION NAME] (anti-psychotic medication that is use to treat [MEDICAL CONDITION] disorder and also Depression) dated 9/26/16 for Resident #4 is not signed by the HCP. Resident #4 was currently receiving the medication [MEDICATION NAME].

Federal Law requires that long-term care facilities, prior to administering [MEDICAL CONDITION] medications, shall obtain the informed written consent of the Resident from the Resident’s Health Care Proxy or the Resident’s Guardian.

On 1/27/17 11:55 A.M., the Social Worker (SW) was interviewed and said that the facility obtained a verbal consent from Resident #4 HCP and the HCP was mailed a Consent Form, but the SW never received it back and said that she had lost track of it. She also said that she is sending another Consent Form today via mail and that she will try to contact the
HCP.

On 1/30/17 the SW told the Surveyor that a Consent Form was emailed to the HCP as an attachment with a request to be faxed back to SW.

On 2/01/17 the SW told the Surveyor that she had not received any fax yet from the HCP.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and staff interview, the facility failed to notify the Physician or Nurse Practitioner of a weight change per physician’s order for 2 Residents (#2 & #13) of 21 sampled Residents.

Findings include:

1. For Resident #2, the facility failed to notify the Physician or Nurse Practitioner (NP) of a 2.5 pound (#) weight change as ordered. Resident #2 was admitted to the facility in 1/2016 with [DIAGNOSES REDACTED].

Review of the clinical record on 1/30/17 indicated that the Resident had a physician’s order for [MEDICATION NAME] (diuretic medication) 20 milligrams (mg) once per day. On 9/8/16 the Physician documented that the Resident had 2+ (plus) [MEDICAL CONDITION] of the lower extremities due to [MEDICAL CONDITIONS]. On 9/9/16 the Nurse Practitioner documented that the Resident’s [MEDICAL CONDITION] had decreased with mediation but to weigh the Resident twice a week, in the morning, on Tuesday and Thursday and if there is a 2.5 #
weight change to contact the Physician or the Nurse Practitioner.

Review of the documented weights on the Medication Administration Record [REDACTED]

-9/22/16 the Resident weighed 169.8 pounds-weight loss of 2.8 pounds
-11/10/16 the Resident weighed 180.2 pounds-weight gain of 5 pounds
-12/20/16 the Resident weighed 170.6 pounds- weight loss of 7 pounds

Review of the nurse’s notes from 9/9/16 to 12/31/16 indicated no documented evidence that the Physician or Nurse Practitioner were notified of the weight changes as specified in the physician’s orders.

On 2/1/17 at 2:00 P.M. the Director of Nurses was interviewed and said that she was not aware of the weight changes or that the physician was not notified of these changes as per the physician’s order.

2. For Resident #13, the facility failed to notify the Physician or Nurse Practitioner (NP) of a weight change as ordered.

Resident #13 was readmitted to the facility in 12/2016 with the following Diagnoses: [REDACTED].

Resident #13 was receiving [MEDICATION NAME] by mouth daily to prevent swelling of the lower extremities.

Review of the Physician’s orders on 1/30/17 indicated that Resident #13 had a Physician’s order to be weighed in the morning every Monday, Wednesday and Friday and to notify the Physician or NP for change of weight of 2.5 pounds in 24 hours or 5 pounds in a week.

Review of Medication Administration Record [REDACTED]

-12/28/16 229 pounds
-12/28/16 222.3 pounds (MD/NP not notified)
-01/02/17 225.3 pounds (MD/NP not notified)
-01/04/17 231 pounds (MD/NP not notified)
-01/06/17 no weights (Resident refused)
-01/09/17 no weights (Resident refused)
-01/11/17 228.8 pounds
-01/13/17 229.6 pounds
-01/16/17 232 pounds
-01/18/17 no weights (Resident refused)
-01/20/17 no weights (Resident refused)
-01/23/17 no weights (Resident refused)
-01/25/17 no weights (Resident refused)
-01/27/17 no weights (Resident refused)
-01/30/17 231 pounds

On 1/30/17 at 11:00 A.M. the Director of Nursing (DON) was interviewed. The DON acknowledged that there were no notifications made to the physician or NP by the staff about change of weights. She additionally mentioned that the Resident is stable at this time and that she will ask the physician or NP to re-evaluate and see if weight could be done weekly instead. The DON also said that on the days that there are no weights obtained, is due to Resident refusal.

Findings include:

Based on record review, observation and interview, the facility failed for 1 Resident (#1) of 21 sampled Residents to ensure that there was adequate supervision and appropriate and effective interventions to prevent falls that resulted in major injury while showering.

Based on record review, observations and interviews, the facility failed for 1 (#8) of 1 Residents requiring [MEDICAL CONDITION] care, out of a total sample of 21 Residents, to ensure that an extra cannula of the correct size and a suction catheter were at the bedside and easily accessible in the event of an emergency and failed to ensure that tracheal suctioning was provided according to facility policy and consistent with acceptable standards of practice.

Findings include:

Resident #8 was admitted to the facility in 5/2016 and had [DIAGNOSES REDACTED]. The Resident was readmitted in 1/2017 following hospitalization for Influenza A, pneumonia and was determined to have colonized sputum Proteus Mirabilis (multi-drug resistant bacteria.) Review of the quarterly Minimum Data Set (MDS) assessment completed 11/8/16, indicated that the Resident was dependent on staff for all activities of daily living, was non-verbal and had a [MEDICAL CONDITION].

During the initial tour on 1/26/17 at 9:00 AM, the Assistant Director of Nurse (ADON) said she was responsible to the daily management of the subacute unit. The ADON said that Resident #8 was admitted to the facility with [MEDICAL CONDITION] and was in a persistent vegetative state which required a G tube for feeding and had a trach. Resident #8 was observed in bed with his/her eyes closed with [MEDICAL CONDITION] place with humidified air and receiving G tube feeding via an infusion pump. During this observation, a suction machine was observed at the bedside but no suction catheters or a [MEDICAL CONDITION] observed. The ADON was asked what [MEDICAL CONDITION] Resident required and she did not respond but began rummaging through a 2 tiered supply care immediately adjacent to the Resident bed that was highly disorganized and cluttered with supplies. The ADON eventually produced a small box and that she said was the [MEDICAL CONDITION] said that the Resident required a 8 cuffed [MEDICATION NAME] trach. The ADON was asked if she also located the suction catheters said no, but then spotted another box of supplies on a table adjacent to the foot of the bed and eventually located the suction catheters. The ADON was asked if both pieces of equipment were readily available in the event of an emergency and she said no.

Review of the clinical record indicated a 1/2017 hospital discharge summary that indicated that the Resident had colonized Proteus in the sputum and that the Resident was discharged to the facility with a #6 [MEDICAL CONDITION] humidified air in place. Review of [MEDICAL CONDITION] plan initiated 5/2016 with the MMQ Nurse on 1/30/17 at 10:00 A.M. failed to identify the size of the trach. The Medication/Treatment Nurse #1 was interviewed with the MMQ nurse on 1/30/17 at 10:05 A.M. and was asked what [MEDICAL CONDITION] Resident required, and said size 7. Nurse #1 was asked where he could verify [MEDICAL CONDITION] and said in the physician’s orders which he checked and stated that the current orders reflected a #6 Shiley cuffed trach. The MMQ Nurse then accompanied the Surveyor to the Resident’s room and observed a #6 [MEDICAL CONDITION](not the #8 [MEDICATION NAME] previously identified on 1/26/17) secured to the wall at the head of the bed. Suction tubing was observed at the suction machine. B. The facility failed to ensure that tracheal suctioning was provided according to facility policy and consistent with acceptable standards of practice.

Review of the facility policy for tracheal suctioning dated 7/21/16 indicated that the equipment for suctioning included personal protective equipment including eyewear. On 1/27/17 at 8:00 A.M., Surveyor #2 observed Nurse #2 during the medication administration pass for Resident #8. Resident #8 was observed to have a large collection of sputum on the tracheotomy dressing and was actively coughing with secretions coming out of [MEDICAL CONDITION] and onto the dressing. Nurse #2 said that she needed to suction the Resident at this time. The Surveyor observed Nurse #2 don gloves and a mask, but no gowns or eye shields.

The Surveyor observed a disorganized, 2 tiered supply cart next to the bed with no precaution gowns or eye shields. The Surveyor asked the nurse what personal protection equipment (PPE) she should wear and the Nurse said You can wear a mask if you’re worried about spraying. Nurse #2 leaned up against the Resident’s bedside rail (less than 3 feet away) and suctioned the Resident for a moderate amount of thick secretions, but did not wear a gown for protection, according to the facility’s Policy for Tracheal Care.

Findings include:

Based on observations, record review (test trays, temperature logs) and staff interviews, the facility failed to ensure that food and drink are palatable, attractive and served at an appetizing temperature to ensure Resident’s satisfaction.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observations, interviews and medical record review, the facility failed to follow its own Infection Control Policy for implementing preventative measures to control the potential spread of infection for 2 Residents (#8 and #11), from a total sample of 21 Residents.

Findings include:

1.) For Resident #11, the facility failed to: 1.) implement contact precautions with universal glove use 2.) cohort the Resident and staff appropriately and 3.) notify housekeeping for enhanced environmental cleaning with an Environmental Protection Agency (EPA) registered germicidal agent effective against [DIAGNOSES REDACTED]icile spores, while the Resident was awaiting laboratory results for [DIAGNOSES REDACTED]icile (according to the facility policy).

Clostridium Difficile is a disease-causing bacterium that can infect the large bowel. Taking antibiotics can kill the normal flora (healthy bacteria), which allows the [DIAGNOSES REDACTED] to multiple and damage the cells lining the intestinal wall, causing diarrhea and abdominal pain. [DIAGNOSES REDACTED] can be found on the surfaces of bedside tables, door knobs, counters, bathrooms and sinks for up to 6 months.

C. difficile risk factors include the following:

* current or recent use of antibiotics
* recent hospitalization
* weakened immune systems as a result of an underlying medical condition or chemotherapy treatment. (C. Difficile.Org)

Review of the facility’s Policy for Clostridium Difficile indicated the following:

#10 b.) Residents with diarrhea and suspected [DIAGNOSES REDACTED]icile infection will be placed on Contact Precautions while awaiting laboratory results.

#10 d.) Residents with [DIAGNOSES REDACTED]icile infection will be placed in a private room, if available. If a private room is unavailable, residents will be cohorted with a dedicated commode for each resident.

1. Resident #11 was admitted to the facility in 4/2016 with the following Diagnoses:
[REDACTED].

On 1/26/17 at 3:00 P.M., the Surveyor reviewed the medical record.

The Quarterly Minimum Data Set (MDS) indicated that Resident #11 was cognitively intact, continent for bowel and bladder and independent with ambulation.

Review of the The Nurse Practitioner’s note dated 1/25/17 indicated that the Resident reported loose stools (5-6 stools per day x 3 days) with lots of gas. Patient toilets self
and to send a stool culture (for [DIAGNOSES REDACTED]icile).

On 1/26/17 at 3:15 P.M., the Surveyor interviewed Nurse #4. She said that the Resident was experiencing loose stools and that a stool culture was still pending. The Surveyor asked if the Resident was on any special precautions pending the results of the stool culture and Nurse #4 said no.

On 1/27/17 at 9:50 A.M., the Surveyor interviewed the Resident in his/her room. The Surveyor observed that there was no precaution cart outside the room for personal protection equipment (PPE). Upon entering the room, the Surveyor smelled a strong, foul fecal odor which lingered during the interview. The Surveyor observed the Resident in the middle bed of a 3 bed room with 2 roommates on either side and one shared bathroom. The Resident said that he/she had been experiencing abdominal pain for at least a week with bad diarrhea for several days. The Resident said that he/she mostly stayed in the room to be close to the bathroom and because he/she was wiped out. The Resident also said that staff had not instructed him/her to wash hands more frequently, pending the stool culture result.

On 1/31/17 at 9:30 A.M., the Surveyor interviewed the Infection Preventionist (IP) in her office. The IP did not have Resident #11 on the line listing for infections for the month of January. The IP said that the staff failed to inform her that the Resident was experiencing diarrhea and cramping or that a stool culture for [DIAGNOSES REDACTED]icile was pending. The Surveyor asked the IP why she thought this could have been missed. She said I’m not sure how it happened, but the nurse on that unit is per-diem and might not be familiar with the communication protocol for infection control surveillance. She also said that during morning clinical rounds it was not reported to her. The IP said that she would expect to get a verbal report from the supervisor on Residents’ new symptoms or potential infections during the morning rounds, but that there was no formal written process for collecting the data from the units. The IP said that the staff should have notified her of the Resident’s symptoms and placed him/her on contact precautions and notified housekeeping for increased environmental cleaning pending the stool culture. The IP also said that she and the Director of Nurses were in the process of developing an improved communication system so that omissions like this are prevented.

2. For Resident #8, the facility failed to ensure that proper use of protective personal equipment was initiated during tracheal suctioning to reduce the potential for spread of infection.

Per a review of the facility policy for tracheal suctioning dated 7/21/16 indicated that the equipment for suctioning included personal protective equipment (PPE) including eyewear (contact precautions.)

Resident #8 was admitted to the facility in 5/2016 and had [DIAGNOSES REDACTED]. The Resident was readmitted ,[DATE] following hospitalization for Influenza A , pneumonia and was determined to have colonized sputum Proteus Mirabilis (multi-drug resistant bacteria.)

Review of the clinical record indicated a progress note dated 1/27/17 by Infection Preventionist (IP) that indicated that the Resident is no longer exhibiting influenza – like illness (was hospitalized and confirmed for Influenza A) has received Influenza [MEDICATION NAME] regimen. Infection surveillance no longer required.

On 1/27/17 at 8:00 A.M., Surveyor #2 observed Nurse #2 during the medication administration pass for Resident #8. Resident #8 was observed to have a large collection of tenacious sputum on the tracheotomy dressing and was actively coughing with secretions coming out of the trach stoma and onto the dressing. Nurse #2 said that she needed to suction the Resident at this time. The Surveyor observed Nurse #2 don gloves and a mask, but no gowns or eye shields. The Surveyor observed a disorganized, 2 tiered supply cart next to the bed with no precaution gowns or eye shields.

The Surveyor asked the nurse what personal protection equipment (PPE) she should wear and the Nurse said You can wear a mask if you’re worried about spraying. Nurse #2 leaned up against the Resident’s bedside rail (less than 3 feet away) and suctioned the Resident for a moderate amount of thick secretions, but did don a gown or eye shield to reduce the potential for spread of infection.