Senior Abuse Law

Based on observation and staff interview, the facility failed to provide housekeeping and maintenance services to maintain a sanitary and orderly environment in 2 of 4 Medication Rooms.

Findings include:

During a tour of Medication Room A on 11/30/16 at 9:15 A.M., the surveyor observed the floor of the room was dirty with ground in dirt. There were bits of paper, gauze pads, plastic bags, a blue tip of an intravenous bag, as well as a build up of dust behind the door and underneath the cabinets. The sink was stained and dirty with rusted areas around the drain. There were old pieces of paper in the drain. The metal countertop was dirty and smeared with an old white substance.

During an interview on 11/30/16 at 9:30 A.M., Nurse #2 said that she did think there was a regular schedule to clean the Medication Room and that it was done when there was a nurse available to be in the room at the same time. Nurse #2 said she was going to alert housekeeping to clean the room.

During a tour of Medication Room F on 11/30/16 at 9:45 A.M., the surveyor observed that the entire sink had a dried-on white ring and rust at the drain site. The metal countertop was dirty and had papers lying on it. The corners of the room and underneath the cabinets had a moderate build up of dirt and dust.

During an interview on 11/30/16 at 9:55 A.M., Unit Manager #2 said that housekeeping would be alerted to clean the room.

During an interview on 11/30/16 at 10:15 A.M., the Account Manager (Housekeeping and Laundry Manager) said that he was not sure if there was a specific schedule to clean the Medication Rooms, but said that he would make sure all of the Medications Rooms would be cleaned regularly from now on.

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

Based on record review, observations and staff interviews, the facility failed to follow the resident’s plan of care relative to falls for 1 resident (#5), in a total sample of 20 residents.

Findings include:

For Resident #5, the facility failed to follow the resident’s falls care plan relative to the following: supervision was not provided when the resident was out of bed, resident was not within the staff’s arm reach when in the Dayroom, alarming seatbelt was not on, bed sensor alarm did not activate and a pillow was not in place to define the edge of the bed, as planned.

Resident #5 was admitted to the facility in 12/2013. The falls care plan of 1/15/16 indicated the following interventions: supervised when out of bed, to be at arm’s length of a staff member while seated in the Dayroom, lamp on in room during night time hours, sensor alarm to bed and to utilize eye glasses.

Review of the Progress Note of 2/19/16 indicated the resident experienced an unwitnessed fall, sustaining a 4 cm. (centimeter) bruise to the forehead. During an interview with UM (Unit Manager) #1 (on 12/1/16 at 7:50 A.M.), he said the fall actually occurred on 2/18/16 and that the fall was not witnessed by the staff. The resident was not being supervised when she/he was out of bed, as planned.

Review of the Progress Note of 3/2/16 indicated the resident experienced an unwitnessed fall, with no injury. During an interview with UM #1 (on 12/1/16 at 7:50 A.M.), he said that the fall was not witnessed by the staff. The resident was not being supervised when she/he was out of bed, as planned. The falls care plans of 3/14/16 and 4/7/16 remained essentially unchanged. Review of the Progress Note of 4/17/16 indicated the resident experienced a fall, with no injury. Review of the investigation indicated the resident was not within arm’s reach while in the Dayroom, as planned. The falls care plan was updated to include: alarming seatbelt.

The falls care plan of 6/30/16 remained essentially unchanged. Review of the Progress Note of 7/25/16 indicated the resident experienced an unwitnessed fall, with no injury. During an interview with UM #1 (on 12/1/16 at 7:50 A.M.), he said that the alarming seatbelt was not turned on at the time of the fall, as planned. UM #1 further said that the alarm rounds had not been done by the staff, prior to the fall, as planned. The resident was also not being supervised when she/he was out of bed, as planned. The care plan was updated to include: check function of alarming seatbelt at change of shift.

The falls care plan of 9/22/16 remained essentially unchanged. Review of the Progress Note of 9/30/16 indicated the resident experienced an unwitnessed fall, with no injury. The falls care plan was updated to include: pillows to open side of bed under the sheet to define the bed edges.

On 11/30/16 between 10:00 A.M. and 10:05 A.M., the surveyor observed the resident in the Dayroom, with other residents, however, the resident was not being supervised, as planned (2 CNA’s – Certified Nursing Assistants – were observed leaving the Dayroom and no staff members were present to provide the resident with supervision).

During an interview with CNA #1 on 11/30/16 at 3:25 P.M., she said the resident had a history of [REDACTED]. She further said the resident should not be left alone at all. On 12/1/16 at 7:35 A.M., the surveyor observed the resident laying in bed asleep, room was darkened and the resident’s lamp was not on, as planned. The surveyor observed the resident’s bed sensor alarm attached to the bed however, the alarm did not activate with surveyor movement. At 7:40 A.M., CNA #3 entered the resident’s room with the surveyor and attempted to activate the bed sensor alarm by waving her arms/hands in front of it several times, however, the alarm did not activate, as planned. UM #1 then entered the resident’s room and CNA #3 informed him of the malfunctioning alarm. A discussion was held with UM #1 regarding the lamp also not being on, as planned. At 8:00 A.M., UM #1 informed the surveyor that the resident’s pillow to define the edge of the resident’s bed was also not in place, as planned.

During an interview with UM #1, (on 12/1/16 at 7:50 A.M.), a discussion was held regarding the facility failing to follow the resident’s falls care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations and staff interviews, the facility failed to provide adequate supervision and effective interventions to prevent accidents for 1 of 8 applicable residents (#5), in a total sample of 20 residents.

Findings include:

Review of the quarterly Minimum Data Set (MDS) Assessment of 1/1/16 indicated that the resident was severely cognitively impaired; required extensive assistance with transfers and ambulation and exhibited an unsteady balance. Review of the Progress Note of 1/6/16 indicated the resident experienced a fall (in the Dayroom), with no injury. During an interview with UM (Unit Manager) #1 (on 12/1/16 at 7:50 A.M.), he said the plan, after the fall, was for the resident to be at arm’s length of a staff member while seated in the Dayroom.

The falls care plan of 1/15/16 indicated the following interventions: supervised when out of bed, to be at arm’s length of a staff member while seated in the Dayroom, lamp on in room during night time hours, sensor alarm to bed and to utilize eye glasses. Review of the Progress Note of 2/19/16 indicated the resident experienced an unwitnessed fall (in the Dayroom), sustaining a 4 cm. (centimeter) bruise to the forehead. During an interview with UM #1 (on 12/1/16 at 7:50 A.M.), he said based on the investigation the fall actually occurred on 2/18/16 and that the fall was not witnessed by the staff. The resident was not being supervised when she/he was out of bed, as planned. The falls care plan was updated to include: resident to be in wheelchair in Dayroom doorway until all the meal trays are passed out, then will be assisted to the table. Review of the Progress Note of 3/2/16 indicated the resident experienced an unwitnessed fall, with no injury. During an interview with UM #1 (on 12/1/16 at 7:50 A.M.), he said that the fall was not witnessed by the staff. The resident was not being supervised when she/he was out of bed, as planned. The falls care plan was updated to include: resident is not to be left unattended in the hallway.

The falls care plan of 3/14/16 remained essentially unchanged. Review of the quarterly MDS of 3/25/16 indicated that the resident remained essentially unchanged except to indicate that the resident now was dependent for transfers and ambulation and experienced falls. The falls care plan of 4/7/16 remained essentially unchanged. Review of the Progress Note of 4/17/16 indicated the resident experienced a fall (in the Dayroom), with no injury. Review of the investigation indicated the resident was not within arm’s reach while in the Dayroom, as planned. The falls care plan was updated to include: an alarming seatbelt.

Review of the Annual MDS of 6/17/16 indicated that the resident remained essentially unchanged except to indicate that the resident now was an extensive assist for transfers. The falls care plan of 6/30/16 remained essentially unchanged. Review of the Progress Note of 7/25/16 indicated the resident experienced an unwitnessed fall (in the Dayroom), with no injury. During an interview with UM #1 (on 12/1/16 at 7:50 A.M.), he said that the alarming seatbelt was not turned on at the time of the fall, as planned. UM #1 further said that the alarm rounds had not been done by the staff, prior to the fall, as planned. The resident was also not being supervised when she/he was out of bed, as planned. The care plan was updated to include: check function of alarming seatbelt at change of shift.

Review of the quarterly MDS of 9/9/16 indicated that the resident remained essentially unchanged. The falls care plan of 9/22/16 remained essentially unchanged. Review of the Progress Note of 9/30/16 indicated the resident experienced an unwitnessed fall, with no injury. During an interview with UM #1 (on 12/1/16 at 7:50 A.M.), he said the resident’s bed wheels were unlocked at the time of the fall. The falls care plan was

updated to include: pillows to open side of bed under the sheet to define the bed edges. On 11/30/16 between 10:00 A.M. and 10:05 A.M., the surveyor observed the resident in the Dayroom, with other residents, however, the resident was not being supervised, as planned (2 CNA’s – Certified Nursing Assistants – were observed leaving the Dayroom and no staff members were present to provide the resident with supervision). The resident was then observed pushing her/him self backwards in the wheelchair.

During an interview with CNA #1 on 11/30/16 at 3:25 P.M., she said the resident had a history of [REDACTED]. She further said the resident should not be left alone at all. On 12/1/16 at 7:35 A.M., the surveyor observed the resident laying in bed asleep, room was darkened and the resident’s lamp was not on, as planned. The surveyor observed the resident’s bed sensor alarm attached to the bed however, the alarm did not activate with surveyor movement. At 7:40 A.M., CNA #3 entered the resident’s room with the surveyor and attempted to activate the bed sensor alarm by waving her arms/hands in front of it several times, however, the alarm did not activate, as planned. UM #1 then entered the resident’s room and CNA #3 informed him of the malfunctioning alarm and he told CNA #3 that he would stay with the resident until a new alarm was secured to the resident’s bed. A discussion was held with UM #1 regarding the lamp also not being on, as planned. At 8:00 A.M., UM #1 informed the surveyor that the resident’s pillow to define the edge of the resident’s bed was also not in place, as planned.

During an interview with UM #1, (on 12/1/16 at 7:50 A.M.), regarding the resident’s falls, he said the resident needs the staff to supervise her/him (as planned). The facility failed to provide effective interventions and adequate supervision to prevent continued falls.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, facility policy and staff interviews, the facility staff failed to follow proper infection control practices regarding a dressing change for 1 sampled resident (#10) and care and services for indwelling catheters to prevent infections for 2 sampled residents (#4 and #6), in a total of 20 sampled residents.

Findings include:

1. For Resident #10, the facility staff failed to conduct a dressing change per facility policy and proper infection control practices to ensure there was no cross contamination and to prevent infection.

Resident #10, was admitted to the facility in 10/2016, with [DIAGNOSES REDACTED]. Review of the facility policy: Wound Dressings: Aseptic, revised 11/30/15 included:
– Gather supplies:
– Gloves (two pairs)
– Prepare label with date and initials
– Gauze – Dressing/Medication/Ointment, as ordered
– Plastic bags.
– Clean over-bed-table.
– Place clean barrier on table and place supplies on the barrier.
– Place a plastic bag for soiled dressing supplies within easy reach.
– Cleanse hands.
– If multiple wounds in close proximity, treat the less contaminated wound first.
– If a break in aseptic technique occurs, stop the procedure, remove gloves, cleanse hands, and apply clean gloves.
– Open dressings without contaminating. Keep the dressing/gauze within the open packet and place it directly on top of the barrier.
– Apply clean gloves and remove the soiled dressing. Discard dressing and gloves. Cleanse hands and apply clean gloves.
– Cleanse or irrigate wound, as ordered.
– Wipe any excess fluid from the surrounding skin using a dry, gauze wipe.
– If gloves become contaminated, remove gloves, cleanse hands, and apply clean gloves.
– Using swab or applicator, apply treatment medication, as ordered.
– Apply and secure clean dressing. Remove gloves and discard.
-Apply prepared label. Cleanse hands.

Review of the 11/2016 Treatment Administration Record (TAR) indicated a Physician’s order of 11/5/16 to cleanse the resident’s left lower shin wound with Normal Saline, and pat dry. Apply [MEDICATION NAME] (cream) to area. Cover with non-adherent abdominal pads, then wrap lightly with Kling (gauze wrap) every day shift.

On 11/30/16 at 10:30 A.M., the surveyor observed Nurse #1 during Resident #10’s dressing change on the anterior lower left shin and lateral aspect of the left shin (two wounds). Nurse #1 cleaned the table and placed a clean towel on the surface. After washing his hands with soap and water, Nurse #1 gathered supplies for the dressing change. He brought in the entire box of gloves, a pair of scissors, a jar of [MEDICATION NAME] (resident specific) wound cleanser and hand sanitizer. When Nurse #1 removed the old dressing from the lower left leg, the surveyor observed that there were two separate wounds. The anterior wound had a copious amount of thick yellow/gray drainage on the old dressing as well as on the wound. The wound bed was grayish in color, with no odor. The wound on the lateral aspect had a moderate amount of serous drainage. Nurse #1 said he forgot to get a bag to dispose of used materials and asked Unit Manager (UM) #1 to get him a bag from the treatment cart. Nurse #1 held the resident’s left heel in one hand and the old dressing in the other hand. UM #1 brought in a Ziploc bag that was not large enough to drop the old supplies into without having to push them in with his hand.

Gloves were changed and hand sanitizer used after wiping off a large amount of drainage with the old dressing. Nurse #1 told UM #1 that he forgot to get the gauze pads to clean the wound. Nurse #1 took over holding up the resident’s left heel (contaminating clean gloves) and asked UM #1 to get the gauze from the Treatment Cart to clean the wound. UM #1 held a newly opened package of 4 x 4 gauze pads and held it out for the nurse. With his contaminated hand, Nurse #1 reached into the clean gauze package and pulled out several clean pads. The whole package was placed on the resident’s bed.

Nurse #1 sprayed the wound cleanser onto the shin wound and patted it dry with gauze. The nurse disposed of the contaminated wad of gauze and pushed it into the bag while still holding some clean gauze in the same hand. Some of the clean gauze touched the inside of the disposable bag. Without changing gloves and cleaning hands, Nurse #1 sprayed the lateral wound with wound cleanser and patted it dry with the leftover gauze in his gloved hand.

While UM #1 held the resident’s leg off the bed, Nurse #1 applied [MEDICATION NAME] Cream first to one wound and then the other, using a new swab each time. The used swabs were placed on the clean table next to clean gloves, Kling wrap and non-adherent dressing pads (). With the same gloved hand, Nurse #1 reached into his uniform pocket to retrieve a pen. He picked up one of the non-adherent dressings with contaminated gloves and initialed and dated it. The non-adherent dressings were approximately 2.0 x 4.0 inches and not the larger abdominal pads as ordered to cover the wounds entirely. Nurse #1 placed the newly contaminated non-adherent dressings over each wound which covered about two thirds of each wound.

After the dressing change, Nurse #1 washed his hands. The contaminated package of gauze pads on the bed were placed into the treatment cart with other patients’ supplies. The surveyor brought this infection control breach to their attention. During an interview on 11/30/16 at 11:30 A.M., (with the Director of Nurses, Nurse Educator, UM #1 and Nurse #1), the Director of Nurses said that Nurse #1 did not follow facility infection control practices and would be re-educated and observed prior to conducting treatments of wounds. After the dressing change, Nurse #1 washed his hands. The contaminated package of gauze pads on the bed were placed into the treatment cart with other patients’ supplies. The surveyor brought this infection control breach to their attention. During an interview on 11/30/16 at 11:30 A.M., (with the Director of Nurses, Nurse Educator, UM #1 and Nurse #1), the Director of Nurses said that Nurse #1 did not follow facility infection control practices and would be re-educated and observed prior to conducting treatments of wounds.

2. For Resident #6, the facility staff failed to ensure the resident’s catheter and tubing were kept off the floor (increasing the risk for infection). Resident #6, was admitted to the facility in 7/2014, with [DIAGNOSES REDACTED]. Review of the resident’s care plan and CNA (Certified Nursing Assistant) care card indicated to keep the catheter bag off the floor. On 11/29/16 at 9:15 A.M., the resident was observed by the surveyor sitting in the dayroom, in the wheelchair. The catheter had a catheter drape cloth over the top, however, the bottom of the catheter bag was resting directly on the floor. On 11/29/16 at 1:35 P.M. and 3:55 P.M., the surveyor observed the resident sitting in the dayroom, in the wheelchair. The catheter bag and tubing were resting directly on the floor underneath the wheelchair. There was no cover on the catheter bag. On 11/30/16 at 6:50 A.M., the surveyor observed the resident lying in bed. The catheter bag and tubing were directly on the floor, next to the resident’s bed. On 11/30/16 at 3:00 P.M., the resident was observed by the surveyor sitting in the wheelchair, in the dayroom. The catheter bag and tubing were resting on the floor. During an interview on 11/30/16 at 3:00 P.M., UM #2 said that the resident has poor positioning in the wheelchair, but was unaware that the catheter bag was on the floor while in bed, as well. UM #2 said that staff inservicing would begin immediately to ensure the catheter bag stays off the floor.

3. For Resident #4, the facility staff failed to ensure that the resident’s catheter bag and tubing were kept off the floor (increasing the risk for infection). Resident #4, was admitted to the facility in 1/2015, with [DIAGNOSES REDACTED]. Review of the indwelling catheter care plan, initiated on 1/28/15, indicated to keep the resident’s catheter bag off the floor. During an observation, on 11/29/16 at 8:50 A.M., the surveyor observed Resident #4 being transported in a wheelchair, down the hallway, by staff, with the Foley catheter bag and tubing dragging on the floor. During an observation, on 11/29/16 at 3:00 P.M., the surveyor observed Resident #4 lying in a low bed, with the Foley catheter bag on the floor. During an observation, on 11/30/16 at 8:45 A.M., the surveyor observed Resident #4 lying in a low bed, with the Foley catheter bag on the floor. During an observation, on 12/1/16 at 7:40 A.M., the surveyor observed Resident #4 lying in a low bed, with the Foley catheter bag on the floor. During an observation on 12/1/16 at 12:30 P.M., with Unit Manager (UM) #1, the surveyor observed Resident #4 lying in a low bed, with the Foley catheter bag on the floor. The surveyor observed UM #1 raise the height of the bed for Resident #4 until the Foley catheter bag was positioned off the floor.

During an interview on 12/1/16 at 12:30 P.M., UM #1 said that Resident #4 is supposed to have a low bed, and that the Foley catheter bag should not be on the floor.