Quincy Health and Rehabilitation Center

Quincy Health and Rehabilitation Center

MI Elder Abuse Free Legal ConsultationDid someone you love suffer elder abuse or neglect at Quincy Health and Rehabilitation Center? Our lawyers can help.

Abuse of the elderly is not acceptable and we fight hard in these types of cases. If you suspect Quincy Health and Rehabilitation Center or caregiver has caused harm to your loved one in someone elses’ care, contact our law firm today for a free legal consultation.

Talking to us does not obligate you to anything, but we may be able to tell you if you have a claim and the value of your case. If we accept your case, you pay no fee unless we recover for you.

About Quincy Health and Rehabilitation Center

Quincy Health and Rehabilitation CenterQuincy Health and Rehabilitation Center is a for profit, 126-bed Medicare/Medicaid certified skilled nursing facility that provides services to the residents of Quincy, Braintree, Milton, Weymouth, Randolph, Hingham, Holbrook, Hull, Dedham, Boston, Brookline, Rockland, Canton, Winthrop, Stoughton and the other towns in and surrounding Norfolk County, Massachusetts.

Quincy Health and Rehabilitation Center focuses on 24 hour care, respite care, hospice care and rehabilitation services.

Quincy Health and Rehabilitation Center
11 McGrath Hwy,
Quincy, MA 02169

Phone: (617) 479-2820
Website: http://quincy-health.com

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 2017, Quincy Health and Rehabilitation Center in Quincy Massachusetts received a rating of 2 out of 5 stars.

Performance Area Rating
Overall Rating 2 out of 5 (Below Average)
State Health Inspections 1 out of 5 (Much Below Average)
Staffing 4 out of 5 (Above Average)
Quality Measures 3 out of 5 (Average)

Fines Against Quincy Health and Rehabilitation Center

The Federal Government fined Quincy Health and Rehabilitation Center $122,103 on May 19th, 2015 for health and safety violations.

Fines and Penalties

Our Nursing Home Abuse Lawyers inspected government records and discovered Quincy Health and Rehabilitation Center 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 interview, the facility staff failed to obtain appropriate consents for the use of anti- psychotic medications and failed to ensure that the Advance Directive formulated by the health care agent was correctly identified in the medical plan of care, for 3 Residents (#1, #14 and #5) in a total sample of 23 residents.

Findings include:

For Resident #1, the facility failed to obtain consents for the use of [MEDICAL CONDITION] medications, from the Resident. Resident #1 was admitted to the facility in 11/2007 with [DIAGNOSES REDACTED]. Clinical Record Review indicated the Resident was receiving the following medications:

  • [REDACTED]
  • [MEDICATION NAME] 0.5 mg one half tablet twice a day (for anxiety)
  • [MEDICATION NAME] 200 mg three times a day (anti-[MEDICAL CONDITION])
  • [MEDICATION NAME] 150 mg every day (anti-depressant)

Further clinical record review indicated that on 5/2/16 the Residents son (the health care proxy on file-(HCP)) gave verbal consent for the medications. The Resident had not been adjudicated incompetent nor had the HCP been invoked, so the Informed Consents should have been signed by the Resident. On 9/8/16 at 9:20 A.M. the DON said the facility failed to obtain the appropriate consents from the Resident.

For Resident #14, the facility failed to obtain consents for the use of [MEDICAL CONDITION] medications, from the Resident. Resident #14 was admitted to the facility in 1/2013 with [DIAGNOSES REDACTED]. Clinical Record Review indicated the Resident was receiving the following medications:

  • [REDACTED]
  • [MEDICATION NAME] 0.25 mg by mouth once a day (anxiety)
  • [MEDICATION NAME] 20 mg every day (anti-depressant)

Further clinical record review indicated that there were no informed consents signed by the Resident. The Resident had not been adjudicated incompetent nor had a HCP been invoked, so the Informed Consents should have been signed by the Resident. On 9/12/16 at 9:30 A.M. the DON said the facility failed to obtain the appropriate consents from the Resident.

For Resident #5, the facility failed to ensure that medical plan of care including physician orders [REDACTED]. Resident #5 was admitted to the facility in 12/2015 with [DIAGNOSES REDACTED]. Review of the most recent quarterly Minimum Data Set (MDS) with a reference date of 9/9/16 indicated that Resident #5 scored a 7 out of 15 on the BIMS (brief interview of mental status) which indicated that the Resident had severe cognitive impairment. The Resident was dependent on staff for all activities of daily living.

The medical record was reviewed on 9/8/16 and 9/9/16. Review of the medical record indicated that Resident #5 had a Do Not Resuscitate (DNR) order which was signed on 8/30/16. Review of the September 2016 physician orders [REDACTED].#5 had an advance directive of full resuscitation.

Review of the individualized care plan for advance directives (last reviewed 6/10/16), indicated that Resident #5’s advance directive was attempt resuscitation. Resident #5 was admitted to the hospital on [DATE] and was treated for [REDACTED].#5’s advance directive was changed from full resuscitation to do not resuscitate (DNR) as indicated by a physician signed comfort care/do not resuscitate order dated 8/30/16. Review of physician’s orders [REDACTED].#5’s advance directive was full resuscitation. During interview with Unit Manager #1 on 9/8/16 at approximately 10:00 A.M., she said that the change in code status was overlooked upon the Resident’s readmission and it should be DNR.

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 interview, the facility failed to notify the Resident’s physicians and/or legal representatives when there was a change in the Resident’s status that could alter the course of treatment for 2 Residents (#7 and #21) in a total sample of 23.

Findings include:

1. For Resident #21, the facility staff failed to notify the physician or nurse practitioner of an abnormally high blood sugar. Resident #21 was admitted to the facility in 6/2014 with the following pertinent Diagnoses: [REDACTED].

(The American Diabetes Association (ADA) indicates that a blood glucose range is too low if it is < 70 and too high if it >240 and to notify the physician for a blood glucose level greater than 300.) Review of the physician’s orders [REDACTED]. The Resident was not receiving sliding scale insulin in addition to the scheduled [MEDICATION NAME] and there were no parameters for blood sugar levels below or above a specific limit.

Review of the blood sugar recordings for 2/2015 indicated a blood sugar record of 475 without a corresponding nursing note to indicate that the physician was notified for possible additional insulin coverage or to document the possible signs/symptoms of [MEDICAL CONDITION] (increased thirst or urination, nausea, blurred vision or increased fatigue). The Resident did have a [MEDICAL CONDITION] infection, which can increase the body’s insulin requirements.

On 9/14/16 at approximately 2:30 P.M, the Surveyor interviewed the Director of Nursing Services (DNS). The DNS said that she would absolutely expect staff to notify the physician with a blood sugar >300. The DNS could not locate a policy for blood glucose monitoring and said that there were no policies available from the new corporation, which recently purchased the facility.

2. For Resident #7, the facility staff failed to notify the physician, nurse practitioner or resident of recommendations made by the psychiatric consultant. Resident #7 was admitted to the facility in 4/2015 with [DIAGNOSES REDACTED]. Record review indicated the physician order [REDACTED]. Review of the psychiatric consult from 12/16/15 through 8/19/16, indicated the following recommendations were made without corresponding nursing notes to indicate that the physician was notified.

Record review indicated that on 12/16/15, the psycho-pharmacology note recommended to increase the Resident’s antidepressant medication [MEDICATION NAME] from 75 mg to 100 mg and to decrease the antipsychotic medication, [MEDICATION NAME] from 7.5 mg to 5 mg. The assessment outlined the bases for the recommendations (which included the Resident had no signs of [MEDICAL CONDITION], but did have symptoms of [MEDICAL CONDITION] and depression) and to continue with 1 to 1 psychotherapy. The medications were not changed and there was no evidence the physician had been made aware of the recommendations.

On 1/25/16, the psychiatric services again recommended the physician to consider medications changes as follows:

-Recommended to taper the scheduled antipsychotic and discontinue the PRN. The consultant outline the plan including recommendations to increase the antidepressant [MEDICATION NAME] and/or [MEDICATION NAME], and to utilize the PRN [MEDICATION NAME] if agitation occurs. At the time of the assessment the Resident was alert and oriented, had no racing thoughts and presented stable. The consulted asked the staff to report the recommendations to the physician and document his response.

The facility staff faxed the recommendations to the physician on 2/9/16 and 2/13/16, however there was no evidence of a physician response or that the facility staff followed up with the physician. The recommendations were not acted upon.

On 2/22/16, the psychiatric consultant reassessed the Resident and noted that there was no response from the physician for the recommendations dated 1/25/16. The consultant re-outlined her recommendations and requested the Director of Nurse (DON) to schedule psychiatric rounds when the physician was available.

The psychiatric consult re-evaluated the Resident on 5/13/16 and noted the Resident reported he/she was depressed and felt sick to stomach and was having increased periods that he/she yelled out for help. The recommendations included an increase of the antidepressant [MEDICATION NAME] from 100 mg to 125 mg and 1 to 1 psychotherapy. Record review failed to find evidence that the physician was notified of the recommendations. The [MEDICATION NAME] was not increased and 1 to 1 psychotherapy was not provided.

On 7/6/16, the nurse’s note indicated the psychiatric consultant requested [MEDICATION NAME] 25 mg PRN/as needed be ordered. The nurse’s note indicated that the physician agreed with the recommendation and that they called and contacted the wrong HCP (Health Care Agent/Proxy) for consent. The note indicated the nursing staff would correct the mistake, however, the record failed to indicate that the HCP had been invoked and there was no evidence the Resident was notified and consented.

On 7/13/16, the psychiatric consultant recommended to discontinue the scheduled [MEDICATION NAME] (100 mg); increase the PRN [MEDICATION NAME] from 25 mg to 50 mg; increase the [MEDICATION NAME] from 100 mg to 150 mg; and recommend to continue with one to one psychotherapy. There was no evidence the facility staff shared the information with the physician so he could make an informed decision. However, the nurse’s note dated 7/13/16 indicated the facility staff contacted the HCP agent and left a message. On 7/14/16, the nurse’s note indicated the HCP agent called back, but that she was unable to speak with her, and therefore left a second message. Further review of record, found no indication that the facility staff addressed the psychiatric’s recommendation with the physician and/or the Resident as the record indicated that the HCP was not invoked at this time.

On 7/20/16, the psychiatric consultant’s recommendations were to discontinued the [MEDICATION NAME] 100 mg at night, increase the PRN [MEDICATION NAME] from 25 mg to 50 mg, to increase the [MEDICATION NAME] from 100 mg to 150 mg and to invoke the Health Care Proxy.

Record review indicated that on 7/20/16, the Resident was sent out to the hospital due to high blood sugars. There was no evidence that the psychiatric recommendations were addressed with the physician, after he/she returned.

During interview with the Medical Director on 9/13/16 at 2:45 P.M., the Surveyor asked about the recommendations that had been made by the consulting psychiatric service and the lack of evidence that he had been notified. The Medical Director said that communication between the facility staff and he was poor. He said that he frequently calls the facility to respond to a page and is unable to get in contact with anyone. He said staff either do not answer the phone or he cannot connect with the right staff. During interview with the DNS on 9/14/16 at 9:40 A.M., she said that the Medical Director was not good at returning telephone calls.

Failed to keep each resident's personal and medical records private and confidential.

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

Based on record review and interviews, the facility failed to ensure for 1 resident (#2) out of a total sampled of 23 residents, that the Resident’s right to personal privacy and confidentiality was protected and provided by it’s contracted services.

Findings include:

Resident #2 was admitted to the facility in 5/2015 and had [DIAGNOSES REDACTED]. Review of the most recent Quarterly MDS dated [DATE] indicated a score of 15 out of 15 on his/her Brief Interview of Mental Status (BIMS), was capable of communicating and making needs known, exhibits symptoms of verbal abuse and was own decision maker. The MDS indicated the Resident did not have a Health Care Proxy.

Record review indicated the Resident had received 1 to 1 psychotherapy from 7/23/15 through 9/3/15. During this time period the therapist documented 7 visits, in 3 of which the therapist reported the Resident was not available and that he discussed the Resident’s problems with Resident #2 roommate.

On 7/30/15, the psychotherapist’s note indicated the Resident was not present today, but per staff . and resident’s roommate was sent to emergency roiagnom on [DATE]. The note indicated the Resident was agitated and complained of pain and called for an ambulance. The Resident’s roommate informed the therapist that the Resident’s behaviors had escalated and that the Resident was spending increased time out of the facility and missing medications. The roommate said when staff tried to stop the Resident from going out the Resident would become verbally aggressive towards staff.

On 8/6/15 the psychotherapist’s note indicated the Resident was not present today, but per staff . and resident’s roommate out on 8/5/15. The note indicated the Resident complained of chest pain. The Resident’s roommate informed the therapist that the Resident’s behaviors had not improved.

On 8/27/15 the psychotherapist’s note indicated the Resident was not present today, but per resident’s roommate the Resident complained of bowel obstruction. In addition, the roommate told the therapist the Resident had confided to him/her that the Resident drinks alcohol.

On 9/9/16 at 11:20 A.M., the Director of Nurses was informed of the therapist notes indicating that he discussed confidential information with the Resident’s roommate. The Director made no statement at the time or subsequent to the interview.

On 9/13/16 at 10:20 P.M., the consulting psychiatric practitioner was shown the therapist notes. She said that this therapist no longer worked for the service, but agreed that the therapist should not have been discussing the Resident’s private information with a roommate.

Failed to keep each resident free from physical restraints, unless needed for medical treatment.

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

Based on record review, observation, and interviews, the facility failed to ensure that Residents attained or maintained their highest practicable level of physical and psychological well being by engaging in a systematic process of assessment, evaluation, and a gradual process toward the reduction of physical restraint use for 2 Residents (#3 and #15) with restraints in a total sample of 23.

Physical restraints are defined as any manual method of physical or mechanical device, material, or equipment attached or adjacent to the Resident’s body that the individual cannot remove easily which restricts freedom of movement or normal access to one’s body (e.g. leg restraints, arm restraints, hand mitts, soft ties or vests, lap cushions, and lap trays the Resident cannot remove easily).

Findings include:

1. For Resident #15, the facility failed to obtain a physician’s orders [REDACTED]. During interview on 9/7/16 at 10:30 A.M., the Ombudsman informed the survey team that facility staff had obtained a jumpsuit for Resident #15 to deter his/her behavior of lifting up his/her shirt in public, manually disimpacting him/herself and eating feces. She said that the Resident tore up the first jumpsuit that was obtained because the material was not able to withstand his/her pulling on it to get to his/her body and staff had subsequently obtained another jumpsuit made of a more durable material. The medical record was reviewed on 9/13/16.

Resident #15 was admitted to the facility in 2/2010 with [DIAGNOSES REDACTED]. Review of the most recent quarterly Minimum Data Set (MDS) with a reference date of 6/20/16, indicated that Resident #15 had severe cognitive impairment as evidenced by a score of 0 out of 15 on the Brief Interview of Mental Status (BIMS), exhibited behaviors and was dependent on staff for all activities of daily living and did not have a restraint.

During interview with staff nurse #5 on 9/13/16 at approximately 1:00 P.M., she said that the activities department obtained the jumpsuit for Resident #15 which fastened in the back, to see if it would stop the Resident from lifting up his/her shirt in public and manually disimpacting his/herself and eating feces. Staff nurse #3 showed the Surveyor a green jumpsuit which fastened in the back hanging in Resident #15’s closet. She said that although the Resident was not wearing the jumpsuit today, she has seen him/her wearing it before.

During interview with the Activity Director on 9/13/16 at 2:00 P.M., she said that Resident #15’s family was upset by his/her behavior and she ordered a jumpsuit a few months ago for Resident #15 which fastened in the back to deter him/her from lifting up their shirt and disimpacting him/herself.

Further review of the medical record failed to indicate that the facility obtained a physician’s orders [REDACTED].#15’s access to his/her body.

2. For Resident #3, the facility failed to ensure that the restraint was the least restrictive and used for the least amount of time.

Resident #3 was admitted to the facility in 2/2015 with [DIAGNOSES REDACTED]. Review of the most recent quarterly MDS with a reference date of 6/15/16 indicated that Resident #3 had severe cognitive impairment, was dependent on staff for activities of daily living, used a wheelchair and had a restraint.

The medical record was reviewed on 9/8/16. During the initial tour of the unit on 9/6/16 at approximately 9:30 A.M., Resident #3 was observed seated in his/her wheelchair in the hallway with an alarm seatbelt fastened around his/her waist.

Review of the medical record indicated that Resident #3 used an alarmed seatbelt while in the wheelchair for poor trunk control, lack of safety awareness due to dementia and to prevent falls. The physical restraint was ordered on [DATE] and indicated that the restraint was to be released every 2 hours and during meals and activities. There was no documented evidence in the medical record to indicate that quarterly assessments were conducted following the initiation of the restraint in 3/2015 until 2/2016. An annual assessment was not conducted until 5/10/16 (2 months after it was due). Additionally, there was no documented evidence that a restraint reduction had been attempted from the date of initiation on 3/11/15 until 2/2016.

Resident #3 was observed at various times on all days of the survey with the alarmed seatbelt fastened. In addition, on 9/9/16 at 9:30 A.M. and 12:30 P.M. and 9/12/16 at 12:25 P.M., the Resident was observed being fed by facility staff in the dining room with the alarmed seatbelt secured around the Resident’s waist. The restraint was not released during meals per physician’s orders [REDACTED].

Failed to hire only people with no legal history of abusing, neglecting or mistreating residents; or report and investigate any acts or reports of abuse, neglect or mistreatment of residents.

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

Based on record review and staff interview, the facility failed to ensure that alleged allegations involving mistreatment, neglect, or abuse are reported immediately to the administrator and to other officials in accordance with state law. In addition, the facility failed to do a complete investigation and take immediate action to ensure the Resident (#3) were protected. The total sample was 23 residents.

Findings include:

A review of the facility’s policy for Incident/Accident Reports and Abuse and Event Report checklist indicated that a report is to be completed by the licensed nurse following any reported or witnessed occurrences of the incidents/accident which may include, but are not limited to the following:

  • Abuse or suspected Resident abuse
  • Self -inflicted injury

Procedures included the following:

  • The licensed nurse will complete the accident and incident report
  • The licensed nurse will immediately notify the physician of the occurrence
  • The licensed nurse will immediately notify the Resident’s responsible party of the occurrence
  • The incident/accident form will be submitted to the Director of Nursing Services for review and administrative follow up and appropriate filing
  • Complete an Event report-only the facts-what you saw/heard when you arrived to assess the Resident
  • Obtain witness statements from staff on duty
  • If the incident/accident is a reportable occurrence to the State Regulatory Agencies, the Administrator and/or the Director of Nursing Services will be responsible for initiating timely and efficient investigative reporting and follow up.

1. For Resident #3, the facility failed to report an allegation of abuse to the administration of the facility; failed to ensure that the allegations was thoroughly investigated and reported to other officials in accordance with state law; and failed to take immediate action to ensure the Resident was protected.

The medical record was reviewed on 9/8/16. Review of the medical record indicated that Resident #3 was seen by the facility’s psychiatric consultant on 12/18/15 for review of his/her psychiatric medications. Further review of the progress note indicated that the clinician was told by staff that Resident #3 had been assaulted by staff members.

The medical record failed to indicate that Resident #3’s physician had been notified of the alleged assault and further review and interviews indicated the facility failed to complete an investigation and report to the Department of Public Health (DPH).

The Director of Nursing (DON) was interviewed on 9/9/16 at 11:15 A.M. She said that she had heard about the incident, but didn’t have any further information about it. The Surveyor asked if the incident was reported to DPH and she said yes. The Surveyor requested a copy of the incident report and complete investigation to review. On 9/14/16, 5 days after the initial request, the DON said that she did not believe the incident occurred and therefore did not report it to DPH and did not conduct an investigation.

Failed to provide medically-related social services to help each resident achieve the highest possible quality of life.

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

Based on record review, staff interview and observation of the Resident, the facility failed to provide medically related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being for 1 Resident (#7) in a total sample of 23 Residents.

Findings include:

For Resident #7, the facility failed to ensure the Resident received 1 to 1 psychotherapy as prescribed in his/her psychiatric treatment plan and to obtain a competency evaluation to determine the Resident’s capacity to make medical decisions.

Resident #7 was admitted to the facility in 4/2015 with [DIAGNOSES REDACTED]. Review of the most recent Quarterly Minimum Data Set (MDS) assessment, dated 7/8/16, indicated the Resident scored an 11 out of 15 on the BIMS (Brief Interview for Mental Status) indicating a mild cognitive deficit and exhibited some verbal outburst. The Health Care Proxy (HCP) was not invoked.

Review of the Resident psychosocial history indicated the Resident had ineffective coping due to multiple traumatic losses, alcoholism and depression. The record indicated the Resident had initially been placed at the facility for short term placement but that due to additional losses (caregiver and home) and need for 24 hour care status was changed to long term.

The record indicated that he/she received services from the psychiatric consultant services, which included monthly 1 to 1 psychotherapy for major depression. The 1 to 1 therapist met with the Resident monthly from 10/8/15 through 1/8/16. The progress notes indicated the Resident was responding well and expressing his/her difficulties with depression and ineffective coping (exhibited by insomnia). The therapist provided the Resident with support, encouragement and counseling to decrease the Resident’s depression, sense of loss and anxiety. The therapist noted that the Resident felt hopeful and encouraged the Resident to focus on his/her hope and to not focus on self defeating thoughts. The one to one psychotherapy ended without evidence of termination on 1/8/16. The consulting Psychiatric Nurse Practitioner (NP) continued to assess the Resident for medication effectiveness and non-pharmacological interventions. On 5/13/16, the Psychiatric NP indicated that the Resident needed 1 to 1 psychotherapy for his/her depression. However, there was no supporting evidence the Resident was receiving it after 1/8/16.

On 7/13/16, the Social Worker’s progress note indicated the Resident’s behaviors included yelling out/screaming to get attention and verbal abuse. The note indicated that the Facility’s consulting psychiatric service was addressing the psychoactive medication and anxiety issues. The note indicated the Resident continues to want to go home and is unhappy at facility (poor adjustment to long term care). The Social Worker indicated a competency evaluation to determine the Resident’s ability to make medical decision was pending and that counseling services was recommended.

The psychiatric consultant saw the Resident on 7/13/16 and recommended changes in medication and to continue with the 1 to 1 psychotherapy, however it was not provided. The consult did not indicate if they assessed for competency.

However, on 7/20/16, the psychiatric consultant assessed the Resident and indicated the Resident’s mental status varied throughout the day and ordered to invoke the Health Care Proxy. There was no evidence that the psychiatric recommendations were addressed with the physician and the HCP was not invoked. From 7/21/16 through survey, the HCP was not invoked and the Resident did not receive 1 to 1 psychotherapy.

On 9/13/16 at 10:20 A.M., the consulting psychiatric practitioner was interviewed. She said that there were a number of problems with facility staff’s follow through when she made recommendations. She said she was unaware that the Resident had not received 1 to 1 services since 1/18/16. In addition, the consultant said she had asked the Director of Nurses to schedule a meeting with the Medical Director to discuss a number of these type of problems and said that the meeting had not been scheduled.

During interview with the Director of Social Services (DSS) on 9/14/16 at 9:50 A.M. she stated that it is the role of Social Services to oversee the care provided by the other services (psychiatric). The DSS was asked if she were aware of the types of services being provided to Resident #7 (medication, group or 1 to 1 psychotherapy) and how the facility ensured that services provided were implemented into the Resident’s plan of care. The DSS initial said that she would have to review the Resident’s record to provide information, but then added that the behavior meetings were held weekly with the consulting staff (psych). She said that the nursing staff were responsible for following up with the recommendations made by the consultant because it would require the physician and family consent. She said she could not explain why there was no 1 to 1 psychotherapy or why the HCP was not invoked. The DSS re-stated that her main job was to oversee things (hands off) and direct.

Failed to review or revise the resident's care plan after any major change in a resident's physical or mental health.

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

Based on staff interview and record review the facility failed to complete a significant change Minimum Data Set (MDS) assessment for one Resident (#10) who was started on Hospice Services out of a sample of 23 total residents.

Findings include:

Resident #10 was admitted to the facility in 6/2008 with [DIAGNOSES REDACTED]. Per the quarterly MDS completed on 6/13/16 Resident #10 has a Brief Interview of Mental Status (BIMS) score of 10 out of 15, which indicates moderate cognitive impairment. Resident #10 had a guardianship in place.

Review of Resident #10’s medical record on 9/8/16 indicated that the last MDS completed for Resident #10 was a quarterly MDS, completed on 6/13/16. Further review of the clinical record indicated a physician telephone order that the resident may be referred for hospice services, dated 7/25/16. Per review of the Hospice documentation, the Resident began hospice care on 7/27/16.

The MDS Coordinator was interviewed on 9/9/16 at 2:00 P.M. The MDS Coordinator stated that he/she was unaware that Resident #10 had started on Hospice services in 7/2016 and therefore a significant change MDS was never completed.

Failed 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 interview, the facility failed to accurately assess one resident (#6) for language and need for interpreter services in a sample of 23 residents.

Findings include:

For Resident #6, admitted on [DATE], the admission nursing assessment dated [DATE] indicated the resident could not be interviewed because he/she did not speak English and the activity assessment dated [DATE], dated indicated the resident spoke only Mandarin Chinese. The hospital discharge summary indicated the resident spoke only Mandarin Chinese.

Review of the minimum data set (MDS), dated [DATE], indicated in Section A, Identification Information, A 1100 Language; that the resident was coded as not needing or wanting an interpreter to communicate with a doctor or health care provider and the preferred language section was not completed with the resident’s primary language of Mandarin. Review of the resident’s comprehensive care plan indicated there was no plan for communication with this resident.

Observation on 9/9/2016 at 10:00 A.M., indicated the resident was alert and verbal and could only respond to the Surveyor’s greeting in Chinese.

During an interview on 9/9/2016 at 2:30 P.M., the MDS coordinator said that it was a coding error and he should have coded the resident as needing an interpreter for Mandarin Chinese and should have developed a communication care plan for Resident #6.

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 record review, staff and Resident interviews, the facility failed to develop an individualized, interdisciplinary, comprehensive plan of care that addressed the needs for 2 Residents (#11 and #15) related to (1.) suicidal ideation and (2.) behaviors of ingesting non-food items, lifting up his/her shirt, disimpacting his/herself and the use of a jumpsuit garment to control the Resident’s behaviors out of a total sample of 23 Residents.

Findings include:

1. For Resident #11, the facility failed to develop a care plan to address verbalizations of suicidal ideation. Resident #11 was admitted to the facility in 10/2012 with [DIAGNOSES REDACTED]. The medical record was reviewed on 9/7/16.

Review of the most recent quarterly Minimum Data Set (MDS) with a reference date of 4/11/16 indicated that Resident #11 had severe cognitive impairment as evidenced by a score of 5 out of 15 on the Brief Interview for Mental Status (BIMS) and required extensive assistance of staff for all activities of daily living.

Review of the facility’s psychotherapy consultant’s note dated 12/3/15 indicated that nursing and CNA staff reported to the consultant that Resident #11 consistently and frequently wandered the halls and make statements indicative of passive suicidal ideation. Review of the facility’s psychiatric nurse practitioner’s notes dated 12/12/16, 4/3/16 and 8/26/16 indicated that Resident #11 continued to have passive suicidal ideation. Review of the Resident’s comprehensive, interdisciplinary care plan revealed that the facility had neither identified nor developed specific interventions to address his/her frequent verbalizations of passive suicidal ideation.

On 9/12/16 at 1:40 P.M., the Surveyor observed Resident #11 slowly propelling his/her wheelchair from the dining room down the hallway. The Resident was observed to have his/her hands on their abdomen and told nurse #2 that he/she was in pain, wanted help getting to his/her room and wanted to die. Nurse #2 conducted a pain assessment, but ignored Resident #11’s verbalization that he/she wanted to die.

2. For Resident #15, the facility failed to develop a care plan to address a.) behavior of ingesting non-food items and b.) the use of a jumpsuit garment to control the Resident’s behaviors of manually disimpacting his/herself and eating feces.

Resident #15 was admitted to the facility in 2/2010 with [DIAGNOSES REDACTED]. The medical record was reviewed on 9/13/16. Review of the most recent quarterly MDS indicated that Resident #15 had severe cognitive impairment as evidenced by a score of 0 out of 15 on the BIMS, exhibited behaviors and was dependent on staff for all activities of daily living.

Review of nursing progress notes dated 1/13/16 indicated that Resident #15 consumed Peri-Wash solution (bottled personal cleanser for perineum area). The physician was informed and gave an order to encourage fluids for 48 hours and monitor the Resident for nausea and vomiting for 48 hours. Review of the comprehensive, interdisciplinary care plan revealed that the facility had neither identified nor developed specific interventions to address Resident #15’s ingestion of non food items (peri-wash solution).

During interview on 9/7/16 at 10:30 A.M., the Ombudsman informed the survey team that facility staff had obtained a jumpsuit for Resident #15 because he/she had a behavior of lifting up his/her shirt in public, manually disimpacting him/herself and eating feces. During interview with staff nurse #3 on 9/13/16 at approximately 1:00 P.M., she said that the activities department obtained the jumpsuit which fastened in the back for the Resident to see if it would stop the Resident from lifting up his/her shirt in public and manually disimpacting his/herself and eating feces. Staff nurse #3 showed the Surveyor a green jumpsuit which fastened in the back hanging in Resident #15’s closet. Nurse #3 did not know how often the Resident wore the jumpsuit

During interview with the Activity Director on 9/13/16 at 2:00 P.M., she said that Resident #15’s family expressed to her that they were upset with the Resident’s behavior. The Activity Director said that she searched online and purchased a jumpsuit about a month ago. The jumpsuit fastened in the back (out of the Resident’s reach) to deter him/her from lifting up their shirt and disimpacting him/herself and eating feces.

Review of the comprehensive, interdisciplinary care plan revealed that the facility had neither identified nor developed specific interventions to address Resident #15’s behavior of lifting up their shirt, disimpacting him/herself and eating feces or the use of a jumpsuit as a behavior deterrent.

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 interview, the facility failed to meet professional standards of quality for 5 Residents ( #1, #7, #8, #14 and #11) in a total sample of 23 Residents.

Findings include:

1. For Resident #1 the facility failed to reconcile medications after the Resident had an acute hospitalization.

Resident #1 was admitted to the facility in 11/2007 with [DIAGNOSES REDACTED]. The facility policy for medication reconciliation is as follows:

  • Gather the information needed to reconcile the medication list.
  • If this is a re-admission to the facility, obtain the Residents previous Medication Administration Record (MAR) and the discharge summary from the hospital.
  • Review the lists carefully to determine if there are discrepancies/conflicts for example; The medication on the discharge summary does not match the Residents previous MAR.
  • Document the medication discrepancy on the medication reconciliation form
  • Document what actions were taken by the nurse to resolve the discrepancy.

Clinical record review indicated that the Resident’s physician had discontinued the Residents [MEDICATION NAME] (used for the inhibition of gastric secretions) 20 mg daily on 12/18/15. On 3/12/16 through 3/14/16 the Resident had an acute hospitalization . Upon return/readmission to the facility, the discharge summary from the acute hospital indicated the Resident was receiving the [MEDICATION NAME] prior to admission to the hospital, so the hospital discharge summary continued the medication/[MEDICATION NAME]. Upon return to the facility the Residents medications were never reconciled resulting in the [MEDICATION NAME] being restarted and the Resident receiving the [MEDICATION NAME] for 170 days/doses.

On 9/8/16 at 9:20 A.M. the DON said the facility failed to reconcile medications after the Resident had an acute hospitalization resulting in the [MEDICATION NAME] being restarted.

2. For Resident #11 the facility failed to:

a.) obtain a physician’s order for a right ankle brace

b.) ensure that scheduled and sliding scale insulin was administered per physician’s order, injection sites were identified and rotated.

Resident #11 was admitted to the facility in 10/2012 with [DIAGNOSES REDACTED]. Review of the most recent annual Minimum Data Set (MDS) with a reference date of 7/11/16 indicated that Resident #11 was cognitively intact, required extensive assistance with activities of daily living and received insulin injections daily. The medical record was reviewed on 9/7/16.

a.) Resident #11 was observed on 9/7/16 at 10:00 A.M. and 12:00 P.M. seated in a wheelchair in the unit dining room donning a right ankle brace. On 9/8/16 at 12:45 P.M., the Resident was again observed seated in a wheelchair in the unit dining room donning a right ankle brace. During interview with Resident #11 at the time of observation, the Resident said that he/she didn’t know what the brace was for, but the staff wanted him/her to wear it.

Review of physical therapy (PT) notes indicated that Resident #11 started PT services on 8/15/16 for generalized muscle weakness. Further review of the treatment notes indicated that on 8/31/16, an air cast for the right foot was obtained by the physical therapist. The 9/1/16 treatment note indicated that the right ankle air cast was applied to increase ankle support to prevent injury. The 9/5/16 treatment note indicated that the Resident was resistant to wearing the brace and the therapist educated him/her on the importance of wearing it daily.

Review of the medical record indicated that there was no physician’s order for the right ankle air cast and no orders directing use of the cast. During interview with PT #1 on 9/12/16 at 1:50 P.M., she said that she obtained the right ankle air cast for Resident #11 on 8/31/16, but forgot to get a physician’s order for it. She said the Resident is supposed to wear the cast every day for support and she had educated a CNA on how to apply it.

During interview with the Director of PT on 9/12/16 at 2:20 P.M., she said that PT #1 did not get a physician’s order for the right ankle air cast. b.) Review of the August 2016 physician’s orders indicated that Resident #15 had an order for [REDACTED].M. (initiated 1/17/15), check blood sugar twice daily at 6:00 A.M. and 4:00 P.M., and [MEDICATION NAME] R 100 units/ml vial per sliding scale (initiated 9/8/15):

151-199 = 1 unit

200-249 = 2 units

250-299 = 3 units

300-349 = 4 units

350-399 = 5 units

400-449 = 6 units

450-499 = 8 units

Above 500 = 10 units, call MD

Review of the April 2016 through August 2016 diabetic monitoring flowsheets indicated the following:

  • April 2016 of 71 [MEDICATION NAME] and [MEDICATION NAME] injections administered, the injection site was not rotated on 11 occasions.
  • of 71 [MEDICATION NAME] and [MEDICATION NAME] injections administered, the injection site was not identified on 1 occasion.
  • on 1 occasion, [MEDICATION NAME] 44 units was not administered per physician’s order and on 3 occasions, sliding scale dosage of [MEDICATION NAME] was not administered per physician’s order.
  • May 2016 – of 69 [MEDICATION NAME] and [MEDICATION NAME] injections administered, the injection site was not rotated on 12 occasions.
  • of 69 [MEDICATION NAME] and [MEDICATION NAME] injections, the injection site was not identified on 5 occasions.
  • on 4 occasions, sliding scale dosage of [MEDICATION NAME] was not administered per physician’s order. June 2016
  • of 65 [MEDICATION NAME] and [MEDICATION NAME] injections administered, the injection site was not rotated on 15 occasions.
  • of 65 [MEDICATION NAME] and [MEDICATION NAME] injections administered, injection sites were not identified on 5 occasions.
  • on 11 occasions, sliding scale dosage of [MEDICATION NAME] was not administered per physician’s order. July 2016
  • of 74 [MEDICATION NAME] and [MEDICATION NAME] injections administered, the injection site was not rotated on 18 occasions.
  • of 74 [MEDICATION NAME] and [MEDICATION NAME] injections administered, injection sites were not identified on 4 occasions.
  • on 6 occasions, sliding scale dosage of [MEDICATION NAME] was not administered per physician’s order.
  • August 2016 – of 80 [MEDICATION NAME] and [MEDICATION NAME] injections administered, the injection site was not rotated on 17 occasions.
  • of 80 [MEDICATION NAME] and [MEDICATION NAME] injections administered, injection sites were not identified on 6 occasions.
  • on 6 occasions, sliding scale dosage of [MEDICATION NAME] was not administered per physician’s order.

Further review of the medical record failed to identify the above noted sites of injections and failed to indicate that the insulin administration omissions on the diabetic monitoring flowsheets were actually administered.

During interview with Unit Manager #1 on 9/8/16 at 10:15 A.M., she said that injections should have been administered per physician’s order, and injection sites should have been documented and rotated.

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 interview, the facility failed to implement physician’s orders and the medical plan of care 2 Residents (#1 and #15) in a total sample of 23.

Findings include:

1. For Resident #15, the facility failed to ensure that bilateral heel protector boots were applied to the Resident’s feet while in bed as ordered by the physician. Resident #15 was admitted to the facility in 2/2010 with [DIAGNOSES REDACTED]. The medical record was reviewed on 9/13/16 and 9/14/16. Review of the 9/2016 physician’s orders indicated that Resident #15 was to have bilateral heel protector boots applied to his/her feet at all times while in bed. This order was initiated on 3/16/16.

Review of the 5/ 2016 through 9/14/16 treatment administration record (TAR) indicated that the boots were applied as noted by staff initials in a box for each day of the month. The Resident was observed lying in bed on 9/14/16 at 8:00 A.M. without bilateral heel protector boots applied to his/her feet.

During interview with staff nurse #1 on 9/14/16 at 11:00 A.M., the Surveyor alerted her that Resident #15 was not wearing bilateral heel protector booties per physician’s orders and as documented on the TAR. She said that the Resident does not wear booties. CNA #1 was interviewed on 9/14/16 at 11:20 A.M. She said that she has taken care of the Resident for a long time, works the 7 – 3 shift and assists Resident #15 with personal care in the morning. CNA #1 said that she has never seen booties on Resident #15 feet when she has gotten him/her out of bed in the morning.

2. For Resident #1, the facility failed to ensure Vitamin D was administered per the physician’s orders. Resident #1 was admitted to the facility in 11/2007 with [DIAGNOSES REDACTED]. Clinical record review indicated a physician’s order for Vitamin D2 50,000 units one tablet by mouth monthly on the 18 th. Further Clinical record review indicated that Resident was not administered the Vitamin D2 50,000 units on 7/18/16. On 9/13/16 at 11:00 A.M. the DON said that the facility failed to ensure the Vitamin D was administered per the physician’s orders.

Failed to make sure that residents receive proper treatment and assistive devices to maintain their vision and hearing.

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

Based on record review and interviews, the facility failed to obtain appropriate services for vision problems, after the Resident had reported problems with his/her vision and several consultants made recommendations to have the vision issues addressed, for 1 resident (#8) out of a total sample of 23 residents.

Findings include:

Resident #8 was admitted to the facility in 9/2014 and had [DIAGNOSES REDACTED]. The most recent MDS dated [DATE], indicated the Resident scored a 15 out 15 on his BIMS, had no difficulties communicating his/her needs or understanding. The MDS indicated the Resident required extensive assistance in activities of daily living and his/her hearing and vision was adequate.

Record review indicated that the current physician order’s included a generic order for eye services. The Resident had agreed to be seen regularly by the facility’s consulting eye service (upon admission) and according to facility policy eye services was considered a standing physician order.

On 10/29/15, the record indicated the Resident was evaluated by the facility’s psychiatric consultant. During the assessment, the Resident reported that he/she had decreased his/her participation in Bingo from 3 times per week to one time and had stated he/she can no longer read well because of her eyes (needing glasses the Resident thought). The consultant included in her recommendations that the Resident be assessed for trouble with his/her vision.

Although, the review of the medical record failed to indicate that staff addressed the recommendation at the time of the consult (10/29/15), the Resident was evaluated by the consulting eye service two and half months later on 1/14/16.

The 1/14/16 eye assessment indicated the Resident’s vision indicated that there was a strongly suspected evidence of [MEDICAL CONDITION] (with vision loss) and recommended the Resident be evaluated by an ophthalmologist as soon as possible. Record review failed to indicate that the facility staff arranged for the Resident to be assessed for [MEDICAL CONDITION].

On 5/19/16, the consulting eye clinician re-evaluated the Resident and indicated that [MEDICAL CONDITION] was still suspected and that the Resident be evaluated. Further review of the medical record failed to find evidence that the facility staff ensured the service for additional eye service was provided.

During interview on 9/13/16 at 9:00 A.M., Nurse #3 said she was unaware of the recommendations. She looked in the facility’s calendar for an appointment, but was unable to determine if the Resident was provided the eye service.

Failed to give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.

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

Based on record review, interviews and observation, the facility failed to ensure that effective treatments were implemented to prevent and promote the healing of a facility acquired pressure ulcer for 1 (#7) resident, out of a total sample of 23 residents.

Findings include:

Resident #7 was admitted in 4/2015 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 7/8/16, indicated the Resident scored an 11 out of 15 on the BIMS (Brief Interview for Mental Status) and required extensive assistance in his/her activities of daily living. The MDS indicated the Resident had one unstageable pressure ulcer and significant weight loss. The MDS indicated that pressure reducing devices were implemented when the Resident was in bed and in the wheelchair.

Record review indicated the Facility had identified Resident #7 at risk for the development of pressure ulcers and on 3/9/16 had developed a facility acquired right heel pressure ulcer.

The Resident was followed weekly by the Facility’s designated wound nurse (Assistant Director of Nurses/ADON). The assessment evaluated the condition of the wound. The assessment documented the size, coloring and other descriptions. The assessments included an area that outline preventative pressure redistribution devices, but this part of the assessment had not been completed.

A care plan, developed on 4/22/16 and updated on 7/26/16, identified the right heel pressure ulcer. The care plan was standardized and required the staff to check boxes that were considered appropriate to described the problems, goals and interventions. *For contributing factors that placed the resident at risk for pressure ulcers, the boxes checked were pressure, diabetes and non compliance.

*The boxes checked for the Resident goals were promote wound healing, prevent infection and prevent additional wounds.

*The interventions checked were treatments as ordered, monitor vital signs, dietician consult PRN (as needed), monitor meal consumption, administer dietary supplements as ordered, monitor labs as ordered, standard precautions, float heels (on all times while in bed) and monitor daily.

Review of the 7/2016, 8/2016 and 9/2016, physician orders [REDACTED].

On 9/6/16, the weekly skin assessment indicated the right heel was unstageable, 1.2 cm by 1.5 cm and had a necrotic scab covering the area. Previous weekly skin assessments dated 7/19/16, 7/26/16, 8/2/16. 8/9/16, 8/16/16, 8/23/16 and 8/30/16 indicated the wound bed was generally dry and the tissue was dark and flakey. The length of the right heel pressure ulcer varied (up and down) from 1.8 -1.0 centimeters and the width from 2.0 – 1.1 cm. During the initial tour of the facility on 9/6/16 at approximately 9:30 A.M., the ADON said the Resident had a right foot pressure ulcer. The ADON said the area was necrotic, that it had been acquired at the facility and that there was no current treatment. She said the area was left open to the air. The Surveyor observed the Resident in bed. The bed was flat and the Resident was asleep on his/her right side. The Resident was covered with a sheet and the right foot was exposed. The Resident was wearing a non-skid slipper sock and the foot and heel were in contact with the mattress. Although, the mattress was a standardized low air pressure relieving mattress, the heel was not off-loaded. Resident #7 was observed in bed on 9/7/16 at 7:10 A.M. and on 9/8/16 at 8:30 A.M. and both observations revealed the Resident’s right heel was not off-loaded and there was no pillow in the bed.

On 9/8/16 at approximately 11:00 A.M., Resident #7 was observed in his/her wheelchair. The wheelchair had no foot rest and the Resident had a non-skid sock on his/her right foot. Observation indicated the Resident used the right foot to mobilize him/herself forward. There was no pressure reducing device evident in the wheelchair.

On 9/9/16 at 12:30 P.M., the Resident was mobilizing around the unit. Surveyor #1 approached the Resident for an interview. The Resident was agreeable to the interview and mobilized him/herself back to the room by using the right foot. The Resident’s bed was made and covered with a sheet. Surveyor #1 inquired about the right heel and the Resident said there was a wound. The Resident said it was painful sometimes and that the staff were watching it. The Surveyor asked if there was a treatment and he/she said just the sock. The Surveyor inquired if he/she had any protective/preventative treatment (i.e. booty, pillows etc), and the Resident said no.

In addition, during review of the medical record, the dietician had recommended a nutritional supplement to support the healing of the pressure ulcer (and weight loss). On 6/11/16, the physician order [REDACTED]. Record review indicated that the Facility staff provided the Boost supplement through the end of 7/2016. The Medication Administration Record [REDACTED]. However, record review failed to find a physician’s orders [REDACTED]. During interview on 9/9/16 at 12:50 P.M., Nurse #4 said the supplement had not been discontinued and would notify the physician. Nurse #4 was asked about the Resident’s heel and she said the Certified Nursing Assistants applied a protected cream and that the wound nurse (ADON) looks at the heel weekly. She said she did not work on the floor a lot and thought it (the heel) was doing better.

On 9/9/16 at approximately 2:00 P.M., the ADON was asked about the weekly skin checks and the facility’s process of ensuring that effective treatments were in place to promote and prevent pressure ulcers. The ADON said she did weekly documentation of the pressure ulcers. She said she expected the staff nurses to observe the area and notify the physician to report changes. She said that she did not update the care plans or implement changes or assess for the effectiveness of the treatment.

On 9/12/16 and 9/13/16 during brief observations during the days, there was no change in what was previously observed. The resident was either in bed without his/her heel offloaded or mobilizing without devices to prevent pressure.

On 9/14/16 at 10:20 A.M., Surveyor #2 interviewed the Resident and observed the right heel, which was dry, intact with a necrotic center (approximately 1 cm by 1 cm), There was no off-loading of the heel, a pillow on the bed that did not effectively relieve the pressure on the heel.

Surveyor #2 discussed the Resident’s heel with the ADON following her observation on 9/14/16. The ADON said that she had spoken to Surveyor #1 and had provided copies of the assessments. She said the facility followed physician orders [REDACTED].

Failed to give the right treatment and services to residents who have mental or psychosocial problems adjusting.

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

Based on observations, staff interviews and record review the facility failed for 1 resident (#7) out of total sample of 23 residents, to ensure that they consistently provided effective psychosocial interventions as recommended by the consulting psychiatric services to ensure the Resident was able to effectively cope with multiple losses, depression and anxiety, which resulted in additional symptoms of depression that could have been potentially avoided.

Findings include:

Resident #7 was admitted to the facility in ,[DATE] with [DIAGNOSES REDACTED]. Review of the most recent Quarterly Minimum Data Set (MDS) assessment, dated [DATE], indicated the Resident scored an 11 out of 15 on the BIMS (Brief Interview for Mental Status) and exhibited some verbal outburst. The MDS indicated he/she required extensive assistance in his/her activities of daily living. The Health Care Proxy (HCP) was not invoked.

Review of the social service history indicated the Resident had initially been admitted in ,[DATE] for short term placement due to a history of multiple falls. Shortly, after admission a psychiatric assessment was ordered for behavioral issues ([DATE]). The initial assessment indicated the Resident had attention seeking behaviors, yelling for no particular reason and could be very agitated, verbally inappropriate with others and physically aggression. At the time of the assessment, the Resident had indicated he/she yelled out because he/she was in pain and was depressed. The Resident told the psychiatric consultant he/she had many losses (son died at age 11, [MEDICAL CONDITION], loss of brother (associated with a murder) and mother, loss of limb, etc). The assessment indicated the Resident was difficult to redirect and recommended medications to stabilize his/her mood.

Further review indicated that from [DATE] through [DATE], the Resident was monitored by the psychiatric consultant for medication management. A standardized care plan had been implemented to address the Resident’s behaviors, but not his/her depression and anxiety. The care plan identified the Resident as having outbursts and combative with care. The goal was for medication, minimize outbursts and to become social with others. The interventions were medications, discuss procedures when caring for resident, psychiatry services, encourage finishing tasks, use behavior monitoring sheets to document behaviors and determine the effectiveness of the interventions and do not corner if agitated. In addition, the staff were to report changes to the physician. The last update was [DATE]. Record review indicated that a new psychiatric service was contracted (changed) in ,[DATE] and the Resident was re-assessed by the new service.

Review of the assessments made by the psychiatric services from ,[DATE] through [DATE] indicated that many of their recommendations, services and treatments were not addressed accordingly. The following indicated that the facility staff failed to ensure that the assessments and recommendations were implemented to ensure the Resident could effectively cope with adjustment difficulties, life losses, depression and anxiety. The following described the multiple failures that occurred by the facility staff, which prevented the Resident from receiving effective services and treatment.

The psychiatric assessment dated [DATE] indicated the Resident was depressed and anxious. The assessment noted the difficulty the Resident had in his/her ability to effectively cope with his/her significant past losses and current losses and changes (including placement in the facility). The psychiatric plan was to address the Resident mood and anxiety, with psychiatric counseling (which would included 1 to 1 psychotherapy and psychopharmacology).

The Resident’s plan of care was not altered, it remained standardized (staff checked boxes off a pre-printed form).

The Resident received 1 to 1 psychotherapy monthly ([DATE] through [DATE]) for [MEDICAL CONDITION]. The progress notes indicated the Resident was responding well and expressing his/her difficulties with depression and ineffective coping (exhibited by [MEDICAL CONDITION]). The therapist provided the Resident with support, encouragement and counseling to decrease the Resident’s depression, sense of loss and anxiety. The therapist noted that the Resident felt hopeful and encouraged the Resident to focus on his/her hope and to not focus on self defeating thoughts. The facility plan of care did not specifically include 1 to 1 psychotherapy, and the 1 to 1 therapy stopped on [DATE], without evidence of termination and with documented evidence that it should continue. The facility interdisciplinary notes were generic and only associated the treatment outlined in the psychiatric evaluations as psych services. There was no integration of the service into the facility’s plan of care for the Resident who had significant depression and losses.

In addition, the psychiatric services provided monthly psycho-pharmacology assessments. The consultant assessments were thorough and contained non-pharmacology recommendations and medication recommendations. The record indicated that facility staff were not consistent in ensuring the recommendations were addressed with the physician; that the facility staff and/or the physician documented supporting evidence of the decision to accept or reject the recommendation; and the facility staff failed implement the services, as in accordance with the treatment outlined.

As of [DATE], the Resident’s [MEDICAL CONDITION] medications included the antidepressants, [MEDICATION NAME] 100 mg daily, [MEDICATION NAME] 50 mg daily and 25 mg, PRN (as needed), Zyprexia (antipsychotic) 10 mg daily and 2.5 mg, PRN, and [MEDICATION NAME] (anticonvulsant also used for mood stabilization) 250 mg, twice daily.

Record review indicated that the Resident psychiatric assessments, beginning on [DATE], indicated that medication changes were recommended, by the consulting services, based on a safer medication profile. The assessment indicated the Resident did not have [MEDICAL CONDITION] and suffered from depression and [MEDICAL CONDITION]. On [DATE], the pharmacology assessment to decrease the the scheduled antipsychotic Zyprexia from 10 mg to 7.5 mg and increase the antidepressant [MEDICATION NAME] from 50 mg to 75 mg was accepted by the physician.

On [DATE], the pharmacology note recommended to increase the [MEDICATION NAME] from 75 mg to 100 mg and to decrease the antipsychotic medications from 7.5 mg to 5 mg . The assessment outlined the bases for the recommendations (which included the Resident had no signs of [MEDICAL CONDITION], but did have symptoms of [MEDICAL CONDITION] and depression) and to continue with 1 to 1 psychotherapy. The medications were not changed and there was no evidence the physician had been made aware of the recommendations.

On [DATE], the Social worker’s progress note indicated the the facility staff met with the Resident and family. The Resident, who had been admitted for short term and had worried about his/her discharge back to home, was informed that he/she would not be discharged home, would remain long term and the Resident’s home would be relinquished. The social worker indicated the facility provided education on financial responsibilities surrounding long term care to the Resident and family. (The 1 to 1 therapist had noted on [DATE], that the Resident was anxious about returning home and that depending on plan and would require support.)

On [DATE], psychiatric services re-recommended the physician to consider medications changes as follows: Recommended to taper the scheduled antipsychotic and discontinue the PRN. The consultant outline the plan including recommendations to increase the antidepressant [MEDICATION NAME] or [MEDICATION NAME], and to utilize the PRN [MEDICATION NAME] if agitation occurs. At the time of the assessment the Resident was alert and oriented, had no racing thoughts and presented stable. The consulted asked the staff to report the recommendations to the physician and document his response.

The facility staff faxed the recommendations to the physician on [DATE] and [DATE], however there was no evidence of a physician response or that the facility staff followed up with the physician. The recommendations were not acted upon. On [DATE], the psychiatric consultant reassessed the Resident and noted that there was no response from the physician for the recommendations dated [DATE]. The consultant re-outlined her recommendations and requested the Director of Nurse (DON) to schedule psychiatric rounds when the physician was available.

Subsequently to the [DATE] note, the physician tapered the Resident off the scheduled dose of the antipsychotic medication Zyprexia. The PRN Zyprexia was not discontinued until a followup assessment on [DATE] (psych services) and the 2 antidepressant medications and the mood stabilizer were not changed. The [DATE] and [DATE] follow-up psychopharmacology notes indicated the Resident was found in bed (during both visits), did not want to answer questions and was frustrated (wanting to go home). There was no evidence that the Resident was receiving 1 to 1 psychotherapy or that the facility Social Worker had been available to support the effects of the change from short term to long term placement adjustment issues.

Record review indicated that a quarterly note was written by the social worker on [DATE]. The note indicated that the Resident was long term and was followed by the psychiatric service.

On [DATE], the psych service indicated there were medical changes in the Resident, but recommended to discontinue the antidepressant [MEDICATION NAME] (as on 2 antidepressant and could cause serotoni[DIAGNOSES REDACTED]). Although, there was no physician note, the assessment had an undated notation declining the recommendations. The note had initials next to it, but it could not be determined whose initials they were. The psychiatric consult re-evaluated the Resident on [DATE] and noted the Resident reported he/she was depressed and felt sick to stomach and was having increased periods that he/she yelled out for help. The recommendations included an increase of the antidepressant [MEDICATION NAME] from 100 mg to 125 mg and 1 to 1 psychotherapy. Record review failed to find evidence that the physician was appraised of the recommendations. The [MEDICATION NAME] was not increased and 1 to 1 psychotherapy was not provided.

On [DATE], the social worker’s note indicated the Resident wanted to go home and requested to speak with family. There was no follow-up note. On [DATE], the Resident was assessed by the psychiatric service for group therapy. The assessment indicated the Resident would participate in group therapy 2 to 4 times per month for 90 minute sessions. Record review failed to indicate how it had been determined that the Resident’s required group therapy (as all the recommendations had indicated to continue with 1 to 1 psychotherapy). The group therapy was not included in the physician’s plan of care or mention in the psychiatry or social worker’s notes.

On [DATE], the Resident was hospitalized for [REDACTED].

On readmission, on [DATE], the psychiatric consultant assessed the resident and indicated the Resident was tired and depressed. The recommendations were to monitor, and see if when the Resident’s medical conditions resolves that his/her mental status may resolve too. Although, the psychiatric’s note made no mention that the PRN [MEDICATION NAME] had not been included on the readmission orders [REDACTED]. The note indicated that the physician agreed with the recommendation and that they contacted the wrong HCP (Health Care Agent/Proxy) for consent. The note indicated the nursing staff would correct the mistake, however, the record indicated that the HCP had not been invoked. On [DATE], a telephone order was obtained to clarify the order for [MEDICATION NAME] (25 mg every 6 hours for agitation/PRN).

On [DATE], a telephone order was obtained to start the anti-depressant [MEDICATION NAME] 7.5 mg daily. Other than the telephone order, there was no corresponding documentation indicating the targeted need for the third antidepressant medication. On [DATE], the Social Worker’s progress note indicated the Resident’s behaviors included yelling out/screaming to get attention and verbal abuse. The note indicated that the consulting psychiatric service was addressing the psychoactive medication and anxiety issues. The note indicated the Resident continues to want to go home and is unhappy at facility (poor adjustment to long term care). The Social Worker indicated a competency evaluation to determine the Resident’s ability to make medical decision was pending and that counseling services was recommended.

On [DATE], the psychiatric consultant recommended to discontinue the scheduled [MEDICATION NAME] (100 mg); increase the PRN [MEDICATION NAME] from 25 mg to 50 mg; increase the [MEDICATION NAME] from 100 mg to 150 mg; and recommend to continue with one to one psychotherapy. The assessment identified that the Resident yells out when he/she does not feel well and therefore staff were encouraged to offer support, distraction and assess for pain and discomfort.

There was no evidence the facility staff shared the information with the physician so he could make an informed decision. However, the nurse’s note dated [DATE] indicated that the nurse contacted the HCP agent and left a message. On [DATE], the nurse’s note indicated that the writer was informed that the HCP agent had called back, but that she (the nurse) was unable to speak with her, and therefore left a second message. Further review of record, found no indication that the facility staff addressed the psychiatric’s recommendation with the physician. The record indicated that the HCP was not invoked at this time.

The nurse’s notes form [DATE] through [DATE], indicated the Resident was anxious, depressed and exhibited episodes of verbal abuse and calling out. The Resident’s blood sugars were not controlled and the Resident complained of non specific ailments. On [DATE], the psychiatric consultant assessed the Resident and indicated the Resident mental status varied throughout the day, had uncontrolled blood sugars, makes complaints of not feeling well (with non-specific symptoms), depressed and over sedated. The re-recommendations were to discontinued the [MEDICATION NAME] 100 mg at night, increase the PRN [MEDICATION NAME] from 25 mg to 50 mg, to increase the [MEDICATION NAME] from 100 mg to 150 mg and to invoke the Health Care Proxy.

Record review indicated that on [DATE], the Resident was sent and returned to/from the hospital due to high blood sugars. There was no evidence that the psychiatric recommendations were addressed with the physician. From [DATE] through [DATE], the Resident medical and emotional status declined. The Resident yelled out, was verbally abusive towards others, spent increased time in bed, was sad, anxious and depressed. The HCP was not invoked and the Resident did not receive 1 to 1 psychotherapy.

However, the record indicated that Resident #7 participate in 8 sessions of group therapy. It was unclear how effective the group treatment was. On [DATE], the facility staff informed Resident’s #7 family of a significant weight loss and during the discussion informed the facility that the Resident would be relocated. The nurse’s note indicated that they informed the physician and that he requested psychiatric services to evaluate the resident.

On [DATE], the psychiatric consultant indicated the Resident continued to exhibited attention seeking behaviors. The Resident indicated he/she does not want to be in the facility and cries out. The recommendations was to discontinue the [MEDICATION NAME] as the Resident receives [MEDICATION NAME] and both have similar effects (used for sleep and sedating) and places the Resident at risk for adverse affects. The note indicated the Resident was easily redirected and soothed when provided attention.

On [DATE], the nursing staff documented that the physician was informed of the [DATE] recommendations, but that he was not in agreement due to the ongoing behaviors. The nurse’s note indicated that the Resident called out on and off throughout the day, frequently sleeping and did not utilize the PRN [MEDICATION NAME] due to sedation. The subsequent notes indicated the Resident mental status varied and remained depressed. Discharge planning (a goal the Resident had been holding onto since admission in ,[DATE]) was minimal addressed by the Social Worker on [DATE].

During the initial tour on [DATE] at approximately 9:30 A.M., the Resident was observed in bed and appeared asleep. The ADON (Assistant Director of Nurses) said the Resident was alert and oriented, had behaviors of yelling out, stayed in bed and did not participate in many activities and planned to be discharged . The ADON did not what services the Resident received or when the discharge was planned for. Multiple observations were made of Resident #7 in bed on [DATE] at 7:10 A.M. and [DATE] at 8:30 A.M. Resident #7 was observed in wheelchair on [DATE] at approximately 11:00 A.M. and [DATE] at 12:30 P.M., mobilizing around the unit. Surveyor #1 approached the Resident for an interview. The Resident was agreeable to the interview and stated he/she was tired and wanted to go back to bed. The Resident said that he/she was not interested in activities. Resident said that he/she wanted to leave the facility but was unaware when that might be. The Resident said that he/she did not know the social worker and was unaware of any support services that addressed his/her problems. The Resident engaged and shared his/her multiple losses and stress. The Resident said he/she tried but felt un-motivated.

On [DATE] at 10:20 A.M., the consulting psychiatric practitioner was interviewed. She said that there were a number of problems with communication between the facility staff, the physician and the facility’s staff follow through. She said she was unaware that the Resident had not received 1 to 1 services since [DATE] and was not sure how the group therapy services were implemented. The consultant said that due to the number of problems that she had asked the Director of Nurses to schedule a meeting with the Medical Director, but that the meeting had not been scheduled.

During interview with the Medical Director on [DATE] at 2:45 P.M., the Surveyor asked about the recommendations that had been made by the consulting psychiatric service and the lack of evidence that he had been notified and that treatment was being implemented. He said that he did not have confidence in the psychiatric service and did not pay attention to their recommendations. The Medical Director said that communication between the facility staff and he was poor. He said that he frequently calls the facility to respond to a page and is unable. He said staff either do not answer the phone or he cannot connect with the right staff. He said that unless they bring it to his attention during his onsite visit he does not look for the recommendations. The Surveyor asked if he felt that the service was ineffective why did he order the consults. The Medical Director made no comment.

During interview with the Director of Social Services (DSS) on [DATE] at 9:50 A.M. she stated that it is the role of Social Services to oversee the care provided by the other services (psychiatric). The DSS was asked if she were aware of the types of services being provided to Resident #7 (medication, group or 1 to 1 psychotherapy) and how the facility ensured that services provided were integrity and subsequently implemented into the Resident’s plan of care. The DSS initial said that she would have to review the Resident’s record to provide information, but than added that the behavior meetings were held weekly with the consulting staff (psych). She said that the nursing staff were responsible for following up with the recommendations made by the consultant because it would require the physician and family consent. She said she could not explain why there was no 1 to 1 psychotherapy or how the group therapy worked. The DSS re-stated that her main job was to oversee things (hands off) and direct, but then could not explain why she did not know that multiple recommendations, services and treatments were not being provided. The facility relied on consulting services to to identify the mental and psychosocial functional needs of Resident #7, but failed to act upon the recommendations and provide the services and treatment to ensure the Resident psychosocial emotional difficulties would be addressed.

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 incident report review, record review, observations and staff interview, the facility failed to ensure the Resident’s environment was free from accidents and hazards and failed to provide adequate supervision and effective interventions to prevent 1 Resident (#15) with a history of wandering and ingesting non-food items from drinking soap on 2 occasions out of a total sample of 23 Residents.

Findings include:

For Resident #15 the facility failed to provide adequate supervision and effective interventions to prevent Resident #15 who has a history of wandering and ingesting non-food items from drinking soap on 2 occasions.

Resident #15 was admitted to the facility in 2/2010 with [DIAGNOSES REDACTED]. Review of the most recent quarterly Minimum Data Set (MDS) with a reference date of 6/20/16, indicated that Resident #15 had severe cognitive impairment as evidenced by a score of 0 out of 15 on the Brief Interview of Mental Status (BIMS), exhibited behaviors and was dependent on staff for all activities of daily living.

The medical record was reviewed on 9/13/16. During interview with Resident #15’s physician on 9/13/16 at 8:20 A.M., she said the Resident had advanced dementia, was very intrusive, wandered into others rooms and had behaviors of exposing his/her body in public areas. The physician also said that a few months prior, Resident #15 drank a bottle of soap.

Review of nursing progress notes indicated that Resident #15 consumed a non-food item (Peri-Wash solution, bottled personal cleanser) which the Resident found in his/her bedside drawer on 1/13/16.

Review of the care plan for behaviors and cognitive loss, initiated on 3/4/14, identified that Resident #15 exhibited intrusive behavior, wandered and entered others rooms. The care plan was not updated to include the Resident’s behavior of drinking Peri-Wash on 1/13/16 and failed to include interventions to prevent this behavior from recurring. Review of nursing progress notes indicated that on 2/15/16, Resident #15, again, drank a non-food item (dermavera body soap).

Review of the care plan for behaviors and cognitive loss, identified that Resident #15 ingested non-food items on 2/15/16 and added an intervention to keep all toiletries out of Resident’s reach.

Further review of nursing progress notes indicated that on 8/27/16, Resident #15’s son alerted staff that he found creams and shower lotion in the Resident’s closet. Surveyors #1 and #2 tour unit 1 Main on 9/13/16 at 12:20 P.M. and the following non-food items were found accessible on bureaus and bedside tables:

  • Resident #15’s unlocked bedside table drawer contained a bottle of Peri-Wash cleanser (the same soap the Resident drank on 1/13/16) and antiperspirant
  • 101 C: 3 tubes of prescription topical ointments(santyl, triamcinolone acetonide, silver sufadiazine)
  • 102 A: Johnson & Johnson Baby Wash, body lotion, Eucerin, antibacterial wipes.
  • 102 B: Baby wipes
  • 102 C: Hydocerin, Aquaphor, Mentholatum Ointment, Aloevesta skin conditioner
  • 106 C: 2 bottles of dry shampoo
  • 107 D: prescription eye drops, artificial tears, Listerine mouthwash, pepto bismol, hand sanitizer and several bottles of lotion
  • 108 B: baby powder
  • 111 C: prescription bottle containing 60 tablets of Wellbutrin, bottles of shampoo and body wash, shaving cream
  • 112 A: bottle of Peri-Wash cleanser
  • 114 C: body wash, shampoo -115 A: body lotion
  • 116 C: body lotion
  • The clean utility room was found unlocked with the following non-food items accessible:
  • -Peri-Wash cleanser
  • -shampoo
  • -body lotion
  • -razors

The facility failed to implement effective interventions to ensure that Resident #15 did not have access to non-food items and drink soap. 2. During general observations, the facility failed to ensure the Resident’s environment was free from accident/hazards.

The following observations were made of the treatment carts (Tx carts) on 2 of the 4 Units:

  • Treatment carts contain numerous Resident specific prescribed topical creams and lotions, dressing supplies, etc. for treatments ordered by the physician.
  • On 9/7/16 at 7:15 A.M. the first (1 Main) floor treatment (tx) cart was observed unlocked. The Tx cart was located in the hallway with no staff near or in the approximate area near the Tx cart. The Surveyor notified the MDS Nurse
  • On 9/9/16 at 1:30 P.M. until 2:05 P.M. the 2 North’s Tx cart was observed unlocked. The Tx cart was located in the hallway, with no staff in the immediate area The Surveyor notified the nursing staff.
  • On 9/12/16 at 7:00 A.M. the 1 Main’s Tx cart was observed un locked. Staff was noted to be sitting at the nursing station, Tx cart not in view. The Surveyor notified the nursing staff
  • On 9/13/16 at 1:30 P.M. the 2 Main’s Tx cart was observed unlock. It was again located in the hallway. Surveyor observed the Tx cart remaining unlocked for one hour, then notified the nursing staff. In addition, other environmental hazards that could cause possible harm to Residents, were observed as follows:
  • On 9/7/16 at 1:45 P.M., the 1 Main clean utility room was unlocked. The unlocked cabinets within room contained Peri-wash cleanser, shampoo, body lotion, mouth wash, soaps and razors.

On 9/13/16 at 11:10 A.M., the 2 Main clean utility room was unlocked. The unlocked cabinets within room contained Peri-wash cleanser, shampoo, body lotion, mouth wash, soaps and razors

On 9/14/16 at 12:30 P.M., shampoo, body lotion and hygiene products were observed in the hallway on top of the linen cart on the 2 Main unit.

Observations of the hazards were brought to the attention of the facility staff at the time of the observation, the pattern during the survey indicated that the staff failed to ensure the environment was free of accident/hazards.

Failed to make sure that each resident gets a nutritional and well balanced diet, unless it is not possible to do so.

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

Based on record review, observation, resident and staff interviews, the facility failed to adequately monitor weight loss, and failed to consistently provide scheduled and effective interventions to prevent further weight loss (of 14.9 % in 90 days) and stabilize weights for 1 (#7) resident, out of a total sample of 23 residents.

Findings include:

Resident #7 was admitted in 4/2015 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 7/8/16, indicated the Resident scored an 11 out of 15 on the BIMS (Brief Interview for Mental Status) and required extensive assistance in his/her activities of daily living and was capable of eating independently. The MDS indicated the Resident had one pressure ulcer and significant weight loss (not prescribed). The MDS indicated that he/she received a therapeutic diet, was 63 inches tall and weighed 136 lbs (pounds), a decrease of 14 lbs (150 lbs) since the previous MDS completed on 4/11/16.

During record review on 9/8/16, the dietary orders included a carbohydrate controlled diet (used to regulate blood glucose levels) and monthly weights. Review of the weight record indicated the Resident showed a weight shift on 6/3/16. The Resident’s weight decreased from 149.5 lbs to 132.8 lbs The nursing staff re-weighed the Resident on 6/3/16 and documented a second weight of 133.2 lbs.

The Dietician assessed the Resident on 6/11/16 and documented that although the Resident’s intake varied, and the Resident had some changes in his/her condition, she assessed that when comparing the facts she questioned the weight loss of 12 % of the Resident overall weight in less than 30 days. The dietician requested the Resident be re-weighed, to add the nutritional supplement Boost, three times per day and weekly weights. The Dietician documented that the Resident consumed 30 to 90 % of each meal.

Record review indicated that the nutritional supplement was ordered by the physician and the nursing staff documented it was provided three times per day from 6/11/16 through 7/31/16.

Following the Dietician’s assessment and recommendations on 6/11/16, the nutritional supplements were ordered by the physician, but there was no indication that weekly weights were ordered or that the staff obtained any subsequent weights. The Dietician’s follow-up note dated 7/1/16, indicated at the time of the assessment the Resident was feeling poorly and was hospitalized , after complaining of stomach pain. On 7/8/16, the physician ordered [MEDICATION NAME] 7.5 mg daily.

On 7/11/16, the Dietician reassessed the Resident. The Dietician indicated the hospitalization (from 7/1/16 through 7/5/16) had been for elevated blood sugars and [DIAGNOSES REDACTED]. The assessment indicated that during her observation the Resident ate poorly and would only take a drink from her. The Resident stated he/she just wanted to sleep. The Dietician indicated that she recommended the physician request a psychiatric consultant for an appetite stimulant, to liberalize the diet due to poor intake (discontinuing the carbohydrate controlled diet) and to continue with the nutritional supplement Boost, three times daily. The Dietician noted the hospital summary’s discharge noted the Resident’s weight was 135.5 lbs on 7/5/16. Record review indicated that no weights were obtained by the facility on his/her readmission, therefore making no current weights available for Dietician’s assessment.

The orders for the nutritional supplements were continued for 7/2016 and the order to change the diet was obtained.

The psychiatric consult assessed the Resident on 7/5/16 and 7/13/16, the assessments made no mention of weight loss and focused on the Residents [MEDICAL CONDITION]. Further review indicated that the 8/2016 MARs did not include the consistently include the nutritional supplement (Boost) and the diet was changed back to the carbohydrate controlled diet (not a liberalized diet). The only weight obtained for the Resident since 6/3/16 was on 8/4/16 (a monthly weight). The weight was 127.3 lbs, a weight loss of an additionally 5.9 lbs since 6/3/16 or 14.9 % loss in 90 days.

The physician progress notes [REDACTED]. He indicated the Resident’s poor intake was causing poorly controlled/unstable blood sugars (making no mention of weight loss). The physician documented that .the resident will eat anything he/she desires, noncompliance due to dementia and sneaks sweets.

On 8/16/16, the Dietician assessed the Resident and identified that the Resident had a significant weight loss of 14.9 % in 90 days and 13.6 % in 180 days. The weights were 127.3 lbs (8/16/16), 149.5 lbs (5/16/16) and 147.4 (2/16/16). She indicated the Resident had a liberalized diet, nutritional supplements and psychiatric support. She said that she was aware of the physician and staff reporting of the Resident sneaking sweets, however when she went to the Resident’s rooms no snacks/sweets or foods were found. The Dietician indicated that the MD be notified of significant weight loss. Review of the nurse’s note, dated 8/16/16, indicated the physician was notified of the significant weight loss and ordered psychiatric services to address the weight loss and decreased motivation.

On 8/19/16, the psychiatric consultant assessed the Resident and indicated that the consult was for behaviors. The assessment did not address weight loss. The assessment indicated the Resident’s behavior was attention seeking and depression as he/she wants to go home. The consultant recommended discontinuing one of the 2 anti-depressants being used for sleep ([MEDICATION NAME] and [MEDICATION NAME]). The consultant indicated that they have an adverse effect when administered together and no need for 2 sleeping medications. Record review failed to indicate if the physician was notified of the recommendation, as no change was made to the Resident’s medication regimen.

Further review indicated that from 8/19/16 through the end of survey, the Resident was not provided with a liberalized diet, weights were not obtained and the nutritional supplements were discontinued. The nursing staff made reference about poor and varied meal consumption, (i.e. refused breakfast or lunch), but there was no evidence the staff monitored the Resident’s weight loss, nutritional intake (including meals, snacks, etc) and made an effort to try alternative interventions to promote further loss of weight and to stabilize the Resident’s weight.

On 9/5/16, the Dietician’s progress note indicated the Resident’s weight was continuing to trend down and documented a weight of 126.8 lbs. On 9/9/16 at 12:30 P.M., the Resident was interviewed in his/her room. The Resident was asked about food and responded that he/she did not like the facility food. The Resident said that he/she did not have any snacks in room and enjoyed going out for meals with family. Observation of room showed no snacks.

During interview on 9/9/16 at 12:50 P.M., Nurse #4 was unaware that the nutritional supplement was discontinued. She said that she did not work consistently on the Unit, but did offer the Resident the supplement when she worked. Nurse #4 checked the orders and said that she would contact the physician, as the orders indicated it had been discontinued. Nurse #4 said she had no knowledge of the order for the [MEDICATION NAME]. During interview on 9/13/16 at 1:20 P.M., the Dietician said she was aware of the Resident’s weight loss and had followed the Resident and made recommendations. The Dietician was unaware that the Facility staff had not follow-up and ensured that the recommendations she made were acted upon and implemented. She said that there had been problems with weight accuracy, timing of weights and following the facility weight policy in the past, but after inservicing the nursing assistant staff in 6/2016, had thought it was corrected.

Failed to Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses

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

Based on observation, review on policies and procedures and interviews, the facility staff failed to provide [MEDICAL CONDITION] care and suctioning according to facility policies and procedures for one of two applicable residents (#9), in a total sample of 23 residents.

Findings include:

Resident #9, was admitted in a vegetative state with a [MEDICAL CONDITION] related to [MEDICAL CONDITIONS] from [MEDICAL CONDITION] and acute [MEDICAL CONDITION]. The facility policy for [MEDICAL CONDITION] care as provided to the surveyor on 9/8/2016, indicated that [MEDICAL CONDITION] care should be a sterile procedure and should be done daily and as needed (prn). The procedure is as follows:

Wash hands; suction patient if needed; set up equipment while keeping a sterile field; explain procedure as appropriate; put on sterile gloves; [MEDICAL CONDITIONS] and remove the 4 by 4 gauze and discard both; clean and inspect the skin under [MEDICAL CONDITION] all around the neck using a gauze pad soaked in sterile water; use Q-tips to clean under the flange of [MEDICAL CONDITION] itself ; place a 4 by 4 gauze pad under and around [MEDICAL CONDITION]; all skin to dry completely and replace [MEDICAL CONDITION]. Document date and time, integrity of the skin [MEDICAL CONDITION] and any change in color, consistency or odor of secretions.

The policy and procedure for tracheal suctioning is as follows: suctioning should be a sterile procedure; Gowns, gloves and goggles are recommended; wash hands and put on protective equipment; place patient in semi-fowlers; turn suction on and check pressure setting; increase oxygen to maximum setting for patients on oxygen if not contraindicated; open catheter package keeping sterile; put on sterile gloves; only hand touching catheter must remain sterile; use non-sterile hand to remove oxygen away from patient; without applying suction, insert catheter until patient coughs or meet obstruction, , withdraw catheter applying suction intermittently and rotate the catheter during removal; place oxygen back on patient with non-sterile hand for about 30 seconds and then repeat; wrap catheter in gloves to discard, place patient back on oxygen and remove protective clothing. The effectiveness of therapy should be assessed by auscultation of breath sounds before and after procedure. Document date and time, description of sputum including amount, color and consistency and patient tolerance.

Observation of [MEDICAL CONDITION] and suctioning on 9/8/2016 at 9:00 A.M. by Register Nurse #1 indicated the following:

RN #1 failed to wash her hands prior to the procedure and failed to don any protective equipment such as gown or protective eye wear. RN #1 set up a sterile suction field, removed oxygen from the patient but failed to assess by auscultation, the resident’s breath sounds prior to suctioning. During suctioning , RN #1 maintained the catheter in a sterile manner but failed to replace oxygen back on the resident in between suctioning entries into the trach, placing the resident at risk for hypoxemia (low oxygenation of the blood). When suctioning was complete, RN #1 did not assess the resident’s lung sounds for effectiveness of the suctioning.

The Resident had thin white sections with suctioning. During care of the [MEDICAL CONDITION], when RN #1 set up the sterile field she contaminated the sterile field by patting the field with her bare hands to make the field lay flat. She then set up the sterile supplies on the contaminated surface to include a container for sterile water, she placed open sterile q-tips on the field and she opened and placed sterile gauze on the contaminated field. After removing [MEDICAL CONDITION] and cleaning the resident’s neck, RN #1 left the Resident'[MEDICAL CONDITION] (at risk of becoming dislodged) and went to retrieve additional gloves.

Review of the treatment sheets indicated that in August 2016 the resident was suctioned 29 times and in September 2016 (as of 9/8/16) the resident was suctioned 8 times as needed but there was no documentation as to the time of suctioning, description of sputum to include amount, color and consistency or the patient’s tolerance to the procedure, in accordance with the policy and procedure.

During an interview on 9/9/16 at 12:30 P.M., the staff developer/infection control nurse said that the use of protective personal equipment (PPE) is a judgement call for each nurse [MEDICAL CONDITION] based on amount of secretions. When Surveyor asked if that is consistent with the policy, the SDC/ICN said no policy says staff should use PPE with no regard to secretions.

Failed to Make sure that each resident's drug regimen is free from unnecessary drugs; Each resident's entire drug/medication is managed and monitored to achieve highest well being.

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

Based on record review and staff interview, the facility failed to ensure an antipsychotic medication was not administered without adequate indication for its use and non-pharmacological interventions were considered and attempted prior to administration of an as needed (prn) dose for 2 Resident (#2 and #11), out of a total sample of 23 Residents.

Findings include:

Review of the facility’s policy for medication management for antipsychotic medications (9/2010), indicated that antipsychotic medications should 1. Resident #11 was admitted to the facility in 10/2012 with [DIAGNOSES REDACTED]. Review of the most recent quarterly Minimum Data Set (MDS) with a reference date of 4/11/16, indicated that Resident #11 had severe cognitive impairment and required extensive assistance of staff for activities of daily living. The medical record was reviewed on 9/7/16.

Review of the December 2015 signed physician’s orders [REDACTED].#11 was prescribed [MEDICATION NAME] (antipsychotic) 12.5 milligrams (mg) daily as needed (prn) and [MEDICATION NAME] (used to treat anxiety) 10 mg daily prn.

Review of the December 2015 Medication Administration Record [REDACTED]. The nurse’s medication notes indicated that the prn dose of [MEDICATION NAME] was administered for anxiety.

Review of nursing progress note dated 12/4/15 indicated that Resident #11 was administered a prn dose of antipsychotic medication for anxiety. Review of nursing progress note dated 12/12/15 indicated that Resident #11 was administered a prn dose of antipsychotic medication after his/her son came to visit and delivered news of his/her father’s death.

Review of the facility’s psychiatric consultant’s note dated 12/12/15 indicated that Resident #11 had anxiety, continued to exhibit symptoms of anxiety and facility staff had not been providing [MEDICATION NAME] for the anxiety symptoms as ordered. During interview with the facility’s psychiatric consultant (new to the facility) on 9/14/16 at approximately 10:30 A.M., she said that antipsychotic medications should not be used for anxiety on an as needed basis.

2. Resident #2 was admitted to the facility in 5/2015 and had [DIAGNOSES REDACTED]. Review of the most recent Quarterly MDS dated [DATE] indicated a score of 15 out of 15 on his/her BIMS, exhibits symptoms of verbal abuse and was an extensive assist in all areas of his/her activities of daily living. Review of the 9/2016 signed physician’s orders [REDACTED].#2 was prescribed the antipsychotic medication [MEDICATION NAME] 50 Mg at HS (hour of sleep) and [MEDICATION NAME] 25 mg, every 6 hours, as needed (prn) for anxiety.

Review of the September 2016 (9/1/16 – 9/9/16) MAR indicated [REDACTED]. The nurse’s medication notes indicated that the prn dose of [MEDICATION NAME] was administered for either anxiety or agitation and on 3 occasions was effective Review of the MAR for 6/2016 indicated the PRN dose of [MEDICATION NAME] was administered 40 times’ and for 7/2016 28 times. The nurse’s medications notes indicated it was for anxiety, agitation and back pain.

Although, the complete 8/2016 was not available from 8/1/16 – 8/15/16, the PRN [MEDICATIONNAME] was administer daily or up to 4 times daily for anxiety and agitation.Record review indicated that the pharmacist had notified the physician of the risk, lackof [DIAGNOSES REDACTED]. The physician chose to not follow the recommendations butindicated that the [DIAGNOSES REDACTED].

On 7/23/15 and 8/20/15 the Resident reported to the 1 to 1 psychotherapist reported the Resident felt the medications administered were not effective. In addition, the consulting psychiatric practitioner made recommendations on 12/14/15, 1/18/16 and 2/27/16 outlined the antipsychotic medications and included risk factors and it’s use as a PRN for anxiety.

During interview with the facility’s psychiatric consultant (new to the facility) on 9/14/16 at approximately 10:30 A.M., she said that antipsychotic medications should not be used for anxiety on an as needed basis. During interview on 9/13/16 at 2:45 P.M, the Resident’s physician said he did not like the psychiatric services. When asked why had he ordered the services he made no comment.

Failed store, cook, and serve food in a safe and clean way

Based on observation and staff interview, the facility failed to store, distribute and serve food under sanitary conditions.

Findings include:

The Surveyor conducted the kitchen/food service observation tour on 9/6/2016 at 9:00 a.m. and noted the following:

a. Observation of the dinnerware indicated numerous bowls, coffee cups, etc which were stained and deeply scratched. The condition of the dinnerware prevented adequate cleaning and sanitizing to ensure the destruction of potential organisms that may cause food borne illness.

b. Observation of the meal trays revealed that numerous trays had broken edges and corners exposing the metal frame beneath the surface material. The condition of the trays prevented effective cleaning and sanitizing to ensure the destruction of potential organisms that may cause food borne illness. Also poses a potential source of injury to a Resident who could by injured on the ridged edges. The Food Service Director stated at this time, that there was no system in place to routinely inspect the dinnerware/trays to ensure they were in good condition.

c. The reach-in/tray line refrigerator was observed to have 4 trays of strawberries in desert cups and covers with no dates/labels, an open bag of hard -boiled eggs, and a container of tofu with no dates/labels. (On 9/13/16 at 9:00 A.M. the reach-in/tray line refrigerator was again noted to have the following items with no dates/labels: 17 individual glasses of orange juice, a container of half and half, 8 individual desert cups of yogurt, and 4 tuna fish sandwiched).

d. The portable steam table used in the kitchen was noted to have an electrical cord that had been taped with electrical tape in several different locations on the cord, posing a potential electrical hazard.

f. The tiled floor throughout the kitchen had a very large build up of black gooey dirt.

g. The sanitizer bucket was tested for the proper concentration and indicated that there was not sanitizer present in the water. The kitchen staff were using this bucket to wash food surfaces in the kitchen.

h. In the back room, the reach in refrigerator was noted to have dripping water inside the reach-in itself and broken gaskets on the doors.

i. The carts used to transport clean dishes/items, were worn, discolored and could not be sanitized correctly due to the gouges all over the cart.

j. Several of the reach in refrigerators had food buildup and were dirty on the inside bottom of the reach-in.

k. All coolers on the push carts had broken covers. These coolers are brought to the Resident units and used for ice. During interview on 9/6/16, at 10:30 A.M., the Food Service Director said that there were no plans/policies/procedures in place to ensure compliance for food storage, procurement and kitchen sanitization.

Failed to maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards.

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

Based on observation, record review and interview, the facility failed to ensure medication that was expired was not available and administered to one non-sampled resident (NS Resident #1), in a total sample of 23.

Findings include:

During inspection of the medication refrigerators on [DATE] on the 2 main unit at 9:00 A.M., a bottle of Omeprazole liquid labeled Do not use after [DATE] was found in the refrigerator belonging to NS Resident #1. On [DATE] at 8:30 A.M., the 2 main refrigerator was observed again with Licensed Practical Nurse (LPN) #1. The expired bottle of Omeprazole was still in the refrigerator. LPN #1 said the resident (NS #1) was still in the facility and that the Omeprazole liquid ( labeled do not use after [DATE]) was the only bottle in the refrigerator and should have been discarded on [DATE].

Observation of the Medication Administration Record [REDACTED].M. Observation of the appropriate medication cart indicated the medication was not on the medication cart as it required refrigeration.

failed to have a program that investigates, controls and keeps infection from spreading.

Based on observation, record review and interview, the facility failed to implement infection control practices consistent with standards of care to prevent and minimize the onset and spread of infection within the facility for one sampled resident (#9) with a tracheostomy and one nonsampled with a tracheostomy (NS #2), in a total sample of 23.

Findings include:

1. On 9/8/16 at 8:15 A.M., Resident #9’s room was observed. The resident was observed to be asleep in bed with a tracheostomy (plastic tube in the neck for breathing), with a tracheostomy collar on for the delivery of humidified oxygen. On the window sill were seven 500 cc bottles of sterile water, two which were opened. Neither of the two opened bottles were labeled with a time and date as to when they were opened. The sterile water bottles were labeled by the manufacturer with discard unused portions. Further inspection of the label indicated there was no preservatives in the sterile water to prevent bacterial growth over time. In the room, across the hall was a second resident (NS #2) with a tracheostomy. Observed on a cart at this resident’s bedside, were 8 bottles of 500 cc sterile water of which one was opened and not labeled or dated.

At 8:45 A.M., on 9/8/16, the Surveyor showed registered Nurse (RN) #1, who said she was responsible for the care of the two tracheostomy residents, the opened bottles of sterile water and asked if they could be used after they were opened. RN #1 said the sterile water was used to perform tracheostomy care such as suctioning and cleansing of the tracheostomy site. RN #1 said she was not sure if the bottles could be reused once opened but that the opened bottles should be dated. RN #1 called the infection control nurse,at the Surveyors requested, who stated the opened bottles should be discarded in accordance with the manufacturer’s directions for use. During an interview, on 9/9/16 at 1:00 P.M., the infection control nurse said it was not good infection control practice to use the open bottles of sterile water for tracheostomy care.

During observation of the tracheostomy care provide to Resident #9 on 9/8/16 at 9:00 A.M., RN #1 did not follow sterile technique and contaminated the sterile field, placing the resident at risk for cross contamination and risk for infection. The facility policy and procedure for tracheal suctioning stated that suctioning and tracheostomy care should be a sterile procedure. The policy also stated that gowns, gloves and goggles are recommended; to start staff are to wash hands and put on protective equipment. The policy standard precautions, which is to be used to care for all resident, indicated that hand hygiene is to be done, for example, before and after an invasive procedure ( suctioning, before and after changing a dressing, after removing gloves. Gloves are to be changes when moving from a dirty to a clean site, to prevent cross contamination and before touching non-contaminated items and environmental surfaces. Wear a mask, a and eye protection or a face shield to protect mucous membranes of the eyes, nose and mouth during procedures and resident-care activities that are likely to generate splashes or sprays of blood, body fluid , secretions (mucus) and excretions.

Observation of the tracheostomy care and suctioning on 9/8/2016 at 9:00 A.M. by Register Nurse #1 (Megan) indicated the following:

RN #1 failed to wash her hands prior to the procedure and failed to don any protective equipment such as mask, shield or protective eye wear. The Resident had thin white sections with suctioning. During care of the tracheostomy, when RN #1 set up the sterile field but she contaminated the sterile field by patting the field with her bare hands to make the field lay flat. She then set up the sterile supplies on the contaminated surface to include a container for sterile water, she placed open sterile q-tips on the field and she opened and placed sterile gauze on the contaminated field.

During an interview on 9/9/16 at 1`:00 P.M., the staff developer/infection control nurse said that she had only been in the role as infection control nurse for about 6 months and had not had any additional training in infection control to mange the position. The ICN said that the use of protective personal equipment (PPE) is a judgement call for each nurse during trach care based on amount of secretions. When Surveyor asked if that is consistent with the policy, the SDC/ICN said no, the policy says staff should use PPE, at a minimum a face shield, mask or eye protection, with no regard to secretions. 3. Inspection of the medication refrigerator on the 2 Main unit on 9/8/2016 at 12:30 P.M., indicated there was an opened bag of renal source tube feeding on the door of the dormitory style medication refrigerator. The bag was labeled 9/8/16 at 9:45 A.M. The access port of the bag was open to air and was not covered.

Failed to keep all essential equipment working safely.

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

Based on observations and staff interview, the facility failed to ensure safe water temperatures.

Findings include:

The survey team observed fluctuations in hot water temperatures that posed a potential hazard for scalding. On 9/6/16 at approximately 8:25 A.M. the Surveyor entered the staff/facility bathroom to wash her hands. After approximately 10 seconds, the Surveyor observed the hot water temperature in the bathroom sink becoming extremely hot. Surveyor then checked the temperature of the water, which was 134 degrees Fahrenheit (F). The Surveyor then proceeded to alert the Administrator who in turn notified the Maintenance director.

The facility notified all units by posting signs that alerted the staff/Residents/family members of hot water temperatures.

The water temperature logs from 1/2016 through 9/2016 indicated the following:

The Maintenance Director Water temperature logs indicated that from 1/2016 through 6/2016 all the water temperatures obtained in different Resident location throughout the facility were recorded at 112 degrees F. The logs from this time period did not indicate any other fluctuations in the water temp, only indicating that all water temperatures were all 112 degrees Review of the water temperature logs dated 7/2016 through 9/2016 indicated that now all the water temps obtained were recorded at 110 degrees F. These logs from this time period also did not indicate any other fluctuations, only indicating that all water temperatures were exactly 110 degrees.

At 11:00 A.M. the Surveyor was brought into the boiler room by the Maintenance Director so that Surveyor could be shown that the water for the facility was 128 degrees F and how the valve was being adjusted. Surveyor proceeded to explain to the Maintenance Director numerous times that the maximum bathing temp was 110 degrees F. The Surveyor and Maintenance Director then proceeded to room 102 and obtained a water temperature which measured at 130 degrees.

The Maintenance Director continued to adjust the mixing valve and monitor temperatures. At 2:35 P.M. the water temperature in the facility/staff bathroom was again noted to be hot when the Surveyor washed her hands. It was measured at 130 degrees F, but at this time the plumber was in the building and now inspecting the system.

The plumber found the following: Upon arrival it was found that the hot water for the building was spiking at 140 degrees F The plumber attempted to adjust the mixing valve. The valve would not maintain at 110 degrees F

The cartridge was removed and cleaned as it was found to be gummed up with corrosion. The plumber could not free it up. The cartridge was reinstalled. The plumber dialed back the hot water flow into the valve (recirculator was turned off). The Valve was maintaining at 110 degrees F On interview with the plumber, It was explained to the Surveyor that a piece of equipment within the hot water system, called a cartridge had stopped functioning. The plumber set the hot water at 110 degrees F, and told Surveyor that the water temperature should/would maintain at the temperature of 110 degrees F until the part could be replaced. The plumber stated that his company would return the following day with the new cartridge.

The plan for 9/6/16 through 9/7/16 was as follows:

1. Maintenance will in-service supervisor (s) (3-11, 11-7) on taking the hot water temperature (every hour).

2. Maintenance Director will demonstrate how to delay the hot water flow into the valve, this will stabilize the temperature in the event the temperature is above 110

3. The log is kept with the supervisor until Maintenance Director returns to facility.

4. Victory Mechanical (the plumber) placed an order for [REDACTED]. The temperatures taken by the facility from 6:00 P.M. on 9/6/16 through 9/7/16 at 7:00 A.M. indicated temperatures all measured at 110 degrees F (no variations noted). On 9/7/16 at 7:45 A.M. the Surveyor washed her hands in the staff/facility bathroom and almost instantly the water became extremely hot. The temperature obtained at this time was 140 degrees F (a temperature of 140 degrees F can cause a 3rd degree burn in approximately 5 seconds).

The Maintenance Director was contacted immediately and together the temperatures taken in room 104 were noted to be 130/129 degrees F. Temperatures taken on the first and second floors ranged from 108 to 132 degrees F.

When questioned regarding the spike in the temperatures, the Maintenance Director told the Surveyor that he had adjusted the mixing valve because the water pressure on the Resident units had been low. When the Surveyor asked the Maintenance Director why he had adjusted the system after the plumber had set the system not to exceed 110 degrees F, he kept referring back to the low water pressure. The system that had been set by the plumber not to exceed 110 degrees F, was now exceeding 110 degrees F due to the Maintenance Director adjusting the valve.

At 9:45 A.M. it was now noted that the staff were complaining that there was no hot water for Resident bathing, and the facility had not implemented any other plan, than posting a sign that the water temperatures were hot.

The system had been adjusted/regulated by the Maintenance Director, who is not a plumber. The system should not have been adjusted/regulated after the plumber had left and set the hot water not to exceed 110 degrees F. A contingency plan for the fluctuations of water, other than posting signs that the water was hot, had not been put into place.

The plumber returned to the facility on [DATE] at which time he removed the old cassette and installed a new cassette. The plumber recommended for the facility to install a low flow mixing valve to prevent future issues. This would also ensure that the water would not exceed 110 degrees F. The facility agreed to the plumbers recommendation and the installation of the recommended piece of equipment. The date of installation was then scheduled for 9/8/16. (on 9/8/16 the plumber indicated that there would also be a disruption of hot water)

The facility then in serviced staff 9/7/16 and 9/8/16 on the following and continued to take hourly water temperatures:

1. Safe water temperatures and the range the water should be kept at to prevent scalding of the Residents.

2. What to do in the event the water temperature exceeds 110 degrees F

3. In the event of a disruption of water what the procedures are so that personal care/bathing is not affected. (The facility shall utilize disposable wipes for the provision of personal care/bathing.)

The Administer had an inservice with the Maintenance Director on 9/7/16 that he should not adjust hot pressure of mixing valve. On 9/8/16 the plumbing company was into the building again and replaced the existing mixing valve and installed a new type of mixing valve (low flow valve) that would ensure the temperature would not exceed 110 degrees F. Temperatures were monitored 9/8/16 through 9/12/16 as per the facility action plan with no temperatures exceeding 110 degrees F. On 9/12/16 at 11:50 A.M. surveyor washed her hands and check the temperature which was 120 degrees F. The temperatures were checked on both units and the temperatures ranged from 112 degrees F to 118 degrees F.

The facility called the plumbing company who came into the facility and completed the following the following:

1. Isolated the system and pulled the low flow valve

2. Cleaned plugged strainers (plugged due to new install)

3. Reinstalled and reset the temperatures to 110 degrees F

4. tested the temperature of the sinks on the floors. The issue as stated by the plumber was that due to the plugged strainer it was not allowing enough cold water through the mixing valve. The facility failed to ensure water temperatures were maintained at safe and comfortable levels for the Residents.

Failed to have enough outside ventilation via a window or mechanical ventilation, or both.

Based on observations and staff interview, the facility failed to provide a clean, comfortable (and to the extent possible), an odor-free environment to enhance residents’ quality of life.

Findings include:

The facility failed to provide a clean, comfortable (and to the extent possible), an odor-free environment to enhance residents’ quality of life. According to the American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE 2/1999) for Indoor Air Quality in long-term care facilities: Higher rates of incontinence, more frequent toileting, more soiled linen, widespread use of portable commodes, and pungent cleaning chemicals used by the housekeeping staff, all conspire to increase the need for controlled exhausts, more frequent air changes and more fresh air ventilation. Nothing deters visitors like stale air or odors from body wastes.

Recommendations from the ASHRAE Handbook include the following: a central ventilation system to provide continuous, controlled outside air distribution with two air changes per hour for resident rooms and 80% efficiency filters. A common design uses a central air-handling unit to provide the outside air to the various spaces within the facility. The toilets in the resident rooms are usually continuously exhausted and humidity should be maintained between 30% to 60% relative humidity. Most of the malodors, associated problems can be effectively ameliorated in re-circulating air systems by using gas phase filters.

On the morning of 9/6/16, during the initial tour, the Survey team noticed pungent odors upon entering the facility lobby. The surveyors continued to be aware of odors throughout survey.

On the morning of 9/13/16, the Ombudsman notified the Survey team of an odor coming from the soiled utility room on Unit 2. The utility room exited to the residents’ hallway where residents, families and visitors would pass throughout the day.

Shortly after the Survey team notification, Surveyor #4 observed the Unit 2 utility room. The pungent odor of feces and garbage was so strong that the Surveyor had difficulty remaining in the space and had to hold the door open to avoid feeling sick. The soiled utility room was utilized for collecting trash, emptying/sanitizing bed pans and storing soiled laundry. The Surveyor observed a vent in the ceiling that was not operational when the light switch was turned to the on position. The Surveyor also observed that the soiled utility room and the clean utility room shared the same space and were only separated by a half door, therefore the air exchange (or lack of), was all part of the same space.

Surveyor went to the soiled/clean utility room on Unit 1. The Surveyor turned on the light switch and observed that the vent was also not operational and therefore, provided no air exchange. There was also a strong, pungent odor. Surveyor was joined by another Surveyor, who could not remain in the utility room due to the pungent odor.

Surveyor notified the interim Maintenance Staff Member (the Director of Maintenance was unavailable for personal matters during survey) of the non-operational vents. The Maintenance Staff Member (MSM) also observed the utility rooms with Surveyors and said that he would look into it and report back to the survey team.

On 9/14/16 at 9:00 A.M. with the 1st Wing Unit Manager #1, Surveyor observed every resident bathroom on the unit to have non-operational vents in the ceiling (rooms 119-126). Every bathroom was shared with the adjacent room and therefore, shared by at least 6 residents (3 beds/room). The bathrooms were humid, sticky and stale with body odors.

Surveyor also observed that the air conditioner was blowing warm air at the nursing station. The Surveyor asked the staff how long it had not been working properly. The staff said that the facility compressors had been damaged during a blizzard over 2 years ago and that the facility never replaced them. The staff said that some of the residents’ rooms had small air conditioners in the windows, but that the air in the residents’ common areas, hallways and nursing stations was very stale and humid, especially on the really hot summer days.

The Surveyor observed three Residents sitting in the common area watching television with CNA #1. The common area’s room air was humid and stale. The facility’s air conditioner was blowing stale, warm air. The Surveyor asked the CNA #1 how long the air conditioner had been non-operational. CNA#1 said that it had been that way a long time and that some families brought in air conditioners for family members to put in the resident room windows.

On 9/14/16 at 10:30 A.M., Surveyor toured Unit 2 resident rooms. The vents in every resident bathroom (rooms 201-217), were not operational and similar to unit 1, shared with up to 6-8 residents. The main ventilation duct adjacent to the nursing station was also not operational. The vents in resident bathrooms 203 and 216 were not secure and hanging from the ceiling.

The common/activity room was filled with residents. The air was humid and stale. The common bathroom, located off of the activity room was observed to have a non-operational vent and smelled of stale urine. On 9/14/16 at 11:45 A.M. the Administrator and MSM said that 4 exhaust fans on the roof were not working at all. The Administrator also said that the 2 facility compressors had not been operational since a winter storm (2 years prior), that damaged them and were, ultimately removed. The MSM said that he had scheduled an HVAC company to assess the issues. The Administrator said that she would fax the report the Surveyor as soon as she received it.

Failed to employ or obtain outside professional resources providing services in the nursing home that meet professional standards.

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

Based on record review and interviews, the facility failed to ensure that referrals were made to specialized medical clinicians as ordered by the physician for 1 Resident (#8) out of a total sample of 23 Residents.

Findings include:

For Resident #8, the facility failed to obtain a consult with a [MEDICATION NAME] per physician orders.

Resident #8 was admitted to the facility in 9/2014 and had [DIAGNOSES REDACTED]. Review of the physician progress notes [REDACTED]. The physician assessed the Resident on 5/13/16, 5/18/16, 6/3/16, 6/8/16, 6/13/16, 6/17/16, 6/22/16, and 7/5/16 and determined that events with changes in medication trials and his/her immobility and slow transit the Resident continued with problems with constipation. The physician indicated on 7/5/16, that the Resident would likely require a colonoscopy and would need to be seen by a [MEDICATION NAME]. The physician requested the facility staff to schedule the consult.

The 7/6/16, nurses note indicated that the facility staff and the Resident were aware of the order for the consult for constipation. The nurse indicated she called the [MEDICATION NAME]’s office but they were closed.

On 7/8/16, the nurse documented that she notified the Resident’s Nurse Practitioner (NP) that the office for the consult could not see the Resident due to his/her wheelchair. The note indicated that the NP did not respond.

On 7/11/16, the nursing staff indicated that they contacted a [MEDICATION NAME] for an appointment for the Resident, but did not have information to fax to the consultant’s office. Subsequent, to this nurses note there was no evidence in the clinical record the resident was seen by a [MEDICATION NAME].

During interview on 9/13/16 at 9:00 A.M., Nurse #3 said she did not think the Resident was sent to the [MEDICATION NAME]. She looked in the facility’s calendar for an appointment, but was unable to determine if the physician order [REDACTED].

Failed to quickly tell the resident's doctor the results of lab tests.

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

Based on record review and interview, the facility staff failed to promptly notify the physician of the lab results for one resident (#9) in a total sample of 23, placing the resident at risk of [MEDICAL CONDITION] from a non- therapeutic level of medication prescribed to prevent [MEDICAL CONDITION].

Findings include:

Resident #9, was admitted in a vegetative state with a [MEDICAL CONDITION] related to [MEDICAL CONDITIONS] from [MEDICAL CONDITION] and acute [MEDICAL CONDITION]. Record review indicated Resident #9 was receiving the anticonvulsant medication, [MEDICATION NAME] 200 milligram (mgs) twice a day. In addition, the physician had ordered the blood levels of [MEDICATION NAME] to be monitored every three months because the medication needs to have a therapeutic range in the blood to be effective in controlling [MEDICAL CONDITION].

Review of the laboratory results in the clinical record indicated the [MEDICATION NAME] level was checked on 7/14/16 and reported as 8.5 ( the therapeutic range is 10-200). Nurses notes and new physician orders [REDACTED]. The results of the repeat level on 7/21/16 when a INR ( test for clotting) was also scheduled. The results of the 7/21/16 [MEDICATION NAME] level was found in the clinical record and was recorded as 7.7 lowered than the previous level. There was no new physician orders [REDACTED]. Review of the 8/2/16 and 9/6/16 physician progress notes [REDACTED].

During an interview on 9/8/16 at approximately 11:00 P.M. , RN #1 said, after reviewing the clinical record, that the physician had not been made aware of the results of the 7/21/16 [MEDICATION NAME] level and she would call him and follow up. At 1:00 P.M., RN #1 said the physician said he was not aware and had ordered a repeat level for this week.

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 interview, the facility failed to obtain a physician’s order for psychiatric consultant services for 4 Residents (#3, #4, #5, #11) out of a total sample of 23 Residents.

Findings include:

1. For Resident #3, the facility failed to obtain a physician’s order prior to receiving psychiatric services for the management of [MEDICAL CONDITION] medication. Resident #3 was admitted to the facility in 2/2015 with [DIAGNOSES REDACTED]. Review of the most recent annual Minimum Data Set (MDS) with a reference date of 1/17/16, indicated that Resident #3 was dependent on staff for all activities of daily living, had moderate impairment in daily decision making and wandered. The MDS also indicated that the Resident was prescribed antianxiety, antidepressant and antipsychotic medication. The medical record was reviewed on 9/8/16.

Review of the consultant psychiatric clinician’s notes indicated that Resident #3 had an initial psychiatric evaluation on 5/14/15 and subsequent visits on 8/24/15, 11/6/15, 12/18/15, 2/11/16, 3/14/1\6 and 8/24/16. Further review of the medical record failed to indicate that there was physician’s order for psychiatric services.

2. For Resident #4, the facility failed to obtain a physician’s order prior to receiving psychiatric services. Resident #4 was admitted to the facility in 1/2016 with [DIAGNOSES REDACTED]. Review of the admission MDS with a reference date of 2/7/16 and the most recent quarterly MDS with a reference date of 8/8/16, indicated that Resident #4 had moderate impairment in daily decision making and both long and short term memory problems and did not take any [MEDICAL CONDITION] medications.

The medical record was reviewed on 9/7/16. Review of the consultant psychiatric clinician’s notes indicated that Resident #4 had an initial psychiatric evaluation on 2/1/16 and subsequent visits on 2/26/16 (sedative was prescribed) and 3/25/16. Further review of the medical record failed to indicate that a physician’s order was obtained prior to receiving psychiatric services for the management of [MEDICAL CONDITION] medications.

3. For Resident #5, the facility failed to obtain a physician’s order prior to receiving psychiatric services for the management of [MEDICAL CONDITION] medications. Resident #5 was admitted to the facility in 12/2015 with [DIAGNOSES REDACTED]. Review of the admission MDS with a reference date of 12/22/15, indicated that Resident #5 had severe cognitive impairment, required extensive assistance of staff for activities of daily living and was taking antianxiety and antidepressant medication. The medical record was reviewed on 9/9/16.

Review of the consultant psychiatric clinician’s notes indicated that Resident #5 had an initial psychiatric evaluation on 1/11/16 and subsequent visits on 2/11/16 and 4/3/16. Further review of the medical record failed to indicate that a physician’s order was obtained prior to receiving psychiatric services for the management of [MEDICAL CONDITION] medications.

4. For Resident #11, the facility failed to obtain a physician’s order prior to receiving psychiatric services for the management of [MEDICAL CONDITION] medications and one-to-one psychotherapy. Resident #11 was admitted to the facility in 10/2012 with [DIAGNOSES REDACTED]. Review of a quarterly MDS with a reference date of 1/14/16, indicated that Resident #11 had moderate cognitive impairment and requires extensive assistance for activities of daily living.

The medical record was reviewed on 9/7/16. Review of the consultant psychiatric clinician’s notes indicated that Resident #11 was seen by the psychiatric nurse practitioner on 12/12/15, 4/3/16, 4/19/16 and 8/26/16. He/she was also seen by the consultant psychotherapist once a week from 12/3/15 with a most recent visit on 9/1/16. Further review of the medical record failed to indicate that a physician’s order was obtained prior to receiving psychiatric services for the management of [MEDICAL CONDITION] medications and one-to-one psychotherapy.

Failed to have a detailed, written plan for disasters and emergencies, such as fire, severe weather, and missing residents.

Based on observation, policy review, and interviews, the Facility failed to ensure that there was an adequate amount of emergency food available.

Findings include:

On 9/6/16, at 10:00 A.M., the Food Service Manager (FSM) toured the Emergency Food Supply with Surveyor. The area where the Emergency Food Supply was observed to be sparse, in that the food on hand did not meet the required amount of food to meet the Seven Day Emergency Menu. The FSM was then asked if the Emergency Food was also stored elsewhere or rotated into the regular food used for the day to day food. The FSD responded No, and agreed with the Surveyor that the facility did not have enough Emergency Food to meet the Seven Day Emergency Menu.

During interview on 9/6/16, at 10:30 A.M., the Food Service Director said the facility did not have an adequate amount of emergency food available according to the facility’s emergency food supply policy.

Failed to train all employees on what to do in an emergency, and carry out announced staff drills.

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

Based on staff interview and observation, the facility failed to ensure that the emergency equipment on 4 of 4 Resident care units were functional in the event of an emergency and also failed to ensure staff were trained in the set up of emergency equipment.

Findings include:

On [DATE] at 12:40 P.M., Surveyor heard a code blue being announced on the over head page. Upon entering the area where the emergency was called it was noted that a Resident was on the floor lying on his/her left side. The AED (automated emergency defibrillator) had been brought to the area. At 12:45 P.M. the Vice President of clinical operations asked where the code cart was, as it had not arrived the yet. (the Resident never was in the need of cardio-pulmonary resuscitation (CPR)).

Once the code cart arrived in the room, the SDC asked Licensed Practical Nurse (LPN) # 2 apply oxygen to the Resident. The SDC then attempted to set up and plug in the suction machine, which she plugged in, but did not attempt to set up due to LPN #2 was not aware of how to attach oxygen tubing to the oxygen tank and apply it to the Resident. The suction machine was never set-up and the SDC completed the task of connecting the O2 tubing to the tank and setting the liter flow. At 12:50 P.M. the Emergency Medical Services (EMS) arrived and the Resident was taken to the hospital.

This occurrence took place during the Residents lunch meal. The SDC nor the LPN could not locate/set up the necessary equipment to assemble the suction machine or oxygen. It should also be noted that none of the code carts had the suction machine connected and ready for use.

Surveyors then proceeded to the Resident Care units and found the following:

1. Unit 2 (main) LPN #1 was unable to set up the suction machine

2. Unit 2 (wing) LPN #3 knew the suction machine was not connected, but was unable to set up the suction machine.

The Surveyors brought the findings to the attention of the Director of Nursing (DON) and the Vice President of clinical operations on [DATE] at 1:00 P.M. 1 At 4:05 P.M. Unit 2 (wing) LPN #4 unit did not know how to assemble and set up the suction machine, and stated that she thought it was set up and ready for use. 2 At 4:15 P.M. on Unit 2 (main) LPN #5 could not demonstrate how to assemble the suction machine tubing to make it operational in the event of an emergency.

An emergency cart content check list, located on all of the code carts indicated the equipment/code cart was checked daily by the 11:00 P.M. to 7:00 A.M. shift, however it did not indicate that the equipment was set up and ready in the event of an emergency Again the Surveyor’s concerns were brought up to the Director of Nursing (DON) and the Vice President of clinical operations on [DATE] at 4:15 P.M. regarding the lack of training in regards to set-up of suction machines and O2, and also not ensuring that all the emergency carts were set up for immediate use.

Quincy Health and Rehabilitation Center, Nursing Home Neglect and Elder Abuse Lawyers

If someone you love has suffered neglect or elder abuse by a senior caregiver, nursing home, or other care facility, our lawyers may be able to help. Regardless of whether or not criminal charges are filed against an alleged abuser, you may still be able to pursue compensation in a civil claim. Compensation in elder abuse cases may be awarded if someone in the care of another suffers harm due to intentional or negligent actions (including failure to take action).

Abuse of the elderly is not acceptable and we fight hard in these types of cases. If you suspect a nursing home or caregiver has caused harm to your loved one in someone elses’ care, contact our law firm today for a free legal consultation. Talking to us does not obligate you to anything, but we may be able to tell you if you have a claim and the value of your case. If we accept your case, you pay no fee unless we recover for you.

Oftentimes, victims of abuse either cannot or will not speak up for themselves out of fear. If you notice any warning signs or symptoms of neglect of abuse an an elderly person, it is important you contact an elder abuse lawyer immediately. Not only are there statute of limitations on filing a claim, but the sooner we start helping you, the easier it will be to collect evidence and talk to any witnesses before important details are lost, hidden, or forgotten.

 

Boston Personal Injury Lawyers for Elder Abuse Cases

We offer a free, no-obligation legal consultation to help you understand your rights and the value of your case. Our personal injury law firm takes cases involving elder abuse and neglect. We offer legal service to clients in Massachusetts, Rhode Island and New Hampshire.


Sources:

Page Last Updated: November 18, 2017

Call Now Button