Senior Abuse Law

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to complete comprehensive Minimum Data Set (MDS) assessments within the required timeframes for 11 Residents (#4, #5, #6, #7, #9, #10, #11, #12, #15, #16 and #17) in a total sample of 17 Residents.

Findings include:

Review of the Centers for Medicare (CMS) Resident Assessment Version 3.0 Manual included the following: Admission MDS Assessments:

-The admission MDS assessment is a comprehensive assessment for a new resident that must be completed by the end of day 14, counting the day of admission as day 1.

-Federal statute and regulations require that residents are assessed promptly upon admission (but no later than day 14) and the results are used in planning and providing appropriate care to attain or maintain practicable well being.

-The MDS completion date (Item Z0500B) must be no later than day 14. Annual MDS Assessments: -The Annual MDS Assessment is a comprehensive assessment for a resident that must be completed an an annual basis.

-The MDS completion date (Item Z0500B) must be no later than 14 days after the Assessment Reference Date (ARD) (ARD plus 14 calendar days). Significant Change in Status:

-The Significant Change in Status is a comprehensive assessment that is completed on the 14th day after determination that significant change in resident’s status occurred.

-The MDS completion date (Item Z0500B) must be no later than 14th calendar day after determination that significant change in resident’s status occurred (determination date + 14 calendar days).

1. For Resident #6 the facility staff failed to complete an Admission MDS Assessment in the required timeframe. Record review indicated Resident #6 was admitted to the facility on [DATE]. The Admission MDS was dated as completed (Item Z0500B) on 5/10/17, 41 days after admission and not 14 days as required.

2. For Resident #9 the facility staff failed to complete an Admission MDS Assessment in the required timeframe. Record review indicated Resident #9 was admitted to the facility on [DATE]. The Admission MDS was dated as completed (Item Z0500B) on 1/19/17, 47 days after admission and not 14 days as required.

3. For Resident #16 the facility staff failed to complete an Admission MDS Assessment in the required timeframe. Closed record review on 9/29/17 indicated Resident #16 was admitted to the facility on [DATE]. The Admission MDS was listed as in progress and had not been completed. During an interview on 9/29/17 at 1:30 P.M. with the facility MDS coordinator she said that the Admission MDS is in progress and not completed. She further said that she is aware that it is late.

4. For Resident #5 the facility staff failed to complete an Annual MDS Assessment in the required timeframe. Record review indicated the ARD for the Annual MDS was 11/27/16, the completion date (Item Z0500B) was 12/26/17, 29 days after the ARD and not 14 days as required.

5. For Resident #12 the facility staff failed to complete an Annual MDS Assessment in the required timeframe. Record review indicated the ARD for the Annual MDS was 4/12/17, the completion date (Item Z0500B) was 12/12/17, 28 days after the ARD and not 14 days as required.

8. For Resident #4, the facility staff failed to complete an Annual MDS and Significant Change MDS Assessments in the required timeframe. Record review indicated Resident #4 was admitted to the facility in 10/2013. -Review of the Annual MDS Assessment with ARD of 10/24/16 indicated a completion date (Item Z0500B) of 11/19/16, 27 days after required completion and not the 14 days. -Review of the Significant Change in Status MDS Assessment with an ARD of 8/18/17 indicated a completion date (Item Z0500B) of 9/14/17, 28 days after completion and not the 14 days.

9. For Resident #15, the facility staff failed to complete two Admission MDS Assessments in the required timeframe. Closed record review indicated Resident #15 was admitted to the facility on [DATE]. a. The Admission MDS Assessment indicated a completion date (Item Z0500B) 6/28/17, 28 days after admission and not the 14 days as required. b. Resident #15 was readmitted to the facility on [DATE]. The Admission MDS Assessment indicated a completion date (Item Z0500B) 8/24/17, 36 days after admission and not the 14 days as required.

10. For Resident #17, the facility staff failed to complete an Admission MDS Assessment in the required timeframe. Closed record review indicated Resident #17 was admitted to the facility on [DATE]. The Admission MDS Assessment indicated a completion date (Item Z0500B)8/25/17, 49 days after admission and not 14 days as required.

During an interview with the facility MDS coordinator on 9/26/17 at 2:55 P.M. she said that MDSs in general are not on time and not completed in a timely basis. She further said we get caught up and then have increased admissions and discharges and things fall behind again.

Based on record reviews and staff interviews, the facility staff failed to ensure quarterly Minimum Data Set Assessments were completed in a timely manner as required for 5 residents (#1, #2, #4, #6 and #12) out of a total sample of 17 residents. Review of the Resident Assessment Instrument 3.0 Manual, dated (MONTH) (YEAR), indicated Quarterly Minimum Data Set (MDS) Assessments are to be completed no later than the Assessment Reference Date (ARD) plus 14 calendar days.

Findings include:

1. Resident #1 was admitted to the facility in 3/2017. Review of the Quarterly MDS Assessment with an ARD of 6/20/17 indicated completion date (Item Z0500B) of 7/20/17, which was 16 days overdue and not the required 14 days.

2. Resident #2 was admitted to the facility in 8/2016. -Review of the Quarterly MDS Assessment with an ARD of 1/10/17 indicated a completion date (Item Z0500B) of 2/2/17, which was 9 days overdue and not the required 14 days. – Review of the Quarterly MDS Assessment with an ARD of 7/11/17 indicated a completion date (Item Z0500B) of 8/4/17, which was 10 days overdue and not the required 14 days.

3. Resident #4 was admitted to the facility in 10/2013. Review of the Quarterly MDS Assessment with an ARD of 7/26/17 indicated a completion date (Item Z0500B) of 8/26/17, which was 17 days overdue and not the required 14 days.

4. For Resident #12 the facility staff failed to complete a Quarterly MDS Assessment within the required timeframe. Record review indicated a Quarterly MDS Assessment with an ARD date of 7/13/17 and a completion date (Item Z0500B) of 8/4/17, 22 days after the ARD date, not 14 days as required.

5. For Resident #6 the facility staff failed to complete a Quarterly MDS Assessment within the required timeframe. Record review indicated a Quarterly MDS Assessment with an ARD date of 7/6/17 and a completion date (Item Z0500B) of 8/7/17, 32 days after the ARD date, not 14 days as required.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility staff failed to provide an environment free of accident hazards related to properly and securely storing medications and failed to obtain consent and assess risk of entrapment from bedrails for 7 sampled residents (#1, #2, #4, #6, #7, #10, and #14) out of a total of 17 sampled residents.

Findings include:

1. During the medication pass observation on 9/27/17 at 9:05 A.M. on the facility secure unit – station 2, the following was observed:

Nurse #1 brought the medication cart into the day room and placed it facing inward against the wall to the left of the doorway . The day room had multiple tables, stationary chairs, wheelchairs and residents in the room. Residents and facility staff were observed ambulating independently in and out of the day room passing by the medication cart. Nurse #1 proceeded to prepare multiple medications for administration to Non-sampled (NS) Resident #2 that included oral medications and a Combivent (brochodilator) inhaler. After preparing the medications for NS #2, the Nurse locked the medication cart and left the Combivent inhaler on top of the cart. She proceeded to bring and administer the oral medication to NS #2 who was seated on the other side of the open doorway, approximately 15 feet away from the medication cart. The medication cart was out of view of Nurse #2 as she was facing the resident.

Nurse #2 returned to the medication cart and proceeded to prepare medications for another resident NS#3. She locked the medication cart, leaving the Combivent inhaler from NS #2 unsecured and accessible on top of the medication cart. She then walked away from the medication cart and once again the medication cart was out of her view, as she administered the prepared medications to NS #3.

During an interview with Nurse #1 on 9/27/17 at 9:20 A.M., she said that the inhaler should have been locked in the medication cart and not left on top.

2. During the medication pass observation on station 1 on 9/27/17 at 9:45 A.M., the following observation was made:

Nurse #2 was preparing multiple medications for administration to sampled Resident #10, including an intravenous (IV) medication Vancomycin (antibiotic). The nurse went into the medication room and obtained the necessary supplies to administer the IV medication. These supplies included tubing and a Normal Saline (NS) flush required to instill in the IV access line to ensure patency prior to administering the medication. However, there were no NS pre-fill syringes in the medication room for Resident #10. The nurse said she hoped that there was a NS flush available in the Resident’s room. The surveyor asked if the pre-fill NS syringes were kept in the resident’s room and the nurse said she did not store them in the resident’s room. Upon entering Resident #10’s room, Nurse #2 opened the top bureau drawer and obtained a 0.9% NS 10 cc pre-fill syringe from a pharmacy labeled plastic bag that contained 3 pre-filled NS flush syringes. During an interview with the Assistant Director of Nurses (ADON) on 9/27/17 at 5:00 P.M., she said that all IV supplies are kept locked in the medication room including IV flushes. She further said that pre-filled IV flush syringes are not to be left in a resident’s room.

3. For Resident #6 facility staff failed to obtain consent and assess risk of entrapment from bedrails, as required. Resident #6 was admitted to the facility 3/2017 with multiple [DIAGNOSES REDACTED]. Review of the current Physician orders [REDACTED]. Review of the clinical record did not indicate that informed consent was obtained by the resident or responsible party for the use of siderails, nor was there any safety assessment completed for the risk of entrapment, as required. Observation of the resident in bed on 9/27/17 at 8:45 A.M. and again on 9/29/17 at 9:00 A.M., the head of the bed was elevated approximately 75 degrees. Upper bilateral 1/2 siderails/grabbars and bottom right 1/2 siderail were in the up position. During an interview with Unit Manager (UM) #1 on 9/29/17 at 9:05 A.M., he said that he did not know why there were three 1/2 siderails up and that it was a mistake.

4. For Resident #7 facility staff failed to obtain consent and assess risk of entrapment from bedrails, as required. Resident #7 was admitted to the facility 6/2016 with multiple [DIAGNOSES REDACTED]. Review of the current Physician orders [REDACTED]. Review of the clinical record did not indicate that informed consent was obtained by the resident or responsible party for the use of siderails, nor was there any safety assessment completed for the risk of entrapment, as required.

5. For Resident #10 facility staff failed to obtain consent and assess risk of entrapment from bedrails as required. Resident #10 was admitted to the facility 9/2017 with multiple [DIAGNOSES REDACTED]. Review of the current Physician orders [REDACTED]. Review of the clinical record did not indicate that informed consent was obtained by the resident or responsible party for the use of siderails, nor was there any safety assessment completed for the risk of entrapment, as required. During an interview with UM #1 on 9/29/17 at 9:05 A.M., he said that there is no consent for use of siderails and a safety risk assessment for entrapment is not completed prior to the use of siderails.

6. For Resident #1, the facility staff failed to obtain informed consent for the use/application of side rails. The facility failed to ensure that the safety of the side rails was assessed for entrapment. Resident #1 was admitted to the facility in 3/2017 with [DIAGNOSES REDACTED]. Review of the 8/17/16 Ancillary Physician order [REDACTED]. During an observation on 9/27/17 at 12:30 P.M., the resident’s bed had 2 side rails in the up position. Review of the clinical record did not indicate that informed consent was obtained by the resident and/or responsible party for the use of side rails, nor was there any safety risk assessment completed, as required.

7. For Resident #2, the facility staff failed to obtain informed consent for the use/application of side rails. The facility failed to ensure that the safety of the side rails was assessed for entrapment. Resident #2 was admitted to the facility in 9/2016 with [DIAGNOSES REDACTED]. Review of the 8/17/16 Ancillary Physician order [REDACTED]. During an observation on 9/26/17 at 8:30 A.M., the resident’s bed had 2 side rails in the up position. Review of the clinical record did not indicate that informed consent was obtained by the resident and/or responsible party for the use of side rails, nor was there any safety risk assessment completed, as required.

8. For Resident #4, the facility staff failed to obtain informed consent for the use/application of side rails. The facility failed to ensure that the safety of the side rails was assessed for entrapment. Resident #4 was admitted to the facility in 10/2013 with [DIAGNOSES REDACTED]. Review of the 10/22/13 Ancillary Physician order [REDACTED]. During an observation on 9/26/17 at 8:50 A.M., the resident’s bed had 2 side rails in the up position. Review of the clinical record did not indicate that informed consent was obtained by the resident and/or responsible party for the use of side rails, nor was there any safety risk assessment completed, as required.

9. For Resident #14, the facility staff failed to obtain informed consent for the use/application of side rails. The facility failed to ensure that the safety of the side rails was assessed for entrapment. Resident #14 was admitted to the facility in 1/2016 with [DIAGNOSES REDACTED]. Review of the 1/27/16 Ancillary Physician order [REDACTED]. During an observation on 9/26/17 at 8:55 A.M., the resident’s bed had 2 side rails in the up position. Review of the clinical record did not indicate that informed consent was obtained by the resident and/or responsible party for the use of side rails, nor was there any safety risk assessment completed, as required. During an interview on 9/29/17 at 9:00 A.M., Unit Manager (UM) #2 said the facility does not obtain informed consents from the resident and/or responsible party for the use of side rails and does not complete a risk safety assessment. During an interview on 9/29/17 at 11:30 A.M., the Administrator said the facility staff has not been obtaining informed consents for the use of side rails and complete a safety risk assessment for entrapment and they should have.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to ensure that medications and biologicals were of current date to provide reliability of strength and accuracy of dosage in 1 of 2 medication rooms.

Findings include:

Inspection of medication storage in the station 2 medication room, with Unit Manager (UM) # 2 on [DATE] at 8:30 A.M., indicated 1 opened multidose vial of Influenza Vaccine that had an expiration date of [DATE]. During interview with UM #2, on [DATE] at 8:30 A.M., she said that the Influenza Vaccine had expired and needed to be removed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, facility policy and staff interviews, the facility staff failed to follow proper infection control practices regarding ensuring transmission based contact precautions were maintained, as required, to prevent the spread of infection for 2 Resident (#2 and #9) and failed to ensure the integrity of a mattress cover for proper cleaning for 1 Resident (#10), in a total sample of 17 residents.

Findings include:

1. For Resident #9, the facility failed to ensure transmission based contact precautions were maintained, as required, to prevent the spread of infection. Review of the undated facility policy for Isolation Precautions specifically Contact precautions, included the following:

Contact precautions must be implemented for a resident known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or patient-care items in the resident’s environment. -Signs – Color coded signs will be used to alert staff of the implementation of isolation precautions, while protecting the privacy of the resident. Orange is the color code for Contact Precautions. An orange sign instructing visitors to report to the nurses’ station before entering should be placed at the doorway. -Resident-care equipment when possible, dedicate the use of non-critical patient-care equipment items such as stethoscope, sphygmomanometer, bedside commode or electronic rectal thermometer to a single resident (or cohort of residents) to avoid sharing between residents.

Resident #9 was admitted to the facility in 3/2017, with multiple [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set Assessment ((MDS) dated [DATE], indicated the resident required extensive assistance for toileting and was incontinent of urine. During the initial tour of the resident’s unit, with Unit Manager (UM) #1, on 9/26/17 at 9:20 A.M., UM #1 identified Resident #9 as being on Contact Precautions for the presence of ESBL (extended spectrum betalactamase) in the urine. (Beta-lactamases are produced by certain organisms these disrupt the actions of certain antibiotics)

Resident #9’s door was observed to have a multi-pocketed fabric holder hanging on the outside of the bedroom door. This holder contained personal protective equipment (PPE) such as yellow gowns and gloves. There was no signage outside the resident’s room to alert staff and visitors that they needed to check with the nurse before entering the room. While in the hallway outside of Resident #9’s room on 9/26/17 at 9:30 A.M. with the UM #1, Resident #9 was observed self propelling their wheelchair to their bedroom, entering the bathroom, telling a Certified Nursing Assistant (CNA) that they had to go to the bathroom. The CNA was observed to don PPE including a yellow gown and gloves and brought the resident into the bathroom.

Record review indicated a urine culture report dated 9/15/17, positive for a urinary tract infection, with greater than 100,000 CFU/ML of Escherichia Coli (ESBL) Review of the current Physician orders [REDACTED]. During interview with UM #1 on 9/27/17 at 8:15 A.M., he said that the sign and commode were not present on 9/26/17 during our tour of station 1 unit, but have since been put in place. He further said that due to sharing the bathroom with his/her roommate, Resident #9 now has a dedicated commode for toileting. During an interview with the facility Infection Control Nurse on 9/27/17 at 4:45 P.M., she said that if a urine culture is positive with ESBL, contact precautions are initiated per physician order [REDACTED]. An orange sign is put up at the resident’s door to alert staff and visitors to report to the nurses station. She further said that a commode would be utilized for the infected resident as the bathroom cannot be shared.

2. For Resident #10 the facility failed to ensure the integrity of the bed mattress cover was intact to allow for proper cleaning and disinfecting. Resident #10 was admitted to the facility 9/2017 with multiple [DIAGNOSES REDACTED]. Review of the nursing admission note dated 9/10/17, indicated the resident was admitted from the hospital after having had debridement of soft tissue and bone of the right foot. Record review indicated Resident #10 had a right heel wound and was followed by the wound clinic. Review of the Physician orders [REDACTED]. Observation of Resident #10’s mattress on 9/27/17 at 8:20 A.M. with Nurse #2, revealed two tears in the bottom 1/3 of the mattress cover exposing the foam component of the mattress. One tear was approximately 6 inches long from top to bottom and the 2nd tear was approximately 2 inches by 2 inches in an right angle shape. Nurse #2 said the mattress should be replaced. Interview and observation of Resident #10’s mattress on 9/27/17 at 8:50 A.M., with UM #1, he said the mattress has 2 rips in the cover, cannot be cleaned and it needs to be replaced.

3. For Resident #2, the facility staff failed to follow good handwashing hygiene to prevent cross contamination while feeding the resident. During an observation of the breakfast meal on Unit 2 Dining Room on 9/28/17 at 8:20 A.M., the following was observed: Certified Nurse Aide (CNA) #1 was seated and feeding Resident #2 at a table. During the meal, CNA #1 observed another resident at the next table put a napkin in his/her mouth and proceed to chew the napkin. CNA #1 got up from her seat and retrieved the chewed up napkin from the resident and threw it in the trash can. She returned to Resident #2 and continued to feed the resident till the meal was finished. CNA #1 did not wash her hands or use hand sanitizer when she returned to the table to continue feeding Resident #2. During an interview on 9/28/17 at 2:00 P.M., CNA #1 said that she did not wash her hands or use hand sanitizer after throwing away the chewed up napkin during the breakfast meal and she said she should have.