Senior Abuse Law

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to follow a physicians order and the plan of care for 1 sampled Resident (#5) out of a total sample of 20 residents.

Findings include:

Resident #5 was admitted to the facility in 2/2014 with [DIAGNOSES REDACTED]. Review of the Resident’s risk for alteration in skin integrity care plan indicated an intervention dated 10/25/16, for use of a special pressure relieving air mattress on the bed. Check mattress inflation every shift.

Review of the Resident’s physician’s orders [REDACTED].

According to the Treatment Administration Record, printed on 2/23/17 at 2:09 P.M., Nurse #1 had initialed the entry indicating that she had checked the inflation of the mattress.

On 2/23/17 at 7:43 A.M., Resident #5 was observed sitting in bed, well dressed and groomed. There was regular mattress on the bed and not an air mattress.

On 2/23/17 at 3:05 P.M., Nurse #1 observed the resident room with the surveyor and said there was no air mattress on the bed as ordered.

During and interview and observation of resident #5’s room on 2/23/17 at 3:10 P.M., the Unit Manager, (U.M.), said resident #5 should have an air mattress as ordered. During an interview with the Director of Clinical Services, (DCS), on 2/23/17 at 3:30 P.M., she had no explanation why the air mattress was not in place. On 2/23/17 at 4:30 P.M., the DCS said that she had spoken to relevant staff and was unable to determine how long the air mattress had been removed from the bed of resident #5.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to maintain sanitary practices during 2 of 2 observations tray line service. Additionally, the facility failed to maintain and monitor sanitary conditions for 3 of 3 resident personal refrigerators, (Resident #9 and Resident #11), and on 2 of 2 unit kitchenettes.

Findings include:

1. The facility failed to maintain sanitary practices causing cross contamination during observations of the food service line on 2/22/17 and 2/23/17.

On 2/22/17 at 11:31 A.M., Surveyor #3 observed the food service line for the lunch meal. Cook #1 was observed placing an oven mitt over his gloved hand to move a hot item and then removed the oven mitt without washing his hands or changing gloves. Cook #1 then picked up a grilled cheese and placed it on a plate to be served with the gloved hand that had been covered by the oven mitt.

During interview with the Food Service Director, (FSD), on 2/22/17 at 11:48 A.M., Surveyor #3 shared the above observations. The FSD said that Cook #1 caused cross contamination and he would re-educate the kitchen staff regarding appropriate hand hygiene. On 2/23/17 at 7:35 A.M., Surveyor #3 observed the food service line for the breakfast meal. Cook #1 was observed wearing gloves and documenting the temperatures of the breakfast foods. Cook #1 did not wash his hands or change gloves after he completed documenting the temperatures of the food items while holding a pen and clipboard. Cook #1 returned to the tray line to and used his gloved hand to place an English muffin on a plate to be served causing cross contamination.

2. The facility failed to maintain sanitary conditions in 2 of 2 kitchenettes. Review of the facility’s kitchenette policy indicated that all food items in refrigerators should be labeled with resident names and dated.

The following observations of the 1st floor kitchenette on 2/22/17 at 7:50 A.M., were noted by surveyor #3:

-The Resident Refrigerator temperature read 45 degrees Fahrenheit
-A zip lock bag with green melon was undated and unlabeled
-A brown bag of take-out french fries in the frozen section was warm to touch and unlabeled and undated
-A plastic bag of an unknown food item was unlabeled and undated
-There were multiple spills of an unknown substance at the bottom of the refrigerator which were sticky to touch

The following observations of the 2nd floor kitchenette on 2/22/17 at 7:55 A.M., were noted by surveyor #2:

-1 individual carton of milk expired 1/20/17, 39 days prior.
-5 individual cartons of milk expired 2/21/17, 1 day prior.

During an interview with a Certified Nursing Assistant (CNA) on 2/27/17 at 7:55 A.M., she said that expired milk should not be in the refrigerator. She removed and threw away the expired milk.

3. The facility failed to ensure sanitary conditions in 3 of 3 resident personal refrigerators.

Review of the facility’s Resident Refrigerator Policy indicated that the CNA staff are responsible for checking contents of resident refrigerators to ensure that items are not expired and that housekeeping staff are responsible to monitor temperatures and to report temperatures above 41 degrees Fahrenheit to their supervisor.

A. On 2/23/17 at 1:05 P.M., Surveyor #3 observed Resident #9’s room where he/she had two mini-refrigerators, (1 black, 1 white). The black refrigerator had expired items and a visible red spill on the inside of an unknown substance. Two salad dressing bottles were observed to have passed their expiration dates. Two items in the frozen section of the refrigerator were not frozen solid and were soft to touch. The white refrigerator had a jar with an unknown substance and no visible date of expiration could read. Two items in the frozen section of the refrigerator were not frozen solid and were soft to touch

On 2/24/17 at 8:55 A.M., Surveyor #3 and Unit Manager #1 made observations of Resident #9’s refrigerators, including the red spill still present and, expired food items, and the food items that were not kept adequately frozen. Resident #9 was present and said that he/she has had issues keeping items that should be frozen at an appropriate temperature. Unit Manager #1 said that the facility staff should be checking the refrigerated food items to ensure that expired food items should be discarded. During interview with the Environmental Service Director, on 2/24/17 at 10:00 A.M., he said that the housekeeping staff is responsible to record and monitor the refrigerators in resident rooms. He said that he was not aware that Resident #9 had two refrigerators, so only one refrigerator temperature was monitored. He said that the facility needs a better system to monitor the refrigerators to ensure that the temperatures and the contents are safe for residents.

B. During an observation of Resident #11’s room, including a refrigerator on 2/23/17 at 11:58 the following were noted:

– The thermometer in the refrigerator was reading 50 degrees.
– Opened, unlabeled, undated container of unidentified food in Chinese food container
– Opened, undated container of carrot ginger soup.
– Evening [MEDICATION NAME] supplement expired in 11/2016.
– Black [MEDICATION NAME] Extract expired in 11/2016.

During an interview with the Unit Manager (UM) on 2/23/17 at 4:20 P.M., she said housekeeping checks the temperatures in the personal refrigerators and that the temperature was too warm for food safety, and she had not been aware that there was an issue with the temperatures in the refrigerator. She removed and destroyed all affected items.

On 2/24/17 at 7:00 A.M., Personal Refrigerator temperature logs for Resident #11 were provided for December and January. The February temperature log was not provided, although requested a second time.

Review of the logs indicated that the temperature was to be recorded daily, the temperature should be between 35 degrees and 41 degrees, and any temperature or sanitation concerns should be reported.

From 12/1/16-12/12/16 the refrigerator temperature was 41 degrees. From 12/13/16-1/23/17 the refrigerator temperature ranged from 43-45 degrees, 2-4 degrees above the recommended food safety range.

During an interview with the Housekeeping Director on 2/24/17 at 11:30 A.M., he said he had not been aware that the temperatures in the refrigerator of Resident #11 had been above 41 degrees since 12/13/16.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and policy review the facility failed to ensure that expired medications were removed and failed to ensure that residents who self store medications had them properly secured for 1 resident(#11) out of a total sample of 20.

Findings include:

Resident #11 was admitted to the facility in 4/2008 with [DIAGNOSES REDACTED]. According to the Quarterly Minimum Data Set completed 12/23/16, resident #11 is totally dependent on staff for all activities of daily living including bed mobility, transfers, bathing, dressing and grooming.

During an observation of resident #11’s room on 2/23/17 at 11:58 A.M. it was noted that the resident refrigerator was unlocked and contained an open container of Evening Primrose supplements which had expired in 11/2016 and an open container of Black Elderberry Extract supplement which had expired in 11/2016.

Review of the policy titled Medication Administration, Self Administration and/or self storage of medications effective 9/2005 indicated that a resident that has orders to store their own medication supply will also have orders for self administration. The resident stores the medications, if ordered, in the locked area designated for use by the facility or deemed appropriate by the facility.

During an interview with the Unit Manager, (U.M.), on 2/23/17 at 4:20 P.M., she said that she was unaware that there were expired medications in the refrigerator. She further said there was no order to administer these medications to resident #11. The U.M. removed and destroyed the medications with the residents permission.

On 2/23/17 at 4:30 P.M. the U.M. said that the most recent self administration of medications assessment indicated that Resident #11 was not a candidate for self administration of medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and facility policy the facility failed to obtain a physician order [REDACTED].

Findings include:

During review of the closed record for Resident #20 on 2/23/17 at 3:24 P.M., the record indicated that the resident passed away. The medical record lacked a physician order [REDACTED].

During interview with the Director of Clinical Services, she said she was surprised that an order was not present in the chart. She looked at the chart and confirmed the order was not present.

Review of the policy titled; Postmortem Management, dated as revised 5/6/08, indicated that; 1. the nurse caring for the resident contacts the physician to pronounce the resident or to give a telephone order for an RN announcement.

2. If the medical doctor, (MD), gives the order for an RN pronouncement, the order should include permission to release the body to a specific funeral home. Under the section of the policy for RN pronouncement it indicated:

Verify that there is a telephone order from the MD for a nurse pronouncement and an order to release the body after pronouncement.