Failure to Send Required Paperwork and Notify POA
Summary
The facility failed to send the appropriate paperwork with a resident who required involuntary transfer to the hospital and did not notify the resident's power of attorney (POA) that a psychotropic medication was discontinued. This deficiency was identified during an interview and record review, affecting three residents reviewed for the facility's policy and procedures. Specifically, a Licensed Practical Nurse (LPN) sent a resident to the hospital for evaluation due to exhibiting unusual behaviors but did not send the required involuntary petition paperwork. The resident was returned to the facility without being admitted to the hospital, and the same emergency medical technicians had to take the resident back to the hospital after the petition was completed by the Social Services Director (SSD). The LPN admitted to not knowing that a petition was required and did not receive the hospital paperwork when the resident initially returned from the hospital. The Director of Nursing (DON) and the Administrator confirmed that the POA was not notified about the discontinuation of the resident's psychotropic medication. The DON stated that it is the social worker's responsibility to complete the petition paperwork when a resident needs to be sent to the hospital due to behaviors, and nurses are expected to complete the paperwork after hours or when the social worker is not available. However, it was revealed that some nurses were not familiar with the process of completing the petition paperwork. The SSD acknowledged that the POA should have been notified about the medication changes and that an in-service was requested to train nurses on completing the petition paperwork. The facility's policies and job descriptions for LPNs and RNs include responsibilities for completing medical forms, charting, and handling admissions, discharges, and transfers. Despite these policies, the failure to send the required paperwork and notify the POA about medication changes led to deficiencies in the facility's handling of residents' behavioral health needs and communication with their representatives.
Penalty
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A resident with paraplegia and a history of trauma was involved in an incident where an LPN physically restrained him by blocking his wheelchair, leading to the resident punching the LPN. The resident had grabbed his medication and attempted to leave, contrary to physician orders. This action violated the facility's Resident Rights policy, which ensures residents are free from restraints. The incident was witnessed by staff, and authorities were notified.
The facility failed to ensure sufficient staffing to meet the behavioral health needs of residents, affecting two residents and potentially impacting all 31 residents on a nursing unit. The inadequate staffing led to delays in care and supervision, resulting in falls and hospitalizations for residents with complex behavioral health needs.
Failure to Ensure Resident Rights and Appropriate Behavioral Health Management
Penalty
Summary
The facility failed to ensure appropriate nursing services to maintain the highest practicable physical, mental, and psychosocial well-being of Resident #115, particularly in relation to mobility and behavioral health needs. Resident #115, who had diagnoses including paraplegia and a chronic ulcer, was cognitively intact and required varying levels of assistance for daily activities. The care plan highlighted the resident's risk for impaired psychosocial well-being due to a history of trauma, emphasizing the need for respectful and compassionate communication. However, an incident occurred where the resident grabbed his crushed pain medication from the medication cart and attempted to leave, leading to a confrontation with LPN #402. During the incident, LPN #402 blocked the resident's path and physically restrained him by placing her foot in the wheel of his wheelchair, as the resident was required to take his medication in front of the nurse. This action led to the resident punching the LPN in the hands. The facility's Resident Rights policy, which states that residents have the right to be free from restraints, was not adhered to in this situation. The incident was witnessed by other staff members, and the police, DON, and Administrator were notified. This deficiency highlights a failure in ensuring the resident's rights and appropriate handling of behavioral health needs.
Insufficient Staffing for Behavioral Health Needs
Penalty
Summary
The facility failed to ensure sufficient staffing to meet the behavioral health needs of the residents, specifically affecting two residents and potentially impacting all 31 residents on the Rosepointe B nursing unit. Resident #101, who had vascular dementia, hemiplegia, hemiparesis, and schizophrenia, exhibited socially inappropriate behaviors and required substantial assistance for daily activities. On multiple occasions, Resident #101 was found on the floor or attempting to remove his incontinence brief and clothing, indicating a need for constant supervision. The staffing on the unit was insufficient, with only two STNAs assigned to care for 31 residents, leading to delays in care and supervision for Resident #101, who eventually fell and was sent to the hospital for evaluation. The staff, including the RN and STNAs, reported difficulties in managing their workload and ensuring timely care for all residents due to the inadequate staffing levels. Resident #76, who had vascular dementia, psychotic disturbance, and other cognitive impairments, also required significant assistance and supervision. This resident frequently removed his incontinence brief and consumed feces, necessitating constant monitoring and care. On one occasion, Resident #76 was found on the floor next to his bed and was later admitted to the hospital for a possible cranial bleed. The staff reported that the unit was challenging to manage with only two STNAs, as many residents required mechanical lifts for transfers and had complex behavioral health needs. The lack of sufficient staff led to delays in providing care and addressing the residents' needs promptly. Interviews with the nursing staff revealed that the workload was overwhelming, and they often had to forgo breaks to ensure residents received care. The DON and Administrator determined the staffing levels, but the assigned staff was not adequate to meet the needs of the residents on the Rosepointe B unit. The staff's inability to provide timely and appropriate care due to insufficient staffing levels directly contributed to the deficiencies observed in the care of Residents #101 and #76.
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