Inadequate Training and Monitoring Leads to Resident Neglect
Penalty
Summary
The facility's administration failed to ensure that nursing staff were adequately trained and competent in the care of residents with specific medical needs, leading to the neglect of a resident with a diagnosis of prostatic hyperplasia. The resident had a catheter inserted to drain urine, but nursing staff did not ensure the catheter was properly inserted and draining. The staff failed to notify the physician in a timely manner when the resident had no urine output for an extended period, resulting in a significant delay in addressing the resident's condition. The nursing staff also neglected to monitor the resident's vital signs and condition after the catheter was removed, despite the presence of blood clots and a lack of urine output. The resident was eventually found unresponsive and was transferred to the hospital in a critical state. The facility's documentation of the resident's urine output was inconsistent and inaccurate, further complicating the assessment of the resident's condition. Interviews with facility staff revealed that there was a lack of competency assessments for nursing staff regarding catheter care and monitoring. The Director of Nursing admitted that the facility had not been conducting necessary competency evaluations, and the staff educator confirmed that the competency checklist was not properly utilized. This lack of oversight and training contributed to the inadequate care provided to the resident, ultimately resulting in immediate jeopardy to the resident's health and safety.
Plan Of Correction
1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: • Resident #1 no longer resides in the facility. 2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken: • The VP of Operations re-reviewed the job description of the Administrator with Nursing Home Administrator. During this review, it was discussed in detail that the administrator must ensure that each resident receives necessary care and services to attain and maintain the highest practical physical, mental, and wellbeing consistent with the resident's comprehensive assessment and plan on care. • The VP of Operations and NHA re-reviewed the job description of the Director of Nursing with the Director of Nursing. During this review, it was discussed in detail that the purpose of her position is to plan, organize, develop, and direct the overall operation of the nursing services department in accordance with federal, state, and local standards, guidelines, and regulations to ensure the highest degree of quality care is maintained at all times. 3) What measures will be put into place or what systemic changes will you make to ensure that the deficient practice does not recur: Education: • The facility's Staff Development Coordinator/Designee completed competencies with licensed nurses on the proper insertion of with return demonstrations. • The facility's Staff Development Coordinator/Designee completed education with CNAs to ensure that any notable changes in output for residents with and any residents experiencing a change in condition are reported immediately to the nurse. • The facility's Staff Development Coordinator/Designee completed education with licensed nurses on the necessary completion of a change in condition evaluation when the following occur: o Accidents resulting in injury, or the potential to require physician intervention. o A significant change in the resident's physical, mental, or condition such as a deterioration in health, mental, or status. o This may include life-threatening conditions, or clinical complications and changes in output including color, consistency, and output. o Circumstances that may require a need to alter treatment. This may include new treatment and/or discontinuation of current treatment due to an acute condition or a worsening of a condition. o A complete nursing evaluation must be conducted and documented in the medical record of systems including but not limited to functional status, evaluation, evaluation/evaluation, evaluation, skin evaluation, evaluation, and vital signs. o The physician/NP shall be made aware of pertinent evaluation findings. • The facility's Staff Development Coordinator/Designee completed education with licensed nurses on vital sign documentation, and on following timely transfer to a higher level of care upon directive from physician. • The facility's Staff Development Coordinator/Designee completed education with licensed nurses on care to include insertion, monitoring output, and proper documentation of output, including documenting this output on the resident's MAR. The licensed nurse must perform a visual observation of the color and clarity of output each shift. • The facility's Staff Development Coordinator/Designee completed education with licensed nurses on the nurses' requirement to notify the provider of any notable changes in resident condition. • The facility's Administrator and Director of Nursing were reeducated by Regional Nurse Consultant on: o The components of the regulation: F600 Free from and Neglect o Neglect, Misappropriation, Mistreatment, and injury of Unknown Origin (ANEMMI) with indicators of neglect. o Facility standard and guideline P&P Neglect and Investigations to include: - Screening - Training - Prevention - Identification - Investigation - Protection - Reporting • The facility's Staff Development Coordinator/Designee completed education with facility staff on Neglect with an emphasis on the following F600 noncompliance: The facility failed to protect resident rights to be free from neglect by failing to appropriately monitor the resident's output and failure to monitor the resident when the was discontinued. On approximately 4:30 p.m. resident's was discontinued. Resident experienced copious and was passing clots through his penis. The facility neglected to monitor resident's status including vital signs with a significant change in condition. • The DON and Nurse Management Team were educated by the Regional Nurse Consultant on the components of the management of with an emphasis on output monitoring and ANEMI. • The facility's Staff Development Coordinator/Designee completed education with licensed nurses on ensuring new orders for include placement, patency/draining, irrigation, securement device, care Qshift, and to record the output Qshift. • The facility's Staff Development Coordinator/Designee completed education with licensed nurses on the requirement of detailed communication during shift to shift report to include any changes in condition, any new physician orders, and review of any new or existing devices including. • The facility's Staff Development Coordinator completed competencies on the proper insertion of with return demonstrations for staff A, B, C, & D. • The facility's Staff Development Coordinator/Designee completed education on the identification of a change in condition with staff A, B, C, & D. System Change: • The daily clinical meeting form was edited to include: o Review of 24-hour report for change in condition. o The review of vital signs and the timely transfer of all residents that returned to the hospital. o The review of all new admissions and existing residents with to monitor to ensure orders are in place. output o The review of vital signs and the review of the nurse's change of condition evaluation for all residents that had a change in condition. o The review of vital signs for all residents per physician order. • Licensed Nurses and CNAs will complete competencies on care at the time of orientation and annually with the facility's Staff Development Coordinator. • The Director of Nursing/designee will operate as the lead investigator on all clinical investigations to ensure that the review of the care provided to facility residents meets standards. • The Administrator and Director of Nursing will complete a comprehensive investigation to include a 72-hour look of events to ensure no deprivation of care or services occurred. On the Administrator and Director of Nursing were educated by the regional nurse consultant on utilizing an investigation checklist to ensure all elements and facts are thoroughly reviewed and completed. • All facility investigations related to ANEMI will be reviewed in detail with the facility's Medical Director to ensure all areas of the investigation were completed and that the facility has identified the root cause of the incident. 4) How will the corrective action(s) be monitored to ensure the deficient practice will not recur: • The facility initiated the completion of audits seven days a week including weekends and off hours on all residents to ensure vital sign orders and the proper documentation of these vital signs. These audits will be monitored by DON/designee and reviewed by the QAPI committee. These audits will be completed weekly x 4 weeks, biweekly x 2 months, then monthly thereafter until substantial compliance is determined by the QAPI committee. • The facility initiated the completion of audits seven days a week including weekends documentation of output for all residents with. These audits will be monitored by DON/designee and reviewed by the QAPI committee. These audits will be completed weekly x 4 weeks, biweekly x 2 months, then monthly thereafter until substantial compliance is determined by the QAPI committee.
Removal Plan
- The Vice President of Operations reviewed their job descriptions with the Nursing Home Administrator (NHA) and Director of Nursing (DON) to ensure that the administrator must ensure that each resident receives necessary care and services to attain and maintain the highest practical physical, mental and well-being consistent with the resident's comprehensive assessment and plan of care.
- The Vice President of Operations and NHA re-reviewed the job description of the DON with the DON to ensure the purpose of her position is to plan, organize, develop, and direct the overall operation of the nursing services department in accordance with regulations and standards, guidelines, and to ensure the highest degree of care is maintained at all times.
- The DON will be lead investigator on all clinical investigations to ensure resident care met all accepted standards. This investigation will include a 72-hour look in time to include additional information on the events leading to the event.
- Investigations on Neglect, Misappropriation, and Injury will be reviewed in detail with the medical director to ensure all areas of the investigation were completed and that the facility has identified the root cause analysis of the incident.
- The NHA and DON will complete a comprehensive investigation to include a 72-hour look on events to ensure no deprivation of care or services occurred. The NHA and DON were educated by the regional nurse consulted on utilizing an investigation checklist to ensure all elements and facts are thoroughly reviewed and completed.
- The facility conducted an unplanned QAPI (Quality Assurance and Performance Improvement) meeting and a root cause analysis of the incident was done. Attendees of the QAPI included the Medical Director, Director of Nursing, Administrator, Human Resources, Social Service, Activities, Director, Minimum Data Set nurse, Nurse, CNA. The meeting addressed the adequate monitoring of output for residents and the adequate monitoring of vital signs for residents with changes in condition. The DON rereviewed the facility assessment and identified the facility's clinical capabilities included caring for residents without nurse competency for completed.
- The facility initiated training to the nurses for insertion and return demonstration for 42 of 50 nurses with all nurses to be retrained prior to working their next shift. Verified the retraining and return demonstration for Staff A, LPN, Staff C, LPN, Staff B, LPN, and Staff D.
- The facility added to the orientation plan of all newly hired nurses to include complete competencies on the proper insertion of with return demonstration prior to providing resident care.
- CNA education was initiated to ensure the following: any notable changes in output for residents and those residents experiencing a change in condition must be reported immediately to the nurse. CNAs were educated by all remaining CNAs are to be educated prior to working their next shift.
- The facility educated their licensed nurses on completing a Change in Condition Assessment on residents. The education included identifying conditions that required an assessment including: Accidents resulting in injury; significant change in the resident's physical or mental condition, deterioration in health, mental or output status; life threatening conditions or clinical complications including changes in including color, consistency and output: circumstances that require an alteration in treatment including acute and conditions. A complete nursing evaluation must be conducted and documented in the medical record of systems. The nurses were educated to obtain a new set of vital signs and document in the electronic record in that the Change in Condition Assessment would contain the most recent and relevant vital signs. The provider shall be notified of pertinent evaluation findings. Nurses must visualize for amount of output, color and clarity during each shift.
- Nurses were re-educated. The remaining nurses will be educated prior to working their next shift.
- The facility initiated audits of residents in the facility to ensure the nursing staff was recording vital signs and proper documentation of those vital signs.
- The facility initiated audits of residents to ensure the measuring and documenting of the output each shift.
- The facility edited the daily clinical meeting to include the review of all residents with changes in condition to ensure vital signs and a timely transfer was completed; review of all new and existing residents with had monitoring and documenting of output amount in place, review of vital signs for all residents per physician order.
- The Nursing Home Administrator (NHA) and Director of Nursing (DON) were re-educated on the policy and procedure for Neglect, and by the Regional Clinical Nurse. The education included screening, training staff to prevent neglect and all allegations of neglect are to be reported to the NHA or the person in charge immediately. Investigation, protection, and reporting to follow.
- The facility began staff in-service training and education on and Neglect with the emphasis on failure to protect resident rights to be free of neglect by failing to monitor output and to monitor the resident when the was discontinued. The resident experienced copious amounts of and clots through his penis. The facility failed to monitor vital signs with a significant change in condition. 141 of 171 staff members received this education by all remaining staff would be educated prior to working their next shift.
- The DON and nurse management team was re-educated by the regional clinical director on the components of the management of with an emphasis on Neglect, Misappropriation, and Injury.
- The facility initiated education with licensed nurses to ensure new orders for included placement, patency/draining, irrigation, securement, care each shift and recording of output on the MAR.
- 37 nurses out of 50 were educated. The surveyor verified through interviews that the nurses were educated prior to working their next shift.
- The facility educated nurses on the requirement of detailed communication during shift-to-shift report will include any changes in condition, any new orders, and review any new or existing devices including verified the training of 39/50 nurses by all remaining licensed nurses will be educated prior to working their next shift. This education has also been added to the orientation agenda for all newly hired licensed nurses to be provided prior to resident care.
- A QAPI (Quality Assurance and Performance Improvement) meeting was held, and a root cause analysis of the incident was done. Attendees of the QAPI included the Medical Director, Director of Nursing, Administrator, Human Resources, Social Service, Activities. Director, Minimum Data Set nurse. Nurse. CNA.
- The surveyor verified through interviews with the DON and facility staff, review of the audits, and review of 6 random resident records to ensure accurate assessment of resident vital signs, obtaining and documenting output and proper documentation for residents experiencing a change in condition.