Decatur Health & Rehab Center

Penalty

Inspection fine: $17,346

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to notify the physician of a significant change in condition for a resident identified as RI #497. On January 4, 2025, the resident experienced an elevated heart rate of 142 beats per minute at 1:24 PM, which was not communicated to the physician. Later that day, at 9:22 PM, the resident's heart rate remained elevated at 120 beats per minute, yet again, the physician was not informed. This lack of communication resulted in no additional treatment or interventions being implemented, leading to a delay in necessary medical care. The resident, who had a history of Chronic Obstructive Pulmonary Disease and Atrial Fibrillation, continued to experience elevated heart rates and eventually complained of chest pain and difficulty breathing. Despite these symptoms, the resident was not transferred to the hospital until the early hours of January 5, 2025. Upon arrival at the hospital, the resident was admitted to the Intensive Care Unit for treatment of Atrial Fibrillation with Rapid Ventricular Response. Interviews with facility staff revealed that there was a failure to follow the facility's policy on notifying physicians of changes in a resident's condition. The Registered Nurse and Licensed Practical Nurse involved did not notify the physician or follow up on instructions given by the Certified Nurse Practitioner. This oversight was identified as a deficiency under Resident Rights, specifically regarding the notification of changes in a resident's condition.

Removal Plan

• The Director of Nursing (DON) provided 1:1 in-service with the licensed nurse who failed to notify the physician on physician notification when resident experiences change in condition and notification parameters on vital signs.
• All residents in house most recent vital signs were reviewed by the DON, Regional Director of Health Services and Regional Assessment Coordinator for any change of condition as well as vital signs outside parameters that were set forth by the Medical Director.
• Any resident with a change of condition or vital signs outside the parameters, the provider was notified by DON, Unit Manager or Charge nurse for any additional orders or treatment.
• All licensed nurses, which are 31 in total, were educated on notification to the provider for change in condition, to include vital signs outside the parameters given by the DON and Staff Development Coordinator. Any licensed nurse who did not receive the in-service will not be allowed to work until the in-service has been provided. There is 1 LPN pending (on medical leave) and the DON is responsible to ensure they are educated before working.

Penalty

Inspection fine: $17,346

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that licensed staff followed professional standards of practice, resulting in a significant deficiency. Specifically, an LPN did not accurately transcribe a critical order for a resident with an elevated heart rate. The resident, identified as having chronic obstructive pulmonary disease, hypertension, and atrial fibrillation, had a heart rate of 142 bpm. The LPN received an order to manually check the resident's heart rate twice daily and to send the resident to the emergency room if the heart rate did not decrease. However, the LPN failed to transcribe the order to send the resident to the ER and did not reassess the resident's heart rate before the end of her shift. The resident's heart rate was not checked again until several hours later, at which point it was still elevated. No new interventions were implemented, and the resident was not transferred to the ER until the following day when they complained of chest pain and difficulty breathing. Interviews with the LPN and CRNP revealed that the LPN did not communicate the order to the oncoming nurse, and the CRNP confirmed that the resident should have been sent to the hospital if symptomatic. Additionally, the facility failed to have a system in place to ensure the resident's heart rate was assessed before administering Digoxin, a high-risk medication. The standard of practice requires checking the apical pulse before administering Digoxin, but this was not done. Interviews with nursing staff and the DON revealed a lack of understanding and documentation regarding the necessity of heart rate monitoring before administering the medication.

Removal Plan

• The facility failed to ensure licensed staff followed standards of practice and completely and accurately transcribed an order received from a CRNP to send RI#497 to the emergency room if heart rate did not go down. The nurse also did not communicate the order to the oncoming nurse. The nurse further failed to re-assess RI #497's heart rate at the time the order was provided to ensure RI#497 did not need to be transferred to the ER. The facility further failed to ensure process was in place to ensure resident's HR was checked prior to administration of digoxin.
• The Director of Nursing (DON) provided 1:1 education to the licensed nurse that took the verbal order, and did not communicate to the oncoming nurse. Education included completely and accurately transcribing an order received from a physician or CRNP, following up on an order and communicating new orders to the oncoming nurse that require follow up, and assessing residents heart rate prior to administering digoxin.
• The DON reviewed all current in-house residents last recorded vital signs to identify any resident with vital signs outside the parameters set forth by the Medical Director. Any resident identified with vitals signs outside the parameters, the provider was notified, and any new orders as indicated.
• All residents in house on Digoxin (and amiodarone, clonidine) were reviewed by the DON, Regional Director of Health Services (RDHS) and Pharmacist to ensure heart rate/blood pressure documentation was included on the Medication Administration Record with parameters for Digoxin (and amiodarone, clonidine).
• The nurse that transcribes the order will be responsible for ensuring HR/BP as indicated documentation is included for any residents with new digoxin (and amiodarone, clonidine) orders. The clinical meeting by the DON and Nurse Managers will verify HR/BP documentation will be included with any new Digoxin orders.
• The process to ensure the MAR includes vital sign monitoring/parameters for ALL medications which require monitoring of vitals before administration per standards of practice will be: MD and Facility Pharmacist determined the following medications require VS monitoring preadministration: Clonidine-hold if systolic BP <90 or diastolic BP <55 and notify MD/NP; Amiodarone-hold if pulse < 55bpm or systolic BP <100 or diastolic BP <60 and notify MD/NP; Digoxin-hold if pulse <60bpm and notify MD/NP. The DON/ Regional Director of Health Services/ Facility Pharmacist completed an audit of residents' medications to ensure all medications with an established standard of practice to check vitals pre-administration are identified and the monitoring is included on the MAR. During the clinical meeting the DON and Nurse Managers will verify all new orders for medications requiring VS monitoring include the required monitoring and documentation on the MAR. The nurses will know the thresholds for VS, HR monitoring for newly ordered digoxin and HR and blood pressure for Amiodarone and blood pressure monitoring for Clonidine because it was posted at the nurses station by the DON, additionally the specific instructions are included on the MAR to notify the MD/NP if the VS are out of the parameters.
• Vital Sign threshold alerts were updated to the electronic medical record for all residents by the DON and RDHS.
• The RDHS revised the New Admit/Readmit Checklist to include setting the vital sign parameter thresholds set forth by the Medical Director and Pharmacist related to Clonidine, Amiodarone, and digoxin orders have heart rate and or BP parameters for monitoring, holding of medication and notification of MD/NP.
• All licensed nurses were provided with education by the DON and Staff Development Coordinator. Any licensed nurse who did not receive this education will not be allowed to work until the education has been provided. Education included completely and accurately transcribing an order received from a physician or CRNP, following up on an order and communicating new orders to the oncoming nurse that require follow up, and assessing residents' heart rate and or BP prior to administering Clonidine, Amiodarone and Digoxin, the updated procedures including entering the order for assessment and documentation of HR monitoring for newly ordered digoxin and HR and blood pressure for Amiodarone and blood pressure monitoring for Clonidine. The nurses were educated that the thresholds for VS was posted at the nurses station by the DON, additionally the specific instructions are included on the MAR to notify the MD/NP if the VS are out of the parameters.

Penalty

Inspection fine: $17,346

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that a system was in place to assess the vital signs of newly admitted residents at a frequency expected by the physician or CRNP. Specifically, a resident admitted after hospitalization for Atrial Fibrillation with Rapid Ventricular Response had orders for vital signs to be checked only once a month, contrary to the physician's expectation of daily assessments for new admissions. This oversight led to a situation where the resident's heart rate was significantly elevated, reaching 142 bpm, without timely intervention. The deficiency was further compounded by the lack of established parameters for when the physician should be notified of abnormal vital sign values. On one occasion, the resident's heart rate was recorded at 120 bpm, but no action was taken until the resident experienced chest pain and shortness of breath, prompting a request for hospital transfer. Interviews with facility staff, including the DON and CRNP, revealed a discrepancy between the expected and actual practices for monitoring vital signs in newly admitted residents. The facility's non-compliance with the requirements of participation was determined to have caused, or was likely to cause, serious injury, harm, impairment, or death, resulting in an Immediate Jeopardy citation. The deficiency was identified during the investigation of a complaint, highlighting the need for a systematic approach to vital sign monitoring and physician notification for newly admitted residents.

Removal Plan

• The facility failed to ensure a system was in place to ensure newly admitted residents' vital signs were assessed at a frequency expected by the physician/CRNP.
• Resident specific vital sign parameters were established including when the physician should be notified of abnormal values.
• The Director of Nursing contacted the Medical Director for guidance on updating vital sign thresholds for notification.
• The Medical Director was contacted by the DON on his expectations on vital sign monitoring.
• An updated New Admit/Readmit Checklist was implemented to ensure vital sign frequency and parameters are established at the time of admission.
• The vital sign monitoring policy was updated by the RDHS to require at least daily vital signs for all newly admitted or readmitted residents for 2 weeks.
• The Director of Nursing contacted the Medical Director for guidance on updating vital sign thresholds for notification.
• The Medical Director was contacted by the DON on his expectations on vital sign frequency.
• Vital sign parameter thresholds and frequency were updated for all newly admitted or readmitted residents over the last 30 days, vital sign orders by the RDHS and DON.
• The Daily Clinical Meeting form was revised by RDHS to include review of vital signs outside physician ordered parameters with follow up documentation.
• The DON and Staff Development Coordinator provided education for licensed staff on the updated VS Monitoring Policy, monitoring residents' vital signs at least daily for 2 weeks following an admission or re-admission and vital signs thresholds that require physician notification, and process to document vitals, notification, and physician recommendations.

Penalty

Inspection fine: $17,346

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to adhere to proper food safety protocols as outlined by the U.S. FDA 2022 Food Code and the facility's own policies. During an observation, it was noted that frozen chicken was improperly thawed in a preparation sink without running water or submersion, contrary to the FDA guidelines which require thawing under refrigeration or under running water at a specific temperature. The Dietary Manager admitted to placing the chicken in the sink to start the defrosting process before transferring it to the cooler, which is not an approved method. Additionally, two boiled eggs were found in the Reach-in Cooler without a use-by date, violating the facility's policy for date marking. The absence of a use-by date on the eggs meant there was no way to determine how long they had been stored, posing a potential risk for foodborne illness. The Dietary Manager acknowledged the potential danger of not having a date, as it could lead to the consumption of expired food. Interviews with the Dietary Manager and the Registered Dietitian confirmed the improper handling of the chicken and the lack of date marking on the eggs. Both staff members recognized the potential for foodborne illness due to these oversights, as improper thawing and lack of date marking could result in food being stored in the temperature danger zone for too long or being consumed past its safe period.

Penalty

Inspection fine: $17,346

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure proper disposal of garbage and refuse as per the U.S. FDA 2022 Food Code and the facility's own policy. During an inspection, it was observed that two dumpsters located outside the facility were not properly closed. One dumpster had a side door left open, and the other had a broken lid. Additionally, food-related trash was found strewn on the ground around the dumpster area, including plastic utensils, a food container, condiment packages, straws, gloves, and cup lids. The Dietary Manager acknowledged that the open dumpsters and scattered trash could attract rodents, which could potentially enter the facility. The Registered Dietitian also expressed concern that the presence of pests and rodents could affect the residents by potentially entering the facility's kitchen. This deficiency had the potential to impact all 100 residents receiving meals from the facility's kitchen.

Penalty

Inspection fine: $17,346

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain essential kitchen equipment in working order, as observed during a survey. The Tilt Skillet had been out of order for approximately four years and was being used as a countertop. The Double Steamer was also inoperable, having stopped working in 2023. Additionally, there were operational issues with the two Stove Ovens, where the pilot lights would extinguish when the doors were closed. These deficiencies were identified during a kitchen tour and interviews with the Dietary Manager and Maintenance Director. The Maintenance Director explained that the previous and current facility owners were informed that replacing the Tilt Skillet and Double Steamer would be more cost-effective than repairing them. The Maintenance Director also noted that the Stove Ovens' pilot lights were affected by fans used to dry the floor, which would blow them out. The Dietary Manager and Registered Dietitian expressed concerns about the impact of having broken equipment, highlighting the risk of cooking delays and inadequate equipment for food preparation. The Maintenance Director acknowledged that major equipment issues were reported to the corporate office for decisions due to financial considerations, and a change in management had led to some issues being overlooked.

Penalty

Inspection fine: $17,346

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to protect a resident's right to be free from verbal abuse. On the night of the incident, a newly admitted resident with severe cognitive impairment due to dementia was involved. The resident was reportedly being combative and yelling, which prompted the intervention of several CNAs. During this time, an LPN entered the room and was witnessed using profanity towards the resident, telling them to "shut the fuck up." This incident was witnessed by multiple CNAs who considered the language used by the LPN to be verbal abuse. The resident, identified as having severe cognitive impairment, was unable to recall the incident. However, the staff present during the incident reported the LPN's behavior to their supervisor. The LPN's actions were described as inappropriate and unprofessional, and the language used was considered abusive by the staff who witnessed it. The facility's policy on abuse defines verbal abuse as the use of disparaging and derogatory terms, which aligns with the behavior exhibited by the LPN. The incident was reported to the state agency, and the facility conducted an investigation. The investigation confirmed that the LPN used foul language in the presence of the resident. Despite the resident's inability to recall the incident, the staff's testimonies and the facility's policy on abuse led to the conclusion that the resident's rights were violated. The LPN was subsequently terminated for violating the resident's rights.

Penalty

Inspection fine: $17,346

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure an order for the use of oxygen was obtained for a resident upon admission. The resident, identified as having Unspecified Atrial Fibrillation, Respiratory Disorders, and Chronic Obstructive Pulmonary Disease (COPD), was admitted with a hospital order for oxygen to maintain saturation levels above 88%. However, the facility did not have an order for oxygen use upon the resident's admission. The order for oxygen at 2 liters per minute via nasal cannula was not entered into the facility's system until several days later. Interviews with facility staff revealed that the admitting nurse was responsible for verifying and transcribing the hospital orders into the facility's system. However, this was not done, leading to the absence of an oxygen order in the Medication Administration Record (MAR). The CRNP who assessed the resident noted the need for supplemental oxygen but confirmed there was no order at the time. The Director of Nursing and the Medical Director both acknowledged that the resident should have had an oxygen order upon admission, highlighting a lapse in the facility's admission process.

Penalty

Inspection fine: $17,346

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure the timely transmission of a completed Minimum Data Set (MDS) assessment for a resident, identified as RI #38, to the Centers for Medicare & Medicaid Services (CMS) system. According to the CMS Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, comprehensive assessments must be transmitted electronically within 14 days of the Care Plan Completion Date. However, the MDS for RI #38, with an Assessment Reference Date of October 15, 2024, was not submitted within the required timeframe. The oversight was identified during an interview with the Minimum Data Set Coordinator (MDS-C), who acknowledged the delay in submission. RI #38 was admitted to the facility with a diagnosis of Type 2 diabetes mellitus without complications and was later discharged. The MDS-C indicated that the MDS should have been submitted within fourteen days after the Assessment Reference Date to ensure proper reporting to CMS. The MDS was eventually submitted on January 29, 2025, by the Regional Assessment Compliance Coordinator, highlighting a lapse in the facility's compliance with federal and state transmission requirements.

Penalty

Inspection fine: $17,346

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure accurate documentation of medication administration for a resident identified as RI #447. The resident, who was admitted with a diagnosis of Diabetes Mellitus with Hyperglycemia, had an incident where LPN #27 documented the administration of Lantus Insulin on the Medication Administration Record (MAR) when it was not actually given. This discrepancy was noted in a nursing note dated 11/02/2024, where LPN #27 acknowledged mistakenly charting the insulin as administered. During an interview, LPN #27 explained that the insulin was not administered because the resident was not eating or drinking, and she accidentally documented it as given by hitting the wrong key. The Director of Nursing confirmed that the facility's policy requires staff to document medications as not administered if they are not given, along with the reason. This failure to follow the facility's documentation policy resulted in an inaccurate record of treatment for the resident.

Penalty

Inspection fine: $17,346

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure proper infection prevention and control practices were followed by an LPN during medication administration and vital sign assessment. The LPN was observed handling medications with bare hands while preparing them for a resident, which is against the facility's infection control policy. The LPN admitted to normally wearing gloves but failed to do so in this instance, acknowledging the infection control concern associated with touching medications with bare hands. Additionally, the LPN did not follow proper protocol for handling medical equipment used for obtaining vital signs, as the equipment was placed on a resident's bed and later on a medication cart without being cleaned or disinfected. The Director of Nursing and the Infection Preventionist confirmed that the actions of the LPN were not in compliance with the facility's infection control policies. They emphasized that medications should not be touched with bare hands and that medical equipment should be placed on a barrier and sanitized after use. The failure to adhere to these protocols had the potential to affect two residents, as the equipment was used on multiple residents without proper disinfection, posing a risk of infection transmission.

Penalty

Inspection fine: $8,021

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure adequate supervision for a resident with cognitive deficits, leading to an elopement incident. On the specified date, the resident eloped from the facility around 5:35 PM. A CNA noticed the resident was not in their room around 6:00 PM but did not take action to locate them, assuming the resident had been discharged. It wasn't until 8:47 PM that an LPN realized the resident's whereabouts were unknown and initiated a search. The resident was eventually found by local law enforcement at a grocery store 1.9 miles away from the facility at 8:57 PM. The resident had been admitted for rehabilitation services and had diagnoses including dementia, encephalopathy, and alcohol abuse. The resident's care plan indicated a desire to return home, and staff interviews revealed that the resident had expressed confusion and a desire to go home. Despite these indicators, the resident was not identified as being at risk for wandering or elopement. The facility's policies on elopement and missing residents were not adequately followed, as staff failed to monitor the resident and did not conduct timely checks. Interviews with staff revealed lapses in communication and supervision. The CNA who first noticed the resident missing did not report it immediately, and the LPN on duty did not receive a proper handover from the previous nurse. The facility's previous Director of Nursing confirmed that residents should be checked every two hours, but the resident was not monitored for over three hours. This lack of supervision and failure to follow established protocols led to the resident's elopement and the subsequent finding by law enforcement.

Removal Plan

• The resident was located nearby by local law enforcement and taken to the emergency room for an evaluation upon family request. No injuries noted. The resident discharged home with the RP after the ER visit.
• A one-time head count to verify all current residents were inside the facility was completed by the charge nurse on duty. All residents were accounted for.
• All facility exits were verified by the Administrator and DON to be locked and alarms functional.
• DON/Social Worker completed a new elopement risk User Defined Assessment for all current residents to identify any resident who may have had a change in condition deeming them at risk for elopement. Any residents found to be newly at risk will have their care plan reviewed and revised as indicated.
• The front door will be monitored until all reassessments have been completed.
• All staff will be interviewed to ascertain if there are any residents with wandering behavior that may not be documented. If residents are identified with wandering behavior not previously identified, their assessment and care plan will be updated to reflect the wandering.
• A discharge communication form will be instituted to reflect scheduled discharges each day indicating discharge date/time to effectively communicate between discharge planner and direct care staff. The discharging nurse will sign acknowledging when discharge occurs.
• Facility front door was locked and/or supervised. Facility changed the door system to remain locked at all times with keypad code required for entry/exit. Residents and family members notified and educated of change in entry/exit process by resident council meeting and family notifications by phone and written notification.
• Staff re-educated by DON/Designee regarding reporting of new behaviors such as wandering and elopement policy. Staff also reeducated on steps to take if a resident displays wandering behavior. Charge nurses reeducated regarding documentation of behaviors, specifically wandering with the need to obtain an order for a Wander guard Bracelet if indicated.
• 24-hour report/Nurse-to-nurse communication process updated to a more efficient method of communicating changes from shift to shift. A 24-hour notebook will be utilized rather than 24-hour report form. Staff education was initiated. Staff education on the new process for 24-hour report was completed.
• The facility will utilize elopement risk assessment in Electronic Medical Record that scores residents on a scale of 0-10 according to elopement risk level.
• Staff educated regarding discharge communication form initiated by discharge planner to communicate with direct care staff the scheduled discharges each day. The discharging nurse will sign acknowledging the discharge is complete and return to the DON.
• Facility doors will be checked daily x 1 week and then weekly x 4 weeks to verify that all doors are secured and functioning properly.
• The facility Interdisciplinary Team (IDT) will review nurse's 24-hour report information and discuss new or worsening behaviors in daily clinical meetings 5 x weekly. If a new behavior is reported or documented, IDT will verify that care plan and orders reflect interventions as indicated. DON/Designee will also interview 5 staff members to verify reporting and documentation of any new wandering behaviors. The interviews will be weekly x 4 weeks, then monthly x 2 months.
• 24-hour report/Nurse-to-nurse communication process monitored daily in clinical meeting 5 x weekly X 4 weeks to verify the 24-hour notebook is being utilized and report is thorough.
• Elopement risk assessments (that score residents on a scale of 0-10 according to elopement risk level) will be reviewed on all new admissions X 3 months to verify that assessment is complete, interventions in place and care planned if appropriate.
• The facility IDT will review the discharge communication forms from the previous day to verify each discharge occurred as scheduled and will initiate a new discharge communication form listing the discharges scheduled for the day and will provide the form to direct care nurses on each unit.
• An emergency Quality Assessment Program Improvement (QAPI) meeting was conducted, attendance included the Medical Director.