Palm Garden Of West Palm Beach

Penalty

No penalty information released

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 provide appropriate care and services to prevent pressure ulcers for one resident. Upon readmission, the resident was noted to have redness on the buttocks, and assessments documented that the resident was dependent on staff for toileting and required moderate assistance for turning in bed. Despite these risk factors, there were no physician orders or care plan interventions in place to prevent skin breakdown prior to the development of pressure ulcers. The care plan did not reflect that the resident was at risk for pressure ulcers until after the wounds had developed. Subsequent assessments revealed the resident developed an open wound to the sacrum and left buttocks, which progressed to a Stage 4 pressure ulcer on the sacrum and a Stage 3 pressure ulcer on the left buttocks. Documentation showed that the resident's family was not informed about the initial redness upon readmission. Interviews with facility staff confirmed that there were no preventive interventions ordered or implemented before the pressure ulcers occurred.

Penalty

No penalty information released

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 honor a resident's advance directive choices, leading to a deficiency in providing adequate and appropriate health care. The incident involved a resident who was found unresponsive by staff. Despite having an order documented in the electronic health record, the staff did not follow the procedure to verify the code status before initiating emergency measures. The staff nurse, upon finding the resident unresponsive, checked the electronic record and the backup code status binder but did not find the necessary documentation in the binder, leading to the initiation of emergency procedures contrary to the resident's wishes. The resident, who had been admitted with multiple diagnoses, including Type 2 diabetes, was care planned for a specific code status. However, due to human error, the staff nurse second-guessed the electronic record and relied on the absence of a document in the binder, which was supposed to be the primary source of validation. The Social Service Director later acknowledged that the document might have been removed for scanning and not replaced, which contributed to the confusion and subsequent actions taken by the staff. Interviews with various staff members, including the Director of Nursing, Unit Manager, and Risk Manager, revealed that the root cause was identified as human error. The staff nurse involved had been trained on the facility's Advance Directive policy, which emphasized the electronic health record as the primary source for code status verification. Despite this, the nurse did not communicate the resident's code status to emergency services, resulting in actions that were not aligned with the resident's documented wishes.

Plan Of Correction

Resident #1 was transferred to Good Samaritan Hospital and was pronounced at 5:51AM in the ER by Hospital personnel. No further corrective action could be taken. An audit was completed on current residents by the Unit Managers to ensure that residents have Form 1896 with appropriate signatures and date in their medical record and a copy in a red binder located at each nurses station. Irregularities were immediately corrected. Code status for new admissions and re-admissions will be reviewed daily Monday to Friday in AM clinical meetings by the Inter Disciplinary Team and on weekends by the Nursing Supervisor to ensure medical records reflect accurate code status and a copy of Form 1896 that is appropriately signed and dated is uploaded in the EHR and a copy is in the binder at the nurses station if there is an order present. An audit of crash carts located on each nurses station was completed by the Director of Clinical Services to ensure equipment was readily available in an emergency. An audit was completed by the HR Manager to ensure that current Licensed Nurses have a valid license in place. One nurse had no current license on file but has since been completed. Newly hired Licensed Nurses' cards will be verified during the Orientation process. Current team members were reeducated starting on by the Director of Education and/or Designee on code status, policy, and neglect and validation of code status in PCC. 100% compliance was achieved on Licensed Nurses Education to include policy and procedure written post quiz on code status and code procedures for all licensed nurses, checking code status in PCC by a Licensed nurse if a resident was discovered to be pulseless prior to initiating Attestations that were signed for acknowledgement and understanding of policy. New hires will be educated on the policy during the orientation process by the Director of Education/designee, with written post quiz to ensure competency. Enhanced Code blue drills were conducted starting on the shift, every shift x 7 days, then every other day on different shifts x 7 days, then weekly x 7, then one on each shift monthly to include weekends by the Director of Education and/or designee. Re-education post drills as needed. Code Blue Drills will continue monthly by the Director of Education/designee one on each shift to include weekends and holidays. Results will be presented at monthly QAPI meetings to ensure ongoing compliance. The Social Service Director/designee will continue weekly audits of orders to ensure that orders are accurate, and that Form 1896 is appropriately signed and dated and is in place in the EHR, and a copy is in the red binder at the nurses station in the event of a PCC or power outage. New hires will be educated on the center's policy during the Orientation process by the Director of Education or designee with written post quiz and attestations to ensure competency. Results of audits will be presented at the Monthly QAPI meeting to ensure ongoing compliance.

Penalty

Inspection fine: $16,153

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 honor a resident's advance directive choices, resulting in a serious deficiency. The incident involved a resident who had a Do Not Resuscitate (DNR) order documented in the electronic health record. However, when the resident became unresponsive, the staff did not follow the procedure to verify the code status in the electronic record. Instead, they relied on a physical binder, which did not contain the necessary documentation due to an oversight by the Social Service Director. The staff nurse, upon finding the resident unresponsive, checked the electronic record and confirmed the DNR order but second-guessed herself and looked for the physical document in the binder, which was missing. Consequently, the nurse called 911 and initiated resuscitation efforts, contrary to the resident's documented wishes. This action was based on the facility's outdated practice of relying on the physical document as the primary source of verification, despite the electronic record being the official source. The incident was further complicated by the nurse's failure to communicate the resident's DNR status to emergency responders, leading to the continuation of resuscitation efforts upon their arrival. The facility's policy required that the electronic health record be the primary source for verifying code status, but this was not adhered to, resulting in a breach of the resident's rights and the facility's procedures.

Plan Of Correction

Resident # 1 was transferred to Good Samaritan Hospital and was pronounced at 5:51AM in the ER by Hospital personnel. No further corrective action could be taken. An audit was completed on current residents by the Unit Managers to ensure that residents with a have Form 1896 with appropriate signatures and date in their medical record and a copy in a red binder located at each nurses station. Irregularities were immediately corrected. Code status for new admissions and re-admissions will be reviewed daily Monday to Friday in AM clinical meeting by the Inter Disciplinary Team and on weekends by the Nursing Supervisor to ensure medical records reflect accurate code status and a copy of Form 1896 that is appropriately signed and dated is uploaded in the EHR and a copy is in the binder at the nurses station if there is an order present. An audit of crash carts located on each nurses station was completed on by the Director of Clinical Services to ensure equipment was readily available in an emergency. An audit was completed on by the HR Manager to ensure that current Licensed Nurses have a valid license in place; one nurse had no current on file but has since been completed on. Newly hired Licensed Nurses cards will be verified during the Orientation process. Current Team members were reeducated started on by the Director of Education and/or Designee on Code status, policy, and neglect and validation of code status in PCC. 100% compliance was achieved on License Nurses Education to include policy and procedure written post quiz on code status and code procedures for all licensed nurses, checking code status in PCC by a Licensed nurse if a resident was discovered to be pulseless prior to initiating. Attestations were signed for acknowledgement and understanding of policy. New hires will be educated on the policy during the orientation process by the Director of Education/designee, with written post quiz to ensure competency. Enhanced Code blue drills were conducted started on on the shift, every shift x 7 days, then every other day on different shift x 7 days, then weekly x 7 then one on each shift monthly to include weekends by the Director of Education and/or designee. Re-education post drills as needed. Code Blue Drills will continue monthly by the Director of Education/designee one on each shift to include weekends and holidays. Results will be presented at monthly QAPI meetings to ensure ongoing compliance. The Social Service Director/designee will continue weekly audits of orders to ensure that orders are accurate, and that Form 1896 is appropriately signed and dated and is in place in the EHR, and a copy is in the red binder at the nurses station in the event of a PCC or power outage. New hires will be educated on the centers policy during the Orientation process by the Director or Education or designee with written post quiz and attestations to ensure competency. Results of audits will be presented at the Monthly QAPI meeting to ensure ongoing compliance.

Removal Plan

• Education on code status, policy, and neglect policy initiated for current license staff. With post quiz and attestation.
• New hired licensed nurses will be educated on the advanced directive policy with post quiz and attestation. Ongoing.
• Resident's chart review completed.
• Audit of medical records of current residents to validate orders.
• Federal immediate report submitted with the notification to DCF and law enforcement.
• Code books reviewed for accuracy. Books located at each nursing station.
• The nurse involved in the incident was removed from the schedule pending investigation.
• Code blue drills to be performed to include weekends and holidays starting on until all nurses have attended a code blue drill with no deficiencies, alternating different scenarios of code status to increase staff understanding.
• Medical director notified of events and interventions.
• Crash carts audited.
• cards audited for validation.
• Ad hoc meeting with Interdisciplinary Team (IDT) and medical director.
• Quiz presented to licensed nurses to validate knowledge on code status and procedures competency as needed.
• Licensed nurse hires to be educated on current advanced directive policy attestation and competency and post quiz. Ongoing.
• New admissions/readmissions records to be reviewed daily by the nursing supervisor for accurate status. Ongoing.
• Reeducate SSD, UM, DCS, DQA on policy and obtaining form DH1896 (document) with physician and resident representative signature as soon as an order is received for.
• SSD/designee will do audit daily during clinical meeting of binders kept at the nurses' station to ensure that form 1896 is in place for those residents with an order for.
• Results and outcome of audits of binders for Form 1896 to be presented monthly.
• Audit results and outcome of drills to be presented at ad hoc meeting. Then monthly or until compliance to determine the effectiveness of the plan. Plan to be revised as necessary.
• Federal five day report submitted.
• Report to the board of nursing.
• Physician to be re-educated on signing and dating Form 1896.

Penalty

No penalty information released

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 accurately assess two residents, leading to deficiencies in their Minimum Data Set (MDS) assessments. Resident #79 was readmitted to the facility with an indwelling urinary catheter, as documented in multiple progress notes. However, the Admission MDS assessment dated 03/21/24 did not document the use of the catheter. During an interview, the MDS Coordinator acknowledged the oversight, attributing it to the lack of an order for the catheter. An observation on 04/15/24 confirmed the presence of the catheter, further highlighting the inaccuracy in the MDS assessment. For Resident #141, the discharge MDS dated 01/25/24 incorrectly coded the resident as being discharged to a short-term general hospital, whereas the resident was actually discharged home with home health care arranged. A social service progress note confirmed the correct discharge status. The MDS Coordinator admitted the error during an interview and stated that the discharge assessment should have been coded as going home, not hospitalized.

Penalty

No penalty information released

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 develop a comprehensive care plan for a resident with an indwelling urinary catheter. The resident was readmitted to the facility with a Foley catheter in place, as documented in progress notes on multiple dates. An observation confirmed the presence of the catheter, but the current care plans lacked any documentation related to its use. During an interview, the MDS Coordinator acknowledged the oversight and admitted that the care plan for the catheter was likely missed.

Penalty

No penalty information released

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 timely completion of ordered laboratory tests for Resident #194, who was admitted after a hip replacement. A physician ordered a Complete Blood Count (CBC) and a Basic Metabolic Panel (BMP) to be drawn on 04/06/24. However, the CBC was not collected until 04/08/24, and the BMP was never obtained. The progress notes lacked documentation explaining the delay in obtaining the CBC and the failure to obtain the BMP. An additional order on 04/16/24 for a CBC, CMP, and BMP was also not properly executed, leading to the administration of intravenous fluids for dehydration on 04/18/24. During an interview, the Unit Manager explained the process for obtaining physician-ordered labs but was unaware of the failure to obtain the BMP. The laboratory's website indicated that the order was rejected on 04/08/24 due to receiving an incorrect specimen. The Director of Nursing (DON) confirmed the same process for ordering labs and stated that they review labs during morning meetings but had no explanation for the oversight. The CBC completed on 04/08/24 was reviewed by the Unit Manager, but the missing BMP was not addressed.

Penalty

No penalty information released

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 and complete resident records for four residents. For Resident #79, the record lacked an order for the indwelling urinary catheter despite multiple progress notes and observations indicating its use. This omission led to an inaccurate Minimum Data Set (MDS) assessment and a lack of an associated care plan for the resident's catheter care needs. Resident #36's record lacked documentation related to a change in code status. Although the resident changed from a Do Not Resuscitate (DNR) order to a full code status, there was no documentation of a conversation with the resident about the change or evidence that the resident understood the implications of CPR and DNR. The Social Service Director and a Licensed Practical Nurse confirmed the discussions but failed to document them in the electronic health record (EHR). For Resident #57, the record contained inaccurate documentation related to a midline catheter dressing change. The Medication Administration Record (MAR) indicated that the dressing was changed on a specific date, but observations and interviews revealed that the dressing had not been changed as documented. Additionally, Resident #92's record lacked documentation related to blood sugar monitoring. The electronic Medication Administration Record (eMAR) showed missing blood sugar results and no nurse documentation explaining the absence of these results or the administration of insulin as required by the physician's orders.