Regents Park Of Sunrise

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

A deficiency occurred when a resident with severe cognitive impairment and a known risk for elopement exited the facility unsupervised through the main front door. The resident, who had diagnoses including dementia, memory deficit, cerebral infarction, atrial fibrillation, and diabetes, was found by police approximately half a mile away on a busy six-lane roadway after sunset. Facility staff were unaware that the resident had left the premises, and the resident was unable to communicate her address or destination to the police. The facility's policy required systematic monitoring and management of residents at risk for elopement, including timely response to alarms and implementation of care plan interventions, but these measures were not effectively executed. Interviews and record reviews revealed multiple lapses in supervision and communication. Staff members assigned to the resident did not know she was at risk for elopement, and no alarm or beeping sound was heard at the nurse's stations at the time of the incident. The care plan for the resident was not updated to reflect her elopement risk, and there were no interventions documented to address her behaviors of seeking to communicate with family or pacing near exit doors. Additionally, staff failed to redirect the resident or provide additional supervision when she expressed agitation and a desire to contact her daughter earlier in the day. Technical failures also contributed to the deficiency. The main lobby door's alarm system was not functioning as intended: the annunciator device on one wing was muted, and the other wing's device did not have a designated alarm switch for the main lobby door. Reception staff, who were responsible for monitoring the elopement risk binder and door alarms, were not aware of the resident's risk status. The front doors were left unattended and unlocked for a period in the evening, further compromising resident safety. These combined failures in supervision, communication, care planning, and alarm system functionality led to the resident's unsupervised exit and subsequent elopement.

Removal Plan

• Resident #1 returned to facility, placed on one-on-one supervision. Evaluation by LPN revealed no signs of injury or distress. Care Plan updated to reflect current care needs. A head count was conducted of current residents at the facility by RN supervisor. No concerns were identified.
• Current facility residents had elopement risk screens completed. Two additional residents triggered at risk for elopement. Orders and Care Plan were updated to reflect current needs based on updated Elopement Risk Evaluations.
• Elopement risk binders were reviewed to ensure they contain photos and demographic information of residents evaluated to be at risk for elopement. The surveyors reviewed and verified the 3 elopement binders located at the Receptionist desk, C Wing nurse's station and B Wing nurse's station were accurate.
• Elopement Drills to include door alarm drills conducted each shift. Education on elopement process, exit seeking behaviors and exit seeking behavior process/procedures discussed after each drill.
• Education for current staff initiated related to the facility Elopement/ Wandering Residents policy, Abuse, Neglect, Misappropriation and Exploitation, elopement/exit seeking behaviors identification, staff notification of elopement risk, location and contents of elopement risk binders, initiating enhanced supervision for residents actively exit seeking, responding to door alarms and proper actions to take once determined to be exit seeking or at risk for elopement. It also included the change to entry and exit of the facility through designated doors. Licensed nurses received specific education on exit seeking behavior and initiating appropriate care plan, orders and adding the elopement risk alert to the gray bar (this is in the electronic medical record and shows immediately below the picture of the resident in both the nurses charting system and the CNA charting system), immediately updating the elopement risk binders, creating a new elopement risk assessment in the computer and notifying nursing management. Receptionist received specific education followed by specific competencies on monitoring the door alarm system and notification to maintenance if a failure is identified, understanding the importance of the elopement binder and reviewing it at the beginning of each shift worked, and the proper procedures of resident LOA, signature for each oncoming and off-going shift on the clipboard indicating they had both appropriately initiated or deactivated the screamer alarm and for their review of the elopement binder, the process of utilizing the video doorbell for visitor/vendor entry and exit and notification of nursing manager if exit seeking behavior is identified.
• Education was conducted with IDT team on the process of identification, care planning, prevention, and response of elopement/exit seeking behaviors in morning meeting by progress/behavior note review and a review of the elopement risk UDAs, admission and readmission assessments (that contain the elopement risk evaluation for new residents) completed.
• Huddles are conducted at the beginning of each shift to discuss elopement risk and fall risk residents. This is an added communication to ensure staff are aware of at-risk residents.
• Door function and alarms were checked by the Administrator and the Maintenance Director, all doors and alarms were functioning appropriately. During the review by Maintenance Director, the C wing annunciator was noted to be muted. The volume of the annunciator was increased, and the button was disabled to remove the ability of staff to adjust the volume by vendor.
• Education provided by Staff Development Coordinator, DON and Administrator. All facility staff received education on the facility elopement/ Wandering Residents policy, Abuse, Neglect, Misappropriation and Exploitation, elopement/exit seeking behaviors identification, staff notification of elopement risk, location and contents of elopement risk binders, initiating enhanced supervision for residents actively exit seeking, responding to door alarms and proper actions to take once determined to be exit seeking or at risk for elopement. It also included the change to entry and exit of the facility through designated doors. All licensed nurses received education on exit seeking behavior and initiating appropriate care plan, orders and adding the elopement risk alert to the gray bar (this is in the electronic medical record and shows immediately below the picture of the resident in both the nurses charting system and the CNA charting system), immediately updating the elopement risk binders, creating a new elopement risk UDA and notifying nursing management. All receptionists have been educated on monitoring the door alarm system and notification to maintenance if a failure is identified, understanding the importance of the elopement binder and reviewing it at the beginning of each shift worked, and the proper procedures of resident LOA, signature for each oncoming and off-going shift on the clipboard indicating they had both appropriately initiated or deactivated the screamer alarm and for their review of the elopement binder, the process of utilizing the video doorbell for visitor/vendor entry and exit and notification of nursing manager if exit seeking behavior is identified.
• Newly hired staff and staff members on leave will receive education at orientation or prior to working their next scheduled shift.
• Root Cause Analysis (RCA) completed and reviewed by QAPI. Additional contributing root causes were identified and addressed in QAPI, as outlined below. These factors were staff response, staff knowledge of elopement risks and resident safety, appropriate plan of care/interventions for residents, muting of the C wing annunciator.
• The facility conducted an ad hoc QAPI meeting which included the Facility Administrator, DON, Medical Director via telephone, and additional staff members. The Performance Improvement Plan was accepted by the committee. The annunciator and the correction plan of the annunciator was reviewed in QAPI as indicated by the review of the maintenance enhancement plan. Door alarm annunciator volume increased on C wing, mute button on C wing annunciator disabled. Reviewed staff education completed including identification and response/process of exit seeking behaviors, elopement drills conducted. No additional recommendations were made at that time.

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 disburse resident funds within 30 days to the representatives of three deceased residents, as required by their policy. Resident #1 had a Power of Attorney (POA) listed, and after the resident's death, the Business Office Manager (BOM) acknowledged delays in merging accounts due to a change in facility ownership. The BOM stated that the POA was in regular contact and had received a partial refund, but the full disbursement was delayed beyond the 30-day requirement. Resident #2's account remained open with a balance of $100.02 after the resident's death. The BOM admitted to not sending a letter to the resident's representative and acknowledged responsibility for not closing the account promptly. The resident's emergency contacts were documented, but no action was taken to disburse the funds within the required timeframe. For Resident #3, the account also remained open with a balance of $63.03 after the resident's death. The BOM did not send a letter to the resident's representative and planned to send the funds to unclaimed property due to the absence of a POA on file. The BOM was unaware of the cousin listed as an emergency contact having POA papers. The facility's administrator confirmed the 30-day requirement for refunding resident funds, which was not met in these cases.

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 promptly address a grievance related to a resident's Power of Attorney (POA) request for funds reimbursement. The Business Office Manager (BOM) acknowledged that the facility was undergoing a transition to new ownership, which involved merging resident funds accounts. Despite the POA's initial communication requesting assistance in closing the resident's trust account and receiving the remaining funds, there was no documented follow-up from the facility until the POA reached out again. This lack of timely communication and resolution of the grievance was identified as a deficiency. The resident in question had been admitted to the facility and subsequently passed away. The POA was aware of the ongoing merger of funds but did not receive a timely response regarding the reimbursement. The BOM eventually communicated that the account had been closed and a check would be issued, but this response came only after the POA's repeated inquiries. The delay in addressing the POA's grievance and the absence of written documentation of follow-up communication contributed to the facility's failure to honor the resident's right to voice grievances without reprisal.

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 implement an effective infection control program during a COVID-19 outbreak, as evidenced by the lack of adherence to CDC and Florida Department of Health (DOH) recommendations. Observations revealed that three out of five Personal Protective Equipment (PPE) carts on the first and second floors did not contain N95 masks or eye protection, which are essential for healthcare personnel entering rooms of residents with suspected or confirmed SARS-CoV-2 infection. Despite recommendations from the DOH, the facility did not ensure that N95 masks were readily available in isolation carts, and staff were observed using KN95 masks instead. Interviews with staff, including the Director of Nursing (DON), Infection Preventionist (IP), and central supply personnel, highlighted a lack of clear responsibility and accountability for stocking PPE carts. The DON stated that everyone was responsible for ensuring the carts were stocked, but observations showed inconsistencies in the availability of N95 masks and eye protection. Staff members, including CNAs and LPNs, were observed wearing KN95 masks when caring for COVID-19 positive residents, contrary to the facility's guidelines and DOH recommendations. Additionally, there was a lack of consistent signage indicating the appropriate use of PPE outside residents' rooms. The report also detailed specific instances where staff failed to follow proper infection control protocols. For example, a CNA was observed not changing gowns between resident care and leaving room doors open, which should have been closed according to the facility's guidelines. Another staff member, an Occupational Therapist Assistant, admitted to not wearing an N95 mask while providing therapy to a COVID-19 positive resident, acknowledging it was a mistake. These actions contributed to the facility's failure to maintain an effective infection prevention and control program during the outbreak.

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 necessary assistance during dining for a resident with severe cognitive impairment. Resident #44, who was admitted with diagnoses of muscle wasting, anemia, and depression, required supervision with touch-up assistance for eating, as indicated by the Quarterly Minimum Data Set (MDS) assessment. Observations on multiple occasions revealed that Resident #44's meals were left untouched, and staff did not encourage or assist the resident to eat. For instance, on 04/22/24, the resident's breakfast and lunch trays were left untouched, and no staff attempted to wake or assist the resident. Similar observations were made on 04/23/24 and 04/24/24, where the resident was found asleep with untouched meal trays and no staff intervention. Interviews with staff members provided conflicting information about the resident's ability to eat independently. Staff K and Staff L stated that Resident #44 could eat independently and usually consumed a significant portion of her meals, which contradicted the surveyor's observations. Additionally, the CNA task records inaccurately reported the resident's meal consumption. A review of the resident's weight log showed a downward trend in weight, indicating potential nutritional issues. The MDS Coordinator confirmed that Resident #44 required supervision with touch-up assistance, which was not consistently provided, leading to the deficiency in care.

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 address a skin rash for Resident #97 and new symptoms of a urinary tract infection (UTI) for Resident #59 in a timely manner. Resident #97, who had severe cognitive impairment and was dependent on activities of daily living, was admitted with a tracheostomy and feeding tube. The resident was care planned for a rash on the upper back, with interventions including anti-pruritic medications and monitoring for infection. Despite an order for Permethrin lotion on 03/30/24, the medication was not administered until 04/05/24, and there was no documentation explaining the delay. Additionally, there was no documentation of the rash's condition since the initial order, and the Director of Nursing (DON) was unaware of the prescribed treatment. Interviews with staff and the resident's Power of Attorney (POA) revealed a lack of awareness and follow-up on the rash's condition and treatment efficacy. The Nurse Practitioner (NP) and Consultant Pharmacist provided conflicting information about the use of Permethrin, with the NP suggesting a dermatologist consult, which had not been ordered. Resident #59, admitted with cerebral infarction, chronic obstructive pulmonary disease, and type 2 diabetes, reported burning with urination on 04/23/24. The Licensed Practical Nurse (LPN) responsible for the resident did not document any follow-up or new orders until prompted by the surveyor the next day. The LPN claimed to have called the resident's primary doctor, but there was no record of this call. The physician confirmed that no call was received on the previous day. Eventually, an order for Pyridium was received, and a urine sample was collected for analysis. The resident reported feeling better the following day, but the delay in addressing the symptoms was evident. Interviews with the Regional Nurse Consultant and the Director of Nurses confirmed the timeline of events and the eventual actions taken to address the resident's symptoms.

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 maintain physician oversight for worsening pressure wounds for Resident #64, who was admitted with diagnoses including cerebral infarction, type 2 diabetes, and dysphagia. Upon admission, the resident was assessed with a Braden Scale score indicating a mild risk for pressure sores. However, over several months, the resident developed multiple pressure wounds on the sacrum and hips, which progressively worsened. Despite the deterioration, there was a lack of consistent documentation and oversight by the physician, with several visits recorded without any mention of the wounds. The wound documentation revealed a series of worsening measurements and conditions, including necrotic tissue and purulent drainage. The resident's wounds were not consistently assessed by a wound care specialist until several months after the initial identification of the pressure sores. The facility's policy required prompt assessment and treatment of pressure injuries, but this was not adhered to, as evidenced by the delayed involvement of a wound care nurse practitioner and the subsequent surgical debridement. Interviews with staff and the resident's family highlighted concerns about the resident's nutrition and the adequacy of protein in her meals, which could have contributed to the worsening of her wounds. The Director of Nurses admitted that there was a period when the wound care physician was not visiting the facility, and the nurse manager was responsible for weekly wound checks. This lack of specialized oversight and the failure to document and address the wounds in a timely manner led to the deficiency in care for Resident #64.

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 timely identify residents with malnutrition status and provide nutritional interventions, resulting in weight loss and pressure ulcer development for Resident #64. The resident, who had severe cognitive impairment and multiple diagnoses including cerebral infarction and type 2 diabetes, experienced significant weight loss and the development of pressure ulcers due to inadequate nutritional support. Despite being on a carbohydrate diet with pureed texture and thin consistency, the resident's intake was poor, and the facility did not consistently provide the prescribed nutritional supplements or adjust the feeding regimen appropriately. Observations revealed that the resident's tube feeding was not managed correctly, with discrepancies in the type and amount of formula administered. The facility's dietitian failed to recommend or document additional nutritional supplements in a timely manner, despite the resident's declining weight and poor meal intake. The dietitian also did not adjust the tube feeding rate and hours when the formula was changed, leading to insufficient caloric and protein intake for the resident. Interviews with staff and the resident's family highlighted issues with meal tray contents and the provision of nutritional supplements. The family reported that meal trays often lacked protein and that they had to request supplements from the kitchen. The dietitian acknowledged the resident's severe weight loss and the need for increased nutritional support but did not implement necessary interventions promptly. The resident's care plan and physician's notes also failed to address the nutritional status and the development of pressure ulcers adequately.

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 limit a new order for a psychotropic drug used on a PRN basis for a resident reviewed for unnecessary medication. The resident, who was admitted with diagnoses including Chronic Obstructive Pulmonary Disease (COPD), Syncope, Diabetes Type 2, and Anxiety Disorder, had a BIMS score of 15, indicating cognitive intactness. On 04/04/24, the physician ordered Alprazolam 2 MG to be given as needed for sleep at bedtime. However, the consultant pharmacist recommended discontinuing or adding a stop date to the PRN Alprazolam or updating it to scheduled dosing, which the physician disagreed with on 04/12/24 without providing a rationale or indication for the duration of the PRN order in the medical record. The deficiency was identified during a review and discussion with the Regional Nurse Consultant, who acknowledged the recommendation and noted that the order had just been changed to Alprazolam 1 MG at bedtime for anxiety. The facility's policy on unnecessary drugs, revised on 08/02/22, requires that new orders for psychotropic medications used on a PRN basis follow specific requirements, which was not adhered to in this case.