Wrightsville Manor Health And Rehab

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 deficiency involves the facility’s failure to keep the environment free of accident hazards and to provide adequate supervision to prevent elopement for one resident identified as at risk. The facility had an elopement policy stating it would identify, prevent, detect, and respond promptly to resident elopement, and the resident’s care plan documented that he was at risk for elopement due to independent ambulation, paranoid schizophrenia, anxiety, and hallucinations/delusional thoughts. The care plan goals included that the resident would not leave the facility unsupervised and that staff would take appropriate steps to prevent and detect elopement, including use of electronic door locks, staff education, and staff control of door access. The resident had diagnoses including schizoaffective disorder, vascular dementia, psychotic disturbances with hallucinations and delusions due to a known physiological condition, muscle weakness, and dysphagia. A recent MDS showed he was cognitively intact with a BIMS score of 15, had disorganized thinking that did not fluctuate, and was independent with mobility and had no range-of-motion limitations. Progress notes documented that on the day of the incident, a community member called the facility reporting that he believed a facility resident was walking down the street. Facility staff went to the location, verified the resident’s identity, and found him unharmed, but he refused to get into the vehicle to return and stated, “ya’ll are trying to kill me,” demanding that police be called and agreeing to return only with an officer. Interviews and record review showed that the resident was able to exit the building without staff supervision during a staff Christmas party. Staff reported that the resident likely went out behind someone when a door was opened, and that the exit door on the 200 Hall had previously been equipped with a latch/hook used to hold it open for moving a shower bed. The DON and Administrator stated that at the time of the elopement, the side door used for the shower bed was not secured after a staff member brought the shower bed in, allowing the resident to leave the facility. The Administrator confirmed that this occurred while all staff were present at the Christmas party and stated that staff assigned to residents were expected to be accountable to them.

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 administer medications in a manner that prevented cross-contamination for seven of thirteen residents observed during a medication pass. An LPN was observed repeatedly preparing and administering medications to multiple residents without performing hand hygiene between residents. The LPN handled the medication cart, medication cards, water cups, and touched door handles and other surfaces both inside and outside the building, as well as objects in the residents' environments, without cleaning her hands between each interaction. In one instance, the LPN only performed hand hygiene before administering eye drops, which she considered a treatment, but not between other medication administrations. The LPN acknowledged touching surfaces and objects that could contribute to cross-contamination and confirmed that she did not perform hand hygiene between residents unless a treatment was involved. During interviews, the Assistant Director of Nursing stated that staff were expected to perform hand hygiene before starting the medication pass and between each resident, and that handwashing should be repeated if hands became soiled. However, the facility did not have a specific handwashing policy, relying instead on a skills check for staff. Documentation showed that the LPN had been assessed as competent in handwashing, with instructions to perform hand hygiene between each resident's medication pass. Despite this, the observed practice did not align with these expectations, resulting in a failure to prevent potential cross-contamination during medication administration.

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 that a resident was treated with dignity during meal service and the care of an indwelling urinary catheter. The resident, who was admitted with diagnoses including pseudobulbar affect, generalized anxiety disorder, and abnormal weight loss, was noted to have severe cognitive impairment and was dependent on staff for most activities of daily living. During meal service, a CNA stood at the resident's bedside while feeding her, rather than sitting, which is considered a dignity concern. The CNA stated she was unaware that standing while feeding a resident was an issue related to dignity, and the Assistant Director of Nursing confirmed that staff had not been in-serviced on this expectation. Additionally, the resident's urinary catheter drainage bag was observed on multiple occasions to be uncovered and visible, both in the resident's room and in a common area, with urine visible in the bag. The drainage bag was also found lying on the floor under the resident's chair without a dignity cover. Staff interviews confirmed that the use of dignity covers for catheter bags was an expectation, but the cover was not in place at the time of observation. These actions and inactions resulted in a failure to maintain the resident's dignity during care and daily activities.

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 required written transfer notices, including information on appeal rights and ombudsman contact details, to residents and/or their responsible parties (RPs) when residents were transferred to the hospital. Additionally, the facility did not send copies of these notices to the Long Term Care Ombudsman for any of the five residents reviewed for hospitalizations. The facility's policy required that residents and their RPs be informed of transfer reasons, appeal rights, and bed-hold policies, but documentation showed these steps were not followed. Record reviews for multiple residents revealed that while verbal notifications were made to RPs regarding hospital transfers, there was no evidence of written notifications being provided. Bed hold notices, when present, were undated, unsigned, and did not specify the daily bed hold rate for private or semi-private rooms. In several cases, there was no documentation that the resident or RP received any written notice regarding the transfer or the facility's bed-hold policy at the time of transfer. Progress notes and other EMR documentation confirmed the absence of these required notifications. Interviews with facility staff, including the Administrator and Social Services Director, confirmed that written notifications were not consistently provided to RPs or sent to the Ombudsman. The Administrator acknowledged that while residents were sent with bed hold notices, RPs were not provided with this information, and the Social Services Director was unaware of the requirement to notify the Ombudsman for all hospital transfers. These actions and omissions resulted in a failure to comply with regulatory requirements for resident transfer notifications.

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 was identified regarding the management of a urinary catheter and drainage bag for one resident with an indwelling urinary catheter. The facility's Foley Catheter Policy did not address the proper placement of urinary catheter drainage bags and tubing. The resident, who had diagnoses including pseudobulbar affect, generalized anxiety disorder, abnormal weight loss, and was severely cognitively impaired, was dependent on staff for most activities of daily living. The care plan for this resident included interventions to position the catheter bag and tubing below the level of the bladder and to check for kinks to ensure proper urine flow. The resident had a recent hospitalization for a urinary tract infection. During multiple observations, the resident's urinary catheter drainage bag and tubing were found lying on the floor, both while the resident was in bed and when seated in a geriatric chair in the common area. Staff interviews confirmed that the catheter bag and tubing should not be on the floor due to infection control concerns. Both a CNA and the ADON acknowledged that the observed placement of the catheter bag and tubing was inappropriate and not in accordance with infection control practices.

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 was identified regarding the provision of safe and appropriate dialysis care and services for a resident who required such services. The facility failed to ensure that the necessary dialysis care was provided in accordance with the resident's needs. Specific details about the actions or omissions that led to this deficiency, as well as information about the resident's medical history or condition at the time, are not provided in the report.

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 medication error rate of 5 percent or greater was identified during the survey. This indicates that the facility failed to ensure that the administration of medications was performed with an acceptable level of accuracy, resulting in a higher than permitted rate of medication errors among residents. The deficiency was based on direct findings by surveyors regarding the facility's medication administration practices, as evidenced by the calculated error rate exceeding the regulatory threshold.

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 the facility failed to document an episode of hypoglycemia for a resident with type 2 diabetes mellitus. The resident was admitted with orders for fingerstick blood sugar checks before meals and at bedtime, with instructions to notify the physician if levels were below 80 or above 400. On the day in question, the resident experienced symptoms of low blood sugar, which was confirmed by an LPN who measured a blood sugar level of 61. The LPN administered orange juice and sugar, and a subsequent check showed the blood sugar had risen to 91. Despite this event, there was no documentation of the incident in the resident's electronic medical record. Interviews with the resident, the LPN involved, and the Assistant Director of Nursing (ADON) confirmed that the hypoglycemic episode occurred and that it was not documented. The ADON and facility administration both stated that it was their expectation for such episodes to be documented according to current standards of practice. The lack of documentation was verified through review of the entire electronic medical record and direct staff interviews.

Penalty

Inspection fine: $64,279

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 sexual abuse, resulting in an incident involving two residents. One resident, who had severe cognitive impairment, was found standing over another resident, who was legally blind and had Alzheimer's Disease, in her room. Blood was noted on the resident's brief, and upon examination at the hospital, she was found to have vaginal tears and was given STI prophylaxis. The incident was witnessed by a nurse who saw the male resident standing over the female resident, and blood was later found on his pants. The facility's policy on abuse prevention did not include a definition of sexual abuse, which may have contributed to the staff's uncertainty about the nature of the incident. Interviews with staff revealed that the male resident had a history of inappropriate behavior, such as exposing himself, but was not considered to have sexually inappropriate behaviors towards other residents. The Director of Nursing and other staff expressed doubt about the male resident's capability to perform a sexual act, suggesting that any assault would have been with his hands. The incident was reported to the police, and the male resident was arrested but returned to the facility due to his mental capacity. The facility placed him on 15-minute checks and moved him to a locked unit until he could be transferred to a behavioral health facility. The female resident was transferred to the hospital for examination and returned to the facility after the incident. The facility's response to the incident included interviews with staff and residents, but the initial failure to prevent the abuse and the lack of a clear policy definition of sexual abuse were significant factors in the deficiency.

Removal Plan

• Abuse Prevention education is ongoing with staff by Administrator, Staff Development Coordinator or Director of Nursing. All employees have received education. Prevention education is provided upon hire by HR director and periodically throughout employment by regulation guidelines. No new staff will be able to work without receiving the education.
• Social Service Director interviewed all residents with BIMS 13 or above, asking if anyone injured them, came in their room, or sexually abused them. For residents unable to answer, skin assessments are performed on all residents weekly by treatment nurse. Weekly skin assessments were completed with no injuries found per treatment nurse.
• A camera was placed in R1's room and the monitor placed at nurses' station, with family's permission for closer observation and residents' inability to communicate related to potential abusive encounters.
• R1 was assessed upon return by nurse S.T. with no new findings/bleeding observed.
• Social Service Director began interviewing all residents, asking them if a person has been in their room touching or hurting them.
• Medical Director was notified of 3 Ij's.
• Medical Director reviewed the abuse policy and made no changes.
• QA reviewed state report of incident with R1 and R2. R2 did not return to facility, resolving the situation, as R2 was admitted to a behavioral health facility.

Penalty

Inspection fine: $64,279

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 administration failed to protect a resident from sexual abuse by another resident and did not conduct a thorough investigation following the incident. On the night of the incident, a resident was observed by staff entering and leaving the room of another resident. The staff later found the resident in bed with signs of sexual assault, including blood in the vaginal area. The resident was subsequently transferred to the emergency room for evaluation, where a sexual assault exam confirmed injuries consistent with rape. The Director of Nursing (DON) and the Administrator were informed of the incident but did not take immediate and appropriate actions to prevent further harm. The DON expressed uncertainty about whether the incident constituted rape and suggested that the alleged perpetrator was not capable of such an act. Despite the severity of the situation, the facility did not implement one-on-one supervision for the alleged perpetrator, who was only placed on 15-minute checks until he could be transferred to a behavioral facility. The facility's failure to maintain a safe environment and adequately investigate the incident was identified as noncompliance with federal requirements, posing a likelihood of serious harm to residents. The administration's inaction and lack of oversight contributed to the immediate jeopardy situation, which was recognized by surveyors and communicated to the facility's leadership.

Removal Plan

• Director of operation reviewed Abuse Neglect and Exploitation misappropriation program in-serviced Administrator and DON.
• Administrator and DON signed job descriptions on hire date. Director of operations reviewed job descriptions.
• The facility held Ad Hoc QAPI meeting to review the Immediate Jeopardy findings Medical Director was over the phone. Administrator, DON, Adon, Treatment nurse, MDS, Social Service, Activity, Maintenance, Housekeeping, HR, Admissions, Dietary, IFP, CNA, Unit Manager.
• The allegations of sexual abuse of R1 have been reported and investigated by administrator and DON and the necessary corrective actions were taken to assure they do not happen again, R2 was removed from facility and is discharged. R1 has a room monitor with camera and it stays on at the nurse's station to allow staff to see R1.
• Abuse prevention is given by HR on hire. No new employee will be able to work without receiving education.
• Social Service director has called an emergency Abuse and prevention and resident rights meeting. The meeting was held with resident counsel.
• Social Service director completed interview with all residents asking them has a person been in their room touching or hurting them, all that could answer stated no. Residents that could not answer were reviewed on skin assessments for injury, tears, bruises.
• Skin assessments were started on all residents weekly by treatment nurse. Each hall is on a different day, treatment nurse observes for any skin tears, bruises, sores, etc. Skin assessments were completed.
• Confirmation via signed document stating Abuse, Neglect, exploitation misappropriation prevention program was reviewed and in-serviced by the Director of Operations. Signatures by the Director of Operations, Administrator, and the Director of Nursing.
• Review of signed statement indicating the Director of Operations reviewed Administrator and DON job descriptions. Copy of job descriptions attached and signatures by the Director of Operations, Administrator, and Director of Nursing.
• Review of document titled Quality Assurance/Performance Improvement Meeting Format indicated signatures for Administrator, DON, ADON, Treatment nurse, MDS, Social Service, Activity, Maintenance, Housekeeping, HR, Admissions, Dietary, IFP, and Unit Manager.
• Review of the Census of the electronic medical record (EMR) R2 discharged from the facility. Review of Progress Notes indicated that R2 was picked up by transportation and taken to a behavior health center.
• Observation a monitor was observed at the nursing station showing R1 in bed asleep.
• Review of signed document signed by Administrator and Human Resources (HR) indicating HR will be responsible for giving abuse prevention policy to new hires.
• Interview with HR, who confirmed there have been no new hires. She reported that she is responsible for reviewing the abuse policy with new hires and will get them to sign off on this during orientation.
• Review of document titled Resident Council Meeting indicated topics discussed of Resident Rights, Abuse Prevention, and Reporting Abuse. Policy reviewed Abuse Prohibition Policy and Procedures and Resident's Federal and State Rights.
• Interview with the Administrator who confirmed that an Emergency Resident Council meeting was held to discuss abuse prevention and resident's rights.
• Interviews with R3 and with R11 who both confirmed attending the resident council meeting.
• Review of document which listed total residents and their response (No or no response) to a question about anyone coming into their room unwelcomed making sexual advances or inappropriate touch. None of the residents reported yes to the question. This was completed by the Social Services Director.
• Review of skin assessment documentation confirmed skin assessments were completed for all residents.
• Review of the skin assessment documents indicated skin assessments completed weekly. This was also confirmed through a calendar that indicated the dates that skin assessments were completed for each hall.