Danville Centre For Health & Rehabilitation

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 staff followed infection prevention and control practices during wound care for two residents with impaired skin integrity. One resident was admitted with respiratory failure, muscle wasting and atrophy, anoxic brain damage, anxiety disorder, and complications of colostomy, and had an order for left ischium wound care every shift with cleansing, Santyl, and a foam dressing. During observation, an LPN removed the soiled dressing and did not change gloves or perform hand hygiene before cleansing the wound. When interviewed, the LPN stated she knew better but was nervous that someone was watching her and said she should have changed gloves and washed her hands to prevent infections. A second resident was admitted with essential hypertension, osteoporosis, muscle weakness, unspecified protein-calorie malnutrition, muscle wasting and atrophy, and terminal/end-of-life skin failure, and had an order for left buttock wound care every shift with cleansing, calcium alginate with silver, triad cream, and a dressing secured with an ABD pad. During observation, an LPN removed the soiled dressing and did not change gloves or wash hands before cleaning the wound. The LPN stated she should have disposed of the dirty gloves and cleaned her hands before cleaning the wound to prevent germs from the old dressing spreading to the open wound. The Staff Development Coordinator stated the facility had provided a skills fair covering wound care and handwashing, but handwashing audits had not been performed since then, and the DON and Administrator stated staff were expected to follow facility policy to prevent the spread of infection.

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 a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. Survey observations and policy review showed that the facility’s Resident Rights policy required residents to be treated in an environment that promotes quality of life, and the Safe Environment policy required daily maintenance, housekeeping, and laundry services to maintain a safe, comfortable, and clean environment. However, observations in common areas revealed peeling paint on walls and ceilings, rust on ceiling vents, a severely scuffed and scratched door to the Reflections Unit, scuffed and chipped handrails and baseboards throughout the facility, and bubbling and chipping paint on walls. The Reflections Unit also had scuffed walls and dressers in all resident rooms, and a mold-like substance was observed in mini-split units on the unit. In individual resident rooms, R29’s room had rust on the doorframe and bathroom doorframe, unpainted plaster on the walls, and scuff marks on the doors, walls, and dresser. R51’s room had chipped paint and rust on the doorframe and walls. R29 stated the room and facility did not feel homelike and described a leaking pipe under the toilet that staff had covered with a sheet to absorb water rather than fixing the issue; he also stated the scuffs and rust had been present for over 5 years. FM4 stated an air conditioning unit in her family member’s room leaked water all the time and that wet towels were placed on the floor to dry the leaking water, with the issue ongoing for 6 to 8 months. Facility staff and leadership acknowledged the environmental concerns, stating that some issues were overlooked, that there was no effective system to keep walls painted, that paint hanging from a common area ceiling had been there for about two weeks, and that chipped paint and scuffed areas were being deprioritized in favor of other concerns.

Penalty

Inspection fine: $12,444

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 a comprehensive care plan for a resident identified as being at risk for elopement. The resident, who had severe cognitive impairment and a history of wandering and exit-seeking behaviors, was supposed to be monitored closely and equipped with a wander guard to prevent unsupervised exits. However, on the day of the incident, the wander guard system was not functioning due to a sprinkler system inspection, and staff did not provide the necessary supervision or interventions to prevent the resident from leaving the facility. The resident managed to elope from a locked unit without staff knowledge and traveled approximately 120 feet before tripping and falling in a grassy area outside the facility. The staff were unaware of the resident's absence until alerted by a passerby and a family member of another resident. The investigation revealed that staff were not monitoring the exit doors during the alarm system shutdown, and the care plan's interventions, such as providing diversional activities, were not implemented. Interviews with facility staff indicated a lack of awareness and preparation for the alarm system's temporary shutdown. The staff responsible for the resident's supervision were not informed of the need for additional monitoring during this period, and there was insufficient staffing to ensure the safety of all residents in the locked unit. The facility's failure to implement the care plan and provide adequate supervision constituted Immediate Jeopardy, posing a risk of serious harm to the resident.

Removal Plan

• R2 was assessed for injury and assisted back into the facility with a wheelchair by the DON. A head-to-toe skin assessment was completed with no new injuries noted.
• The Administrator initiated a Code Green, and a head count was performed per the Unit Managers on each unit.
• R2's Physician and Family/Responsible Party were notified of the event, and R2 was sent to the Emergency Department for evaluation and returned with no injuries.
• Upon return from the hospital, R2 had a complete head-to-toe skin assessment with no new areas of concern.
• R2 received 1:1 supervision from facility staff.
• Facility staff were assigned to monitor unlocked doors until the fire system and door locks resumed normal function.
• R2's care plan was reviewed and updated by the Social Services Director and MDS1.
• An elopement risk assessment was repeated for R2 and she was noted at risk for elopement.
• All residents had an elopement risk assessment completed; 16 residents were identified to be at risk for elopement.
• The profile for R2 in the elopement binder was reviewed and R2's Activity assessment was updated.
• A root cause analysis via Fishbone Diagram was completed, and a care plan meeting was held for R2 with the resident's family.
• All residents had their care plans reviewed by the DON, Signature Care Consultant, and/or SSD.
• All doors were checked to ensure locks were functioning by the Plant Operations Assistant.
• All exit door codes were changed.
• Activity assessments were updated for all residents on the Reflections Unit.
• All elopement books were reviewed to ensure resident profiles and pictures were updated and accurate.
• Elopement drills and door checks were completed each shift.
• Door checks were performed weekly ongoing, and elopement drills were performed weekly and then monthly ongoing.
• Additional door alarms not tied to the fire alarm system were placed on the two exterior exit doors on the Reflections Unit.
• Vinyl window frosting was placed on the two exterior exit doors on the Reflections Unit.
• A Hasp lock and a key padlock were placed on one door of the nurse's station.
• Prior to any work affecting safety systems, the Administrator and DON must be notified to ensure staff were assigned to doors for monitoring.
• Current staff received education on various policies and completed a post-test with a requirement of achieving 100% passing score.
• Individual resident activity boxes were located on the Memory Care unit.
• A report was created for monitoring doors when the system was down.
• The DON, Unit Managers, SDC, Medical Records Nurse, or Manager on Duty were required to assist the Reflections Unit during staff breaks.
• A new fence with a keypad was installed outside of the Reflections Unit.
• The Administrator or Activities Director audited documentation of activities and care plans for three random residents at risk for elopement.
• An Ad Hoc Quality Assurance meeting was held to review the investigation and the current plan of corrective action.
• A post-education test was provided to 10 random staff on shifts.
• QA meetings were held daily and weekly, then monthly for recommendations and further follow-up.

Penalty

Inspection fine: $12,444

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 adequate monitoring and supervision to prevent the elopement of a resident identified as R2, who was at risk for elopement due to severe cognitive impairment and a history of exit-seeking behavior. On the day of the incident, the facility's wander guard system was not functioning due to a scheduled fire alarm test, and the exit doors were left unmonitored. R2 managed to exit the facility without staff knowledge and was found by a passerby after tripping and falling near a busy highway. The facility's policy required individualized, resident-appropriate care and continuous monitoring of safety risks, but these measures were not effectively implemented. R2's care plan included a wander guard bracelet, but the system's failure and lack of staff awareness allowed the resident to leave the locked unit. Staff were not informed of the need for additional monitoring during the alarm system shutdown, and there was insufficient staff coverage to supervise residents adequately. Interviews with staff revealed that there was no procedure in place to ensure monitoring responsibilities during the alarm system's downtime. The Plant Operations Director and other staff acknowledged the lack of a system to cover exit doors and ensure resident safety. The incident highlighted the facility's failure to implement effective interventions and communication strategies to prevent elopement, resulting in a serious safety breach.

Removal Plan

• R2 was assessed for injury and assisted back into the facility via wheelchair by the DON.
• The Administrator initiated a Code Green, and a head count was performed per the Unit Managers on each unit.
• R2's Physician and Family/Responsible Party were notified of the event.
• R2 was sent to the ED for evaluation and returned to the facility with no injuries, no change in condition, and no new orders.
• R2 received 1:1 supervision from facility staff following her return from the hospital.
• Facility staff were assigned to monitor unlocked doors by the Administrator until the fire system and door locks resumed normal function.
• The care plan for R2 was reviewed and updated by the Social Services Director and MDS Coordinator.
• An elopement risk assessment was completed for R2 and other residents.
• All residents had an elopement risk assessment completed, and 16 residents were identified to be at risk for elopement.
• The profile for R2 in the elopement binder was reviewed and updated.
• A root cause analysis was completed, and a care plan meeting was held for R2 with the resident's family.
• Orders and care plans for residents at risk for elopement were reviewed.
• All doors were checked to ensure locks were functioning.
• All exit door codes were changed.
• Activity assessments were updated for all residents in the Reflections unit.
• Elopement books were reviewed to ensure resident profiles and pictures were updated and accurate.
• Elopement drills and door checks were completed each shift.
• Additional door alarms not tied to the fire alarm system were placed on the exterior exit doors on the Reflections unit.
• Vinyl window frosting was placed on the exterior exit doors on the Reflections unit.
• A Hasp lock and a key padlock were placed on one door of the nurse's station.
• Prior to any work affecting safety systems, the Administrator and DON must be notified to ensure staff are assigned to doors for monitoring.
• Current staff received education on relevant policies, and a post-test was completed by all current staff with a requirement of achieving 100% passing score.
• Individual resident activity boxes were initiated on the Memory Care unit.
• A report was created for monitoring doors when the system was down.
• Additional support was provided during staff breaks on the Reflections Unit.
• A new fence with a keypad was installed outside of the Reflections Unit.
• Daily door checks for proper functioning of locking mechanism were completed.
• Elopement drills were conducted for every shift.
• Elopement binders were reviewed to ensure accuracy.
• Documentation of activities and care plans for residents at risk for elopement were audited.
• An Ad Hoc Quality Assurance meeting was held to review the investigation and the current plan of corrective action.
• Post-education tests were provided to random staff on different shifts.
• QA meetings were held for recommendations and further follow-up.