Vantage At Hampden Llc

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 a homelike environment for resident dining across three units, as observed by surveyors. On multiple occasions, residents were not provided with meals or meal assistance in a timely manner. For instance, on the South Unit, a resident was seated at a table with another resident who received their meal 20 minutes earlier. Similarly, on the North and East Units, residents were observed waiting for their meals while others at the same table were already eating. Meals were consistently served on trays, which was noted as not being homelike. During meal observations, it was noted that some residents were left without meals or assistance while others at the same table were being served. For example, on the North Unit, a resident called out for their meal, which was provided only after a delay. Another resident had a covered meal tray in front of them but was not assisted until much later. These delays in meal service and assistance were consistent across the units, with staff acknowledging that meals were always served on trays, which was not conducive to a homelike environment. Interviews with staff, including a CNA, Unit Manager, and the Director of Nursing, revealed that serving meals on trays was a long-standing practice. The Unit Manager acknowledged the issue of residents being seated without meals or assistance and agreed that covered trays should not be given until assistance is available. The Director of Nursing also recognized that serving meals on trays was not homelike and could be a dignity concern. Discussions were underway to address seating arrangements to better accommodate residents' needs.

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 free from physical restraints, as evidenced by the use of a rectangular cushion placed under the fitted sheet on the resident's bed. This cushion was used to prevent the resident from putting their legs over the side of the bed, which was not assessed or documented as a restraint. The facility's policy on restraints requires that any restraint used must be for the safety and well-being of the resident, and only after other alternatives have been tried unsuccessfully. However, in this case, the use of the cushion was not properly assessed or documented, and it was not clear if less restrictive alternatives had been considered. The resident in question had a history of dementia with behavioral disturbance, lymphedema, and required assistance with personal care. The resident was at high risk for falls and had severe cognitive impairment, requiring substantial assistance with activities of daily living. Despite these needs, the facility did not have documented evidence for the use of the rectangular cushion, bolster mattress, or the bed's placement against the wall. The resident's care plan included interventions such as a bed alarm and side rails, but there was no mention of the cushion being used as a restraint. Interviews with staff revealed that the cushion was placed under the fitted sheet to prevent the resident from putting their legs over the bed's edge, as the resident had issues with edema and previously attempted to get out of bed without assistance. However, the Unit Manager and Director of Nursing were unaware of the cushion's use until it was observed by the surveyor. The Director of Nursing acknowledged that if the cushion was used as an intervention, it needed to be assessed and care planned, and other interventions should have been trialed first. The lack of communication and documentation regarding the use of the cushion led to the deficiency in ensuring the resident was free from physical restraints.

Penalty

Inspection fine: $16,801

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 nursing care and treatment that met professional standards of quality for a resident who was a functional quadriplegic, non-verbal, and totally dependent on staff for care. During an incident, a nurse aide left the resident unattended on the bed, resulting in the resident sliding off the bed. The aide lowered the resident to the floor but did not report the incident as a fall. Nurse #1, who was called to assist, did not conduct a thorough assessment or document the incident, failing to follow the facility's policies on falls and incident reporting. In the days following the incident, the resident exhibited signs of discomfort and pain, including verbalizing neck pain, which was unusual given the resident's typical non-verbal state. Despite these signs, the incident was not reported, and the resident's pain was initially treated as muscular in nature. It was only after further assessment and the discovery of bruising and swelling on the resident's neck that the resident was transferred to the hospital, where multiple cervical spine fractures were diagnosed. The lack of documentation and failure to report the incident as a fall led to a delay in recognizing the severity of the resident's injuries. The facility's policies required a comprehensive assessment and documentation of falls, including obtaining vital signs and conducting neurological assessments, which were not completed. This oversight contributed to the resident's condition worsening, ultimately leading to hospitalization and the resident's subsequent death.

Removal Plan

• Resident #1 was transferred to the Hospital for further assessment and treatment.
• Administrative staff reviewed previous incident reports for the potential for residents with suspected injury of unknown origin, with review of individual residents nursing Plans of Care and CNA Care Kardex, no concerns for failure to report where identified, reviews will continue as needed.
• Facility Administration conducted a Quality Assessment and Performance Improvement (QAPI) meeting, with review of current facility policies, and development of an Action Plan, review of the meeting minutes indicated the Facility Leadership team met and developed a plan of correction related to the deficient practices.
• Facility Administration suspended Certified Nurse Aide (CNA) #1 and Nurse #1, and as a result of the facility's internal investigation, they were both terminated.
• The Staff Development Coordinator and Director of Nursing educated all clinical staff regarding the following: Facility policy's related to Falls and Clinical Protocols which included nursing assessments and nursing documentation and the Facility Policy related to Accidents/Incidents, Investigating and Reporting, Incident reports and staff statements must be completed at the time of the incident, Events that required reporting to the nurses, Nursing Supervisor(s), the on-call Nurse, or the Director of Nursing, Falls: witnessed, unwitnessed, which included if a resident is lowered to the floor, Abuse: verbal, physical, neglect, and reporting requirements, Skin issues: skin tears, bruises, documentation and reporting, Plans of Care/ CNA Care Kardex review of interventions for appropriateness and current based on care needs.
• The Director of Nursing initiated and conducted facility-wide audits to ensure all incidents that have occurred had appropriate and complete incident and accident reports and reviewed that any new onset of pain, skin changes and changes in condition to determine if they should be further investigated. Audits to be continued as needed.
• The Director of Nursing or designee will conduct audits of incidents and condition changes, and findings will be reviewed at the Quarterly QAPI meetings, ongoing.
• The DON and/or designee are responsible for overall compliance.

Penalty

Inspection fine: $16,801

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 supervision to a resident who was a functional quadriplegic and totally dependent on staff for all care needs. During an incident, a nurse aide left the resident unattended on their side with the bed raised, while she went to fill a wash basin in the bathroom. Although the aide claimed to monitor the resident from the bathroom, the facility's investigation determined that the resident was not visible from that position. The resident subsequently slid out of bed, resulting in a fall that caused multiple cervical spine fractures. The resident, who was severely cognitively impaired and had unclear speech, was noted to have signs of discomfort and pain following the incident. Despite the resident's cries of pain and visible bruising and swelling on the neck, the initial assessment by the nurse did not include vital signs, and no documentation or report of the incident was made. The resident's condition worsened over the following days, leading to a hospital transfer where multiple cervical spine fractures were diagnosed. Interviews with staff revealed that the nurse aide attempted to lower the resident to the floor after noticing them sliding off the bed, but the facility's reenactment showed that the resident's head or neck likely encountered the side rail during the fall. The resident's family was unaware of any recent falls, and the facility's internal investigation confirmed that the resident should not have been left unattended in the position described by the aide, as it was unsafe.

Removal Plan

• Resident #1 was transferred to the Hospital for further assessment and treatment, and did not return to the facility.
• Administrative staff reviewed previous incident reports for the potential for residents with suspected injury of unknown origin, with review of individual residents nursing Plans of Care and CNA Care Kardex, no concerns for failure to report were identified, reviews will continue as needed.
• Facility Administration conducted an ad hoc Quality Assessment and Performance Improvement (QAPI) meeting, with review of current facility policies, and development of an Action Plan, review of the meeting minutes indicated the Facility Leadership team met and developed a plan of correction related to the deficient practices.
• Facility Administration suspended Certified Nurse Aide (CNA) #1 and Nurse #1, and as a result of the facility's internal investigation, they were both terminated.
• The Staff Development Coordinator and Director of Nursing educated all clinical staff regarding the following: Facility policy's related to Falls and Clinical Protocols which included nursing assessments and nursing documentation and the Facility Policy related to Accidents/Incidents, Investigating and Reporting, Incident reports and staff statements must be completed at the time of the incident, Events that required reporting to the nurses, Nursing Supervisor(s), the on-call Nurse, or the Director of Nursing, Falls: witnessed, unwitnessed, which included if a resident is lowered to the floor, Abuse: verbal, physical, neglect, and reporting requirements, Skin issues: skin tears, bruises, documentation and reporting, Plans of Care/ CNA Care Kardex review of interventions for appropriateness and current based on care needs, Resident safety related to positioning (seated and in bed), siderails, call bells within reach, bed/chair alarms, bed in lowest position and floor safety mats.
• The Director of Nursing initiated and conducted facility-wide audits to ensure all incidents that have occurred had appropriate and complete incident and accident reports and reviewed that any new onset of pain, skin changes and changes in condition to determine if they should be further investigated. Audits to be continued as needed.
• The Director of Nursing or designee will conduct daily audits of incidents and condition changes, and findings will be reviewed at the Quarterly QAPI meetings, ongoing.
• The DON and/or designee are responsible for overall compliance.