Mn Veterans Home Minneapolis

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 Physician Orders for Life-Sustaining Treatment (POLST) indicating Do Not Resuscitate (DNR), Do Not Intubate, and Allow Natural Death. After the resident, who had Alzheimer's disease and had been a DNR since admission, became unresponsive following a fall, an LPN initiated cardiopulmonary resuscitation (CPR) despite the DNR order. The LPN misread the POLST document, as her finger covered the DNR check mark, leading her to interpret the code status as full code and begin CPR. The ambulance staff continued lifesaving efforts and transported the resident to the hospital, where further resuscitation was attempted. Interviews with facility staff revealed inconsistent practices for verifying code status, with some staff relying on the POLST in the chart, others on the electronic medical record, and some on chart spine color coding. The LPN involved stated she had received training on reading POLST forms but still misinterpreted the document in the emergency. The resident's family member, who was the appointed healthcare representative, confirmed the resident's DNR status and expressed concern upon learning that CPR had been performed. The facility's policy required verification of code status before initiating CPR, but this protocol was not followed in this incident.

Removal Plan

• Health unit coordinator, nurse manager, and registered nurses check all resident charts to ensure POLST matches the electronic medical record banner and the chart's spine color.
• Staff are educated on emergency protocols.
• Staff are educated on where to check code status.
• Two people verify the POLST.
• Audits are completed with staff and training is verified.
• Code drills are completed where staff read the POLST and correctly identify if a full code or DNR.
• Ongoing audit schedule evaluates staff knowledge regarding the POLST and where to find the code status.

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 and maintain a policy and procedure for facility closure, as required. During the survey, when requested, the facility was unable to provide documentation of a facility closure policy. In an interview, the assistant administrator confirmed that the facility was unable to locate such a policy. This deficiency had the potential to affect all residents residing in the building.

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 significant medication error occurred when a licensed practical nurse (LPN) administered 5 ml (100 mg) of liquid morphine to a resident, instead of the prescribed 5 mg dose. The resident, who had a history of cerebral vascular accident (stroke), diabetes, dementia, and atrial fibrillation, was dependent on staff for most activities of daily living and was experiencing respiratory distress. The nurse practitioner (NP) had ordered morphine 5 mg every hour as needed for shortness of breath, with the medication available in a concentration of 20 mg/ml. The LPN failed to correctly calculate and administer the ordered dose, resulting in the resident receiving 20 times the intended amount of morphine. The facility's medication administration protocol required two nurses to verify the amount of liquid narcotic to be given, especially when a dosage calculation was necessary. However, the LPN did not verify the dose with another nurse as required by facility policy. The error was discovered when the nurse manager noticed that the medication order had not been confirmed in the electronic chart and upon review, found that the LPN had documented administering 5 ml instead of the correct 0.25 ml (5 mg) dose. The nurse manager initially believed the resident had received 20 mg, but later calculations revealed the actual dose was 100 mg. Following the administration of the incorrect dose, the resident's condition deteriorated, with declining oxygen saturation and increased agitation. The NP was notified and gave orders to hold further morphine and monitor the resident. The family was informed of the medication error and chose not to transfer the resident to the hospital. The resident's condition continued to worsen, and he passed away a few hours after receiving the overdose. The facility's investigation identified the failure to follow the five rights of medication administration and the lack of required double-checking of the dose as the root causes of the error.

Removal Plan

• The facility completed a thorough investigation identifying the root cause that LPN-A did not follow the medication right or right dose and did not verify the dose with another nurse.
• LPN-A was placed on a leave pending the investigation.
• All nursing staff were educated on the medication order transcription process, order confirmation process, ensuring orders are confirmed and appear on the electronic medication record prior to administration, double noting of liquid narcotics to ensure correct dosing on order and in the narcotic book.
• IDT meeting was held to discuss the use of liquid narcotics in the facility vs. sublingual morphine to propose the change to the pharmacy for emergency medication kit use.

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

Staff failed to serve food in a sanitary manner by not wearing hairnets while preparing and plating meals for residents on the 3rd floor of building 19. During observation, two staff members were seen using gloves but did not have their hair properly contained with hairnets as they stood over and handled food items, including fried chicken, mashed potatoes, gravy, coleslaw, and buns. The food was brought into the facility for a special meal and was not served by dietary staff or from the kitchenette. Interviews with the assistant director of nursing, culinary director, director of dietary services, and director of nursing confirmed that the expectation was for staff to wear hairnets when plating food to prevent contamination. The facility's policy on dress, appearance, and hygiene also indicated that hair must be tied back and/or covered when required for sanitation reasons. The failure to follow these procedures had the potential to affect 32 residents residing on the 3rd floor of building 19.

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 cognitively intact resident reported a missing black long sleeve shirt, alleging it was stolen by a staff member while the resident's back was turned. The resident immediately reported the incident to the nurse manager, but the initial progress notes did not document the missing item until a late entry was made several days later. The facility's missing item tracker did record the missing item, but the grievance was not entered into the facility's official grievance complaint log. Following the report, the nurse manager and assistant director of nursing interviewed both the resident and the accused staff member, reviewed security camera footage, and filed a report with the Minnesota Department of Health. However, there was no documented follow-up with the resident regarding the outcome of the investigation, and the missing item tracker only contained demographic information without investigation results. The resident stated that the nurse manager did not return to discuss the results or clarify whether the investigation was ongoing, and the resident was not offered the opportunity to file a property loss or Tort claim for reimbursement. Interviews with facility staff confirmed that the required property damage/loss form was not completed for the resident, and no follow-up progress notes documented further investigation or communication with the resident after the initial entries. The facility's policy required that a claim report and demand form be provided upon request when a claimant suffered property loss, but there was no evidence this was offered or completed for the resident in question.

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 conduct accurate and ongoing assessments for bruising and did not implement appropriate skin protection interventions for a resident on anticoagulant therapy. The resident, who was cognitively intact and independent with mobility, had a history of easy bruising related to apixaban use. Despite documentation of ongoing bruising and the resident expressing interest in trying skin protection sleeves, staff did not offer or provide these interventions. Interviews with nursing staff confirmed that no skin protectant or derma sleeves were care planned or provided, and the resident had not previously been offered these items, contrary to facility expectations for residents on anticoagulants. Additionally, the facility failed to follow physician orders for the application of ankle compression sleeves for another resident with edema. The resident, who had no cognitive impairment and was being treated with diuretics for edema, had an active order for bilateral ankle compression sleeves to be applied in the morning and removed at bedtime. Observations and interviews revealed that the resident was not wearing the prescribed compression sleeves on multiple occasions, and staff confirmed that the task was not included in the care plan or Kardex. Documentation in the treatment administration record indicated the sleeves were applied and removed, but direct observation and resident statements contradicted this. Both deficiencies were further compounded by the lack of specific interventions in the care plans for the identified conditions and the absence of relevant facility policies for anticoagulant use/monitoring and edema management. The facility's skin management program referenced preventive interventions but did not address the specific needs of residents with anticoagulant therapy or edema, and requested policies were not provided.

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 follow up and implement treatment for a resident who reported hearing loss and expressed interest in obtaining hearing aids. The resident, who had intact cognition and was noted to have adequate hearing on the quarterly MDS, reported to the provider during admission that he had an audiogram indicating some hearing loss, particularly in crowded environments, and was interested in further evaluation for hearing aids. The medical record showed that the resident declined in-house audiology services but wanted an audiology evaluation to pursue hearing aids. However, there was no documentation of any follow-up or action taken to address the resident's request for hearing aids. During interviews, the resident confirmed that he had discussed his need for hearing aids with a doctor but had not received any updates or the devices themselves. The nurse manager was unaware of the resident's request and, after reviewing the medical record and consulting with staff, found no evidence that the request had been addressed. The facility's policy identified audiology as a service that could be provided and charged to residents' personal funds but did not specify the process for assisting residents in obtaining such services.

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 with severe cognitive impairment and significant physical limitations consistently attended scheduled therapy gym sessions as ordered. Documentation showed that the resident was marked as 'not available' for 11 out of 13 scheduled sessions, with no documented reasons for most absences. Staff interviews revealed inconsistent communication and documentation practices regarding the resident's attendance and reasons for missed sessions, despite care plan interventions specifying the need for staff to escort the resident to the gym and provide transportation. Additionally, the facility did not implement or care plan occupational therapy recommendations for another resident assessed as at risk for bilateral hand contractures and impaired skin due to clenching fists. Occupational therapy notes indicated the resident would benefit from holding an object during the day and participating in active assisted and passive range of motion programs. However, these interventions were not included in the resident's care plan or communicated to nursing staff, and observations confirmed the resident was not provided with recommended objects to hold or enrolled in a hand range of motion program. Both deficiencies were identified through a combination of record review, staff interviews, and direct observation. The lack of documentation and follow-through on therapy recommendations and scheduled interventions resulted in residents not receiving appropriate care to maintain or improve their range of motion and mobility, as required by their care plans and therapy orders.

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 analyze and care plan a resident's repeated declinations to wear supplemental oxygen as ordered. The resident, who had diagnoses including COPD, respiratory failure, heart failure, and other chronic conditions, was ordered to receive continuous supplemental oxygen to maintain oxygen saturation at or above 90%. Despite this, documentation and observations revealed that the resident frequently did not wear the prescribed oxygen, with multiple instances of refusal or removal of the nasal cannula noted in progress notes and during direct observation. The care plan for the resident included interventions such as assisting with oxygen tank changes, setting the oxygen flow rate, and monitoring oxygen saturation, but it did not address the resident's refusals or any alternative strategies for non-compliance. Staff documented several occasions where the resident either refused or removed the oxygen, sometimes after education on risks and benefits, but there was no evidence that these refusals were analyzed or incorporated into the care plan. Provider notes also lacked documentation of these refusals, and there was no indication that the care plan was updated to reflect the ongoing issue. Interviews with staff confirmed that the resident often removed the nasal cannula, sometimes unintentionally, and that staff would encourage use and notify the provider. However, there was inconsistency in staff awareness and documentation of the refusals, and the assistant director of nursing stated that ongoing issues should be care planned. The facility's policy required explanations for medications or treatments not administered, but this was not consistently followed for the resident's oxygen therapy refusals.

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 staff were competent and authorized to apply medicated ointment for a resident who was not participating in a self-administration medication program. The resident, who was cognitively intact and had diabetes, had an active order for Triamcinolone Acetonide ointment to be applied to itchy, dry skin. The care plan did not identify a self-administration program, and documentation indicated the resident did not wish to self-administer medications. Despite this, the treatment administration record showed daily documentation of unsupervised self-administration, while observations and interviews confirmed that nursing assistants, rather than licensed staff, were applying the medicated ointment to the resident. Multiple staff interviews revealed that nursing assistants regularly applied the prescription ointment, with one assistant describing the process and confirming the ointment was kept in the resident's room. The nurse educator and assistant director of nursing both confirmed that there were no trained medication aides on campus and that only licensed staff were permitted to administer medications per facility policy. However, a licensed practical nurse described a practice where nursing assistants could apply medicated creams if the resident confirmed their understanding, after which the LPN would document the administration. This practice was not supported by facility policy, which specified that only certified or licensed staff should administer medications.

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 proper implementation of enhanced barrier precautions (EBP) and hand hygiene protocols for residents with wounds. For one resident with a history of MRSA in a right foot wound, staff did not consistently wear gowns and gloves during high-contact care activities such as peri-care, transferring, and toileting, despite signage indicating the need for these precautions. Observations revealed that staff wore only gloves, omitted gowns, and did not perform hand hygiene between glove changes while providing care. Interviews with staff confirmed a lack of adherence to EBP and hand hygiene expectations during these activities. Additionally, the facility did not assign EBP to another resident with a stage two pressure ulcer on the left big toe. This resident's care plan and physician orders did not indicate the need for EBP, and there was no signage or PPE cart outside the room. Staff interviews revealed that EBP was not being used for this resident, and the care plan lacked documentation of an MDRO, which was cited as a criterion for EBP by the assistant director of nursing. However, the facility's own infection prevention program indicated that residents with wounds, such as pressure ulcers, should be identified for EBP. The facility's policies directed staff to use gowns and gloves during high-contact care for residents on EBP and to perform hand hygiene between glove changes. Despite these policies, observations and staff interviews demonstrated that these protocols were not consistently followed, resulting in deficiencies related to infection prevention and control for residents with wounds.

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 assess a resident (R49) for the ability to self-administer medications via a nebulizer. R49 had severe cognitive impairment and diagnoses of COPD and dementia. Despite these conditions, R49 was observed using a nebulizer without staff supervision. During the observation, R49 was seen holding the nebulizer mask away from his face, calling for help, and coughing. Staff were not present in the room or hallway, and it took several minutes before a nursing assistant entered the room to assist R49. The nebulizer machine was left running unattended until a registered nurse turned it off later. Interviews with staff revealed that R49 was not assessed for the ability to self-administer medications and that staff usually checked on R49 after 15 minutes, which was not done on the observed night. The director of nursing confirmed that staff were expected to attend all medication administrations unless the resident was assessed as safe to self-administer medications, which was not the case for R49. The facility's policy on self-administration of medications required that residents be determined capable and safe to self-administer by the interdisciplinary team. However, R49's self-administration assessment indicated that R49 did not request to self-administer medications. Despite this, R49 was left alone with the nebulizer, leading to the observed incident. Staff interviews highlighted inconsistencies in monitoring and assessing R49's ability to self-administer medications, contributing to the deficiency. The facility's failure to properly assess and monitor R49 during nebulizer treatments resulted in a lapse in care and adherence to their own policies.

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 comprehensively assess a resident's food preferences and ensure meal choices were provided. The resident, who was cognitively intact and had diagnoses of Parkinson's disease, diabetes, and depression, was on a liberalized diet due to recent admission to hospice. Despite the resident's care plan indicating they were independent in making food choices, the care plan lacked specific food preferences. The resident expressed frustration with the meals provided, stating they disliked chicken and preferred pasta, but these preferences were not reflected in the meals served. An observation confirmed that the resident's meal tray did not match the meal ticket, and the resident was unable to eat the food provided due to dental issues and personal dislikes. Interviews with staff revealed inconsistencies in the process of gathering and updating resident meal preferences. Nursing assistants and licensed practical nurses indicated that residents attended group meetings to make menu selections, but if a resident was unable to attend, the dietician would review the menu for them. However, the resident's meal preferences were not adequately communicated or documented, leading to repeated instances of the resident receiving meals they could not eat. The dietician acknowledged the resident's dental issues and food dislikes but was unaware of the specific problems with meal tickets not matching the served trays. The dining service supervisor and dietician both stated that meal tickets should be completed in advance and could be changed if necessary, but there was a lack of coordination and communication between the dietary staff and nursing staff. The dietician admitted that the resident's dislikes were not reviewed during the last nutrition assessment, and special requests were not always accommodated by the culinary team. The facility's policy regarding resident choices was requested but not provided, indicating a potential gap in the facility's procedures for ensuring resident meal preferences are honored.

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 voiced grievance of a missing electric toothbrush was acted upon timely for a resident with intact cognition and no delusional behavior. The resident reported the missing item to a nursing assistant and a nurse, who did not take immediate action to resolve the issue. The resident expressed frustration over the lack of follow-up, and the nurse admitted to not completing the required form to report the missing item, hoping it would be found in the resident's room instead. The resident's medical record lacked evidence of any actions taken to locate the missing electric toothbrush or report it to the management team for resolution. The social worker, who would have been responsible for addressing the issue, was unaware of the missing item due to the nurse's failure to complete and route the necessary form. The facility's policy required the first staff person notified of a missing item to complete a form and route it for further action, which was not done in this case.

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 assessed and care-planned interventions for skin monitoring were consistently implemented for a resident (R246) with non-pressure skin impairments. R246, who had intact cognition and required substantial assistance with bathing, was at risk for pressure ulcer development and had current moisture-associated skin damage (MASD). Despite being scheduled for weekly skin checks on bath days, the facility did not consistently perform these checks. The Treatment Administration Record (TAR) indicated that the last completed Weekly Skin Check was on 2/22/24, with no checks or refusals documented for 2/29/24 and 3/14/24. R246 expressed concerns about a recurring rash on his legs, which staff were not applying lotion to daily, and there was no clear documentation of monitoring by nurses. Interviews with registered nurses (RN-B and RN-A) revealed that the facility's protocol required weekly skin checks to be documented in the medical record, but these checks were not consistently completed. RN-B acknowledged the lack of documentation and was unsure where refusals should be recorded. RN-A confirmed the absence of documentation for the required skin checks and noted that the facility had identified this issue but had delayed staff education due to the survey. The facility's Resident Assessment - Care Plan policy emphasized the importance of implementing care plans to assist residents in attaining the highest practicable level of functionality and wellness, which was not adhered to in this case.

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 comprehensively assess and develop a program to maintain bowel continence for a resident (R146) who was cognitively intact and had diagnoses of Parkinson's disease, diabetes, and depression. Despite being dependent on toileting and always continent of bowel according to the MDS, the resident's care plan and assessments were inconsistent. The resident was admitted to hospice services and required physical assistance with all cares, yet the assessment lacked a 3-day bowel assessment summary. The care plan indicated the resident was incontinent of bowel with frequent continent episodes and required assistance for toileting, but the resident was not offered a bedpan and was unaware of any bowel program options. Interviews with the resident and staff revealed that the resident had to defecate in his brief and was not provided with alternatives such as a bedpan, which was not commonly used in the facility. The resident expressed discomfort with having bowel movements in the brief. Staff interviews indicated a lack of awareness regarding the resident's concerns and the absence of individualized interventions to maintain bowel continence. The Director of Nursing stated that staff were expected to assess continence accurately and revise interventions to reflect individualized needs, including the use of bedpans or commodes, which was not done in this case.

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 provider order for a throat culture was obtained in a timely manner for a resident reviewed for infection. The resident, who was cognitively intact and had diagnoses of heart failure and depression, complained of a sore throat and received a STAT order for a throat culture to test for streptococcal bacteria. The throat culture was obtained but later canceled due to a labeling error, and no new orders were obtained despite the resident's ongoing symptoms and complaints of pain. Interviews with staff revealed a lack of communication and follow-up regarding the pending lab results. The LPN and RN involved were unaware of the canceled test until days later, and the facility's communication process for tracking lab tests was not effectively utilized. The Director of Nursing confirmed that the lab would not notify the facility of unprocessed specimens and emphasized the importance of shift-to-shift reporting and using a red binder to track lab tests. However, the facility's procedure for lab collection was not provided upon request.

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 recommended pneumococcal vaccinations were offered and/or provided to reduce the risk of severe disease for one resident reviewed for immunizations. Specifically, a resident with intact cognition and multiple diagnoses, including Parkinson's disease, depression, and COPD, had not received or been offered the pneumococcal PCV20 or PPSV23 dose despite having received the PCV13 vaccine several years prior. The resident did not recall any discussion about an updated pneumococcal vaccination and expressed willingness to receive it if available. Additionally, the resident's immunization record did not indicate that education regarding the benefits and potential side effects of the influenza vaccination had been completed, despite the resident having received the influenza vaccine recently. The facility also failed to ensure that the medical records of five residents included documentation that the resident or their representative was provided education regarding the benefits and potential side effects of the influenza immunization. These residents had various medical conditions, including kidney disease, diabetes, heart dysrhythmia, dementia, depression, anxiety, heart failure, Alzheimer's disease, and seizure disorder. Despite receiving the influenza vaccination, their records lacked documentation of the required education. During interviews, the infection preventionist and the Director of Nursing (DON) acknowledged the lack of documentation and expressed uncertainty about whether the education was being provided and documented as expected. The facility's policy indicated that Vaccine Information Statements (VIS) should be provided to residents, their representatives, and families prior to vaccination, but there was no evidence that this was consistently documented in the medical records. The DON emphasized the importance of providing this education to ensure informed decision-making and maintain residents' dignity.