Dunbar Village Terrace

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 resident was free from a significant medication error when staff administered undiluted Sertraline Hydrochloride (Zoloft) oral solution. The resident was admitted after joint replacement surgery and had a BIMS score of 13, indicating cognitive intactness. The facility policy required medications to be administered according to the manufacturer’s specifications, including proper preparation and administration of the drug. The resident had an order for Sertraline HCl oral concentrate 20 mg/ml by mouth, and the MAR showed the medication was administered on the day of the incident. The medication package and prescribing information stated that Zoloft oral solution must be diluted before use and mixed with 4 ounces of water, ginger ale, lemon/lime soda, lemonade, or orange juice only. Despite these instructions, the medication was given without being mixed in liquid. After administration, the resident complained of a burning tongue and sore throat, and the incident was documented as liquid Zoloft not mixed in liquid. The resident’s representative reported that the resident said her throat was burning because the nurse did not mix the medication, and the resident was taken to the emergency room for evaluation and then home. Interviews with nursing staff and the NP confirmed the medication had been administered without dilution and that the resident experienced mouth and throat discomfort afterward.

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 services were provided in accordance with professional standards of practice during medication administration when an LPN allowed a resident to self-administer two prescribed nasal sprays without confirming that he had been assessed as capable of doing so safely. During observation, the LPN instructed the resident to self-administer one spray to each nostril for both Azelastine Hydrochloride nasal solution and Fluticasone Propionate nasal suspension, but the resident administered two sprays to each nostril of the Fluticasone. The LPN stated she was unsure whether the resident had been assessed to self-administer, and she acknowledged that the resident used two sprays of Fluticasone even though the order specified one spray to each nostril. The resident was admitted with a diagnosis including dementia, though his MDS showed a BIMS score of 13 indicating he was cognitively intact. The resident stated he always gave himself two sprays of each nasal medication because it made it easier for both him and the nurse. The DON stated there were no residents in the facility who had been assessed or had physician orders to self-administer medications, and confirmed her expectation that nurses ensure residents are assessed for self-administration and that medications are administered according to physician orders. Record review showed the resident had an active order for Fluticasone Propionate nasal suspension, but there were no orders for self-administration and no completed Self-Administration Assessment Form in the record.

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

Food was not stored in a safe and sanitary manner to prevent contamination and deterioration during kitchen observations. In the walk-in cooler, seven pints of strawberries with visible mold were observed on a cardboard flat between two flats of grapes. Also observed were eight oranges with a dried appearance, mold, and soft texture, and two lemons with green and black mold. The Dietary Manager confirmed the fruit was stored for resident consumption and stated that fruit was typically inspected at the time of use. He also acknowledged that the oranges had come from that morning's snack cart. In the dry storage room, a drinking cup was stored inside the flour bin and a measuring cup was stored inside the sugar bin, with both cups in direct contact with the food products and being used as scoops. The Dietary Manager immediately removed the cups and confirmed they had been in use. The Registered Dietitian stated she had been informed of the kitchen findings and confirmed the molded fruit was discarded and the cups were removed. The Administrator later acknowledged that the fruit in the cooler had not been served to residents and confirmed awareness of the cups being used as scoops and stored in the flour and sugar bins.

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 all clinical records, including NP visit notes, were readily accessible to licensed nursing staff responsible for resident care for one resident. Resident #5 was observed wearing a right wrist splint and stated she had fallen at home, broke her femur and wrist, continued to have some pain, and was receiving pain medication as ordered. She also stated the NP had recently changed how often she could receive pain medication. During interviews, an LPN stated the resident’s pain medication frequency had been changed from every 4 hours to every 6 hours and confirmed there were no NP progress notes in the EHR for the resident. The DON reviewed the records and stated the NP had seen the resident after hospital discharge, but the NP notes were entered into a separate system accessible only to facility management and were not accessible to floor nurses. The Administrator stated the facility had transitioned to an EHR system that was not compatible with the NP’s software, so the provider’s progress notes were not readily accessible in resident charts and had fallen through the cracks during the software transition. The resident’s record showed admission with diagnoses including aftercare following joint replacement surgery, and the MDS indicated a BIMS score of 13, showing the resident was cognitively intact.

Penalty

Inspection fine: $8,021

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 prevent a resident, identified as an elopement and wandering risk with moderate cognitive impairment, from exiting the facility unnoticed and unsupervised. The resident was observed by a therapy staff member in the lobby at approximately 12:00 PM and was later found near the side of the main road, approximately 100 feet from the facility grounds, at 12:08 PM. Facility staff were unaware that the resident had exited the facility, and the resident was retrieved by a CNA after being informed by the therapy staff member. The resident had been exhibiting exiting behavior earlier that day and was redirected. Despite wearing a wander guard device, the resident managed to leave the facility. The facility's investigation revealed that the door alarms and wander guard devices were functioning properly when tested, but there was radio static interference that could have caused the failure. The resident was found sitting on a cement slab near the main roadway, dressed appropriately for the weather, and was assessed to have no physical injuries or psychosocial harm upon return to the facility. Interviews with staff confirmed the sequence of events and the location where the resident was found. The facility's maintenance director routinely checked the exit doors and wander guard devices, and the door alarm vendor identified radio static interference as a potential issue. The facility's failure to provide adequate supervision and ensure the proper functioning of the wander guard system resulted in the resident's elopement, posing a significant risk to the resident's safety and well-being.

Removal Plan

• The Administrator and Director of Nurses were notified of an immediate jeopardy for failure to provide supervision to prevent an elopement for Resident #1 who was identified as an elopement and wandering risk.
• Resident #1 was retrieved and re-entered the building, she was immediately assessed by the Director of Nurses. A body audit was completed with no injury noted. Resident was interviewed by the Director of Nurses. The Director of Nurses verified that her wander guard was properly placed and functioning.
• Resident #1 was immediately placed on alert charting by the Director of Nurses to identify location every hour.
• The Director of Nurses immediately notified the Administrator of the elopement. The Director of Nurses then notified the responsible party of the resident and the Medical Director. The Administrator notified the Maintenance Director.
• The Administrator notified the State Agency.
• The Administrator notified the Attorney General.
• All residents were checked and accounted for in the building by the Certified Nursing Assistants and reported to the Administrator. Staff was interviewed by the Director of Nurses and the Administrator to determine if any resident was exit seeking that had not already been identified. None were identified.
• The Director of Nurses and Administrator began investigation and collection of statements from all staff present.
• All residents with wander guards were checked for proper placement and function by the Licensed Practical Nurse Supervisor. All were found to be properly placed and functioning.
• All exit doors and alarms were checked for proper functioning by the Maintenance Technician.
• Vendor, the door alarm provider, was called by the Maintenance Director to schedule an onsite visit.
• The Administrator began a door monitoring schedule until Vendor could conduct an on-site visit.
• The notice to visitors on the door was revised by the Administrator to be bigger and brighter instructing to not let any resident out of the door without notifying staff.
• Administrator began inservicing all staff on the Missing Resident policy and the Safe Guarding the Wandering Resident policy. Staff to be inserviced before returning to work.
• The plan of care of Resident #1 was updated to reflect the elopement by the Registered Nurse.
• All tasks in the electronic healthcare record of residents with wander guards were updated by the Licensed Practical Nurse Supervisor to include the task of the Certified Nursing Assistant to check the proper placement of the wander guard every shift. The Certified Nursing Assistants began to be inserviced on this by the Licensed Practical Nurse Supervisor. Staff to be inserviced before returning to work.
• The Elopement Risk Evaluation began being updated on all residents by the nurse supervisors. No new residents with risk of elopement were identified.
• The Elopement Risk Binder was created for all residents with wander guards to include their picture, name, date of birth and medical record number by the Licensed Practical Nurse Supervisor. The staff was inserviced on these binders and their location at each nurse desk. Staff to be inserviced before returning to work.
• All nurses were inserviced and completed a competency check-off on how to test a transmitter (wander guard) every shift as indicated on the Medication Administration Record by the Licensed Practical Nurse Supervisor. Staff to be inserviced before returning to work.
• Daily Stand Up Agenda in which all staff attends on two shifts was updated by the Administrator to include identifying what residents have wander guards. Note that the agenda previously included to identify any doors/alarms not working properly and any elder who is at risk for elopement.
• Vendor serviced the door and installed keypads in which the door remains locked. A code is required in order to enter and exit the door.
• Quality Assurance and Performance Improvement committee met that included the Administrator, Director of Nurses, Medical Director, RN Consultants, Infection Preventionist, Licensed Practical Nurse Supervisor, Maintenance Director, President/Co-Owner, and Chief Operating Officer to discuss the elopement of Resident #1 and updating the plan of care. Reviewed the Missing Resident policy. No recommendations for changes were made.
• Quality Assurance and Performance Improvement committee met again to include Administrator, Director of Nurses, RN Consultant, Nurse Practitioner, Social Service Director, Licensed Practical Nurse Supervisor, Maintenance Director, Activities Director, Admissions Coordinator, Administrative Assistant, and Infection Preventionist as a follow up to ensure all interventions that were put in place were effective. No concerns were noted. All findings will be discussed at the monthly Quality Assessment and Assurance meeting for a minimum of three months or until the compliance is maintained.
• The Elopement Risk Evaluation is to be completed by the Registered Nurse Supervisor on all new residents upon admission and quarterly thereafter.
• Visual checks to be initiated for all residents by the medication cart nurse for the first 72 hours upon admission and a wander guard to be placed if deemed necessary.
• Missing Resident and Safeguarding the Wandering Resident policies continue to be inserviced upon hire and quarterly thereafter.
• Monitoring to be completed as follows: Elopement Drill to continue to be completed quarterly. The wander guard audit will continue to be completed monthly by Licensed Practical Nurse supervisor. Maintenance Director/Housekeeping to continue with daily door checks twice a day. Wander guard proper placement and functioning to be checked every shift on the Medication Administration Record.