Highland Home

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 provide adequate supervision and prevent elopement for two residents with known wandering and elopement risk. Both residents were ambulatory, frequently walked throughout the facility together, and were known to staff as wanderers. Each resident had a diagnosis of dementia with severe cognitive deficits documented on their MDS assessments, and both had Wander/elopement alarms (wander guard bracelets) in place and used daily. The facility’s elopement/wandering policy stated that residents who are incapable of adequately protecting themselves and unable to determine when they are at risk for harm by wandering out of the facility should be placed on the resident security system to ensure safety. On the day of the incident, video surveillance later reviewed by the Administrator showed that a visitor entered an exit door on the B Unit at approximately 6:20 PM. The two residents at risk for elopement approached the door, and the visitor held the door open, allowing them to walk out of the building. The residents were wearing wander guard bracelets, and when they exited, the door alarm sounded. A nurse responded immediately to the alarm, exited the facility, and went down the walkway but did not see the residents. Staff were then alerted that the residents were missing, and a facility-wide search was initiated. Staff interviews and the facility’s documentation confirmed that the residents had previously been observed walking together throughout the facility and approaching doors, including the exit door involved in the incident. The Administrator reported that review of the video showed the two residents had approached the same door together two or three times prior to the elopement event. Despite their known patterns of wandering, severe cognitive impairment, and prior door-approach behavior, the residents were able to exit the facility unnoticed and unsupervised when the visitor held the door open. Staff ultimately located the residents across a four-lane high-capacity highway approximately 528 feet from the exit door and returned them to the facility, where body audits and assessments documented no injuries and intermittent confusion. The State Agency determined that the facility’s failure to provide adequate supervision to prevent the elopement of these residents, who had exhibited exit-seeking behaviors, placed them and other residents at risk for wandering and elopement in a situation likely to cause serious injury, harm, impairment, or death and cited the facility at F689 with Immediate Jeopardy and Substandard Quality of Care. The residents’ medical records and elopement reports documented that both were confused, had impaired memory, and were identified as wanderers. One resident had a BIMS score of 3 and the other a BIMS score of 0, both indicating severe cognitive deficits. Progress notes and elopement reports recorded that staff were notified when the residents were not on the unit and could not be located, that all staff were engaged in searching, and that the residents were ultimately found outside and assisted back into the building. Interviews with CNAs and an LPN described hearing a Code W called, running outside, and seeing the residents across the street after they had crossed the four-lane highway. The DON acknowledged that the residents were always walking in the facility, often together, and that they had wandered to doors and looked out, and agreed that increased monitoring and not allowing visitors to have door codes could have prevented the residents from leaving the building.

Removal Plan

• Conducted a facility search.
• Notified police of missing residents.
• Director of Nursing interviewed staff and residents.
• Notified the Medical Director and residents’ families.
• Administrator and Director of Nursing checked the wander guard system and facility doors to ensure proper functioning.
• Returned Resident #1 and Resident #2 to the facility.
• Completed an incident report.
• Completed an emergency Quality Assurance meeting.
• Initiated in-service training for all staff on the elopement policy, including a quiz to validate comprehension, and required staff (including contract staff) to complete the in-service before working their next scheduled shift, with Administrator monitoring compliance.
• Responded immediately to the door alarm by sending staff outside to locate residents and notifying additional staff to assist with the search.
• Reviewed video surveillance and confirmed a visitor held the door open allowing residents to exit.
• Held an emergency Quality Assurance meeting with the Medical Director, Director of Nursing, Administrator, Regional Director, involved staff, and Infection Preventionist.
• Changed the main entry door code.
• Verified entrance door signage was in place instructing not to allow residents to exit unaccompanied.
• Identified residents at risk for elopement and ensured elopement bracelets/transmitters were functional and doors were locking appropriately.
• Reviewed care plans for residents at risk for elopement.
• Completed body audits on Resident #1 and Resident #2.
• Conducted audits verifying resident location, elopement risk, and wander guard bracelet function.
• Medical Records updated care profiles of residents at risk for wandering.
• Assistant Administrator began audits of all doors for function and security.
• Provided in-services on elopement policy and procedure, Resident Rights, and incident and accident reporting.
• Conducted elopement drills on each shift.
• Implemented monitoring systems to sustain compliance.
• Director of Nursing to monitor wander guard system checks three times weekly for four weeks or until substantial compliance is attained.
• Director of Nursing to monitor resident behavior for elopement attempts via incident reports, observations, and communications weekly for four weeks or until substantial compliance is attained.
• Quality Assurance Committee to meet for four weeks to review compliance with the plan of action, then continue routine Quality Assurance monitoring if no further concerns are noted.
• Administrator to hold follow-up Quality Assurance meetings monthly for two months then quarterly thereafter to ensure sustained compliance.
• Updated entry screening kiosk to include an additional reminder and attestation to ensure resident safety, requiring visitors to agree that no resident comes in or out with them and triggering a staff alert if the visitor refuses.
• Administration spoke directly with the visitor to confirm visitor policies and procedures.

Penalty

Inspection fine: $10,033

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 comprehensive care plans for two residents, leading to deficiencies in their care. Resident #14's care plan indicated a need for assistance with Activities of Daily Living (ADL), including personal hygiene tasks such as shaving and nail care. However, observations and interviews revealed that the resident had not been shaved and had long, unclean fingernails, indicating that the care plan was not followed. The Assistant Director of Nurses and the Minimum Data Set (MDS) nurse confirmed that the care plan was not adhered to, as personal hygiene is a standard practice that should have been provided. Resident #53's care plan addressed pain management, with a goal to decrease pain through medication as ordered. Despite this, the resident reported that the facility ran out of his prescribed pain medication, resulting in inadequate pain relief with over-the-counter alternatives. The Director of Nursing confirmed that the care plan was not followed, as the prescribed medication was not available, and no interventions were documented despite a recorded pain level of ten. The MDS nurse also confirmed the failure to adhere to the comprehensive care plan for pain management.

Penalty

Inspection fine: $10,033

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 adequate pain management for a resident, identified as Resident #53, who experienced frequent pain. The resident had a prescription for Hydrocodone 5 mg - Acetaminophen 325 mg to be taken every eight hours as needed, and Acetaminophen 325 mg to be taken every six hours as needed. However, the facility ran out of the prescription pain medication, and the resident was given over-the-counter medication instead, which did not fully alleviate his pain. This situation persisted from the evening of 5/27/24 until the evening of 5/30/24. Interviews with the Director of Nursing (DON) and other staff revealed that the facility's process for reordering medications was not followed correctly. The reorder request for the resident's pain medication was sent to the pharmacy on 5/23/24, but it was overlooked by the pharmacy staff, and the facility did not follow up. The DON confirmed that the nurse should have notified the on-call provider for a now dose order and obtained the medication from the facility's emergency kit, but this was not done. The resident's pain levels were documented as high, with a pain level of nine on 5/28/24 and ten on 5/29/24, yet no additional interventions were documented. The Nurse Practitioner (NP) was notified of the resident's complaints of pain and potential withdrawal symptoms on 5/29/24. Upon assessment, the NP found the resident's pain to be well controlled and did not observe any withdrawal symptoms. However, the NP acknowledged failing to provide a prescription to obtain the ordered medication. The Registered Pharmacist confirmed that the pharmacy received the faxed medication request but did not follow up, leading to a delay in the resident receiving his medication.

Penalty

Inspection fine: $10,033

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 transmit a discharge Minimum Data Set (MDS) Assessment for one of the residents reviewed for discharge MDS assessments. The facility's policy, titled 'MDS Process' with a revision date of December 2020, outlines that the Assessment Nurse/Nurse Case Manager is responsible for setting the Assessment Reference Date (ARD) and communicating scheduled assessments to the interdisciplinary team. The policy also specifies that the Resident Assessment Instrument (RAI) manual should be used for MDS coding guidelines, time schedules, and requirements. However, the MDS Nurse confirmed during an interview that the discharge MDS for a resident, who was admitted and later discharged with a return not anticipated, was not completed and submitted. This omission resulted in the discharge MDS being over 120 days late.

Penalty

Inspection fine: $10,033

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 assistance with Activities of Daily Living (ADLs) for a resident who required help with personal hygiene. Observations and interviews revealed that the resident had long, jagged fingernails with a brown substance underneath and unshaven facial hair. The resident expressed that it had been a long time since he was shaved and that he wished to have his nails cut. Despite the facility's policies on shaving and nail care, the resident's appearance remained unchanged over two consecutive days. Interviews with staff, including a Certified Nurse Aide (CNA) and a Licensed Practical Nurse (LPN), confirmed that the resident was not receiving the necessary personal hygiene care. The CNA, who was responsible for the resident's care, admitted to not knowing if the resident was diabetic and had never performed shaving or nail care for him. The LPN confirmed that the resident was not diabetic and that the CNAs were responsible for these tasks. The Assistant Director of Nurses (ADON) also confirmed that male residents should be shaved and all residents' nails should be cleaned and trimmed. The resident's medical diagnoses included shortness of breath and muscle weakness, which may have contributed to his inability to perform these tasks independently.

Penalty

Inspection fine: $10,033

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 properly label and store an aerosol nebulizer mask to prevent possible contamination for one of the 27 nebulizers in use. During an observation and interview with a resident, it was noted that the nebulizer machine was placed on the bedside dresser with an unbagged and undated nebulizer mask and tubing lying on top of the machine. The resident confirmed using the mask but was unsure of the frequency. A subsequent observation confirmed the nebulizer mask and tubing remained unbagged and undated. The facility's policy on infection control for oxygen equipment cleaning, revised in August 2021, requires that masks and cannulas be stored in a plastic bag clearly labeled with the resident's name and date when not in use. Interviews with an LPN and the Director of Nursing confirmed that the nebulizer mask should be dated and stored properly. The LPN acknowledged responsibility for ensuring the mask was bagged and dated, while the DON stated that masks and tubing are changed weekly, with dates placed on them at that time. The resident involved was admitted with medical diagnoses including aftercare following joint replacement surgery and unspecified dementia.

Penalty

Inspection fine: $10,033

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 store controlled substances in a permanently affixed locked compartment inside the refrigerator in one of the two medication storage rooms observed. During an observation, a small black refrigerator was found to contain a large tan lock box with four boxes of liquid lorazepam concentrate and a small clear box with three injectable vials of lorazepam. Both boxes were secured with a yellow sealed tab but were not permanently affixed, allowing them to be easily removed from the refrigerator. An LPN confirmed that the boxes contained controlled drugs that required refrigeration and acknowledged that they were not permanently affixed. The Director of Nursing also confirmed the lack of permanent affixation and recognized the need for it to ensure the safety of the controlled drugs.

Penalty

Inspection fine: $10,033

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 accurately document the administration of PRN pain medication for one of the residents reviewed for pain management. The facility's policy on drug administration and documentation requires that medications be promptly recorded on the Medication Administration Record (MAR) immediately after administration, including the reason for giving PRN medications and the result/response. However, a review of Resident #53's records revealed discrepancies between the Individual Resident Narcotic Record and the electronic Medication Administration Record (eMAR). Specifically, 47 out of 98 doses of prescribed pain medication were not documented in the eMAR, despite being signed out on the narcotic sheet. Interviews with the Director of Nursing (DON) and the Administrator confirmed that the eMAR did not accurately reflect the medications administered to the resident. The DON acknowledged that the narcotic record showed the resident received his narcotic pain medication twice daily, but the eMAR did not reflect this, indicating that the resident often went days without documented pain medication. This failure to accurately document the administration of pain medication could lead to medication errors and inaccurate treatment plans. The resident involved was cognitively intact, with a Brief Interview for Mental Status (BIMS) score of 15, and had been admitted with a diagnosis of pain.