Rex Rehab & Nursing Care Center

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 maintain accurate and consistent documentation of a resident's advance directive and code status throughout the medical record. The resident, who was cognitively intact and had diagnoses including chronic kidney disease and hypertension, was admitted with a code status of do not resuscitate (DNR) indicated in the electronic medical record profile. However, a review of the advanced care planning notes revealed the absence of an advance directive, and a Medical Orders for Scope of Treatment (MOST) form in the record stated 'attempt CPR' and 'full scope of treatment.' Additionally, there was no physician's order addressing the resident's code status. Staff interviews confirmed the inconsistency, with the Social Worker and Director of Nursing both unable to explain the discrepancy between the electronic record and the MOST form. The resident herself stated her wish to have a DNR code status, but the documentation in her medical record did not consistently reflect this preference. The deficiency was identified through record review and staff interviews, highlighting a lack of accurate and unified documentation regarding the resident's advance directive and code status.

Penalty

Inspection fine: $15,646

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 the necessary supervision to prevent a severely cognitively impaired resident, who was at high risk for falls, from exiting the interior of the facility through an unlocked door leading to an enclosed exterior courtyard. On the night of the incident, a nearby neighbor heard the resident yelling for help and found her lying face down on the brick-paved ground in the courtyard. The resident was dressed in a nightgown and was shivering, with a body temperature of 90.9 degrees Fahrenheit, indicative of hypothermia. This incident affected one of the three residents reviewed for accidents. The resident, who had a diagnosis of dementia, was admitted to the facility with a care plan that included interventions for fall risk. Despite being assessed as severely cognitively impaired and at high risk for falls, the resident did not have a wander/elopement alarm. On the night of the incident, the resident was able to exit the facility through an unlocked courtyard door, which was supposed to be locked automatically from 9:00 PM to 7:00 AM. The facility's video footage showed the resident walking past the nurses' station and exiting through the courtyard door, which was not captured on camera. Interviews with staff revealed that the courtyard door's locking mechanism had been compromised due to a recent installation of a new wander guard system. The staff were unaware that the courtyard door was not locking as intended. The facility's maintenance director confirmed that the courtyard door had been the only door affected by the disruption to the system. The incident highlighted a failure in the facility's supervision and security measures, leading to the resident's unsupervised exit and subsequent fall in the courtyard.

Removal Plan

• Resident #52 was immediately brought in and assessed by Nurse #1.
• Resident #52 was provided with blankets as she stated she was cold.
• Nurse #1 promptly notified the Medical Director of the incident and Resident #52's current condition.
• The Medical Director instructed Nurse #1 to monitor Resident #52's temperature and if it did not return to normal to send her to the Emergency Department.
• Resident #52 was monitored closely by Nurse #1.
• Nurse #1 maintained direct supervision of Resident #52 and implemented frequent rounding on Resident #52.
• All nurses increased rounding frequency on all residents in the facility.
• Nurse #1 notified the Director of Nursing to escalate the incident.
• The Director of Nursing confirmed that all residents were safe and in their rooms.
• Local police and security personnel were on site following the entrance of two unidentified males into the facility and cleared the scene after finding it safe.
• The Administrator made the executive decision to place a wander guard pendant on Resident #52.
• The Minimum Data Set Coordinator updated the care plan by adding the 'Long Term Care Wander Guard' care plan for Resident #52.
• Nursing staff conducted a search of the facility and determined all residents were accounted for except for Resident #52.
• Nursing assistants and nurses increased frequency of rounding on all residents.
• The Administrator notified the Protective Services Director and the [NAME] President that the courtyard doors were found to not be locking properly.
• The Administrator notified the wander guard company and placed a ticket for repair.
• The Director of Nursing, Director of Protective Services, and the Administrator met via phone to conduct an 'Event After Action Report' to develop an action plan and monitoring processes.
• The Maintenance Director placed an auditory alarm on each courtyard door so that if the door opened, an alarm would sound and notify staff.
• The Director of Protective Services assessed the courtyard doors and tested the access control lock feature, which revealed it was failing.
• The Administrator placed another ticket with the company that installed the wander guard system.
• The wander guard company arrived at the facility but was unable to correct the issue because the installation company needed to be present.
• The installation company arrived and stated that both the remote locking system staff and installation company were needed to resolve the issue.
• The Administrator coordinated with both companies and the issue was corrected.
• The access control company retested the doors to confirm the issue was repaired.
• A new procedure was implemented by the Administrator to coordinate with the remote locking system team to test the remote locking system after any work is completed on the doors.
• The Administrator provided education on the new procedure to the Director of Protective Services and the Director of Nursing.
• The Director of Nursing updated the shift report to include information about the incident and the use of an attached manual audible alarm on the doors leading to the courtyard.
• The Director of Nursing educated the on-site Evening Team Leader about the failed remote locking mechanism and the use of an attached manual audible alarm.
• The Administrator trained the Clinical Manager to perform the remote locking control audits.
• The Clinical Manager trained the four Nursing Assistants (NA) designated to perform the remote locking control audits.
• The Administrator decided to change the responsible staff to night shift nurse team leaders to begin performing the audits.
• The Administrator educated all evening and night shift nurse team leaders on how to perform the remote locking control audits.
• All staff receive education regarding the chain of command used to escalate safety concerns during orientation.
• The monitoring plan started with audits and then became weekly after no failures.
• The audits collected are reported to the Quality Assurance and Performance Improvement (QAPI) committee by the Administrator.

Penalty

Inspection fine: $15,646

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 complete a comprehensive recapitulation of stay for two residents who were discharged home. For Resident #79, the discharge summary completed by various disciplines on the date of discharge did not include essential components such as customary routine, cognitive patterns, communication, vision, mood and behavior patterns, psychosocial well-being, continence, skin conditions, dental status, physical function, and structural problems. The Social Worker involved was unaware of the need to ensure all sections of the discharge summary were completed, and the Administrator acknowledged that the electronic system used, titled After Visit Summary, did not contain the required components. Similarly, for Resident #146, the discharge summary also lacked the necessary components of a recapitulation of stay. The Social Worker again indicated a lack of awareness regarding the completion of all sections, and the Administrator admitted to not realizing the deficiencies in the After Visit Summary form. Both residents were coded as cognitively intact at the time of discharge, and the facility did not have a designated person responsible for ensuring the completion of all sections of the discharge summaries.

Penalty

Inspection fine: $15,646

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 obtain a physician's order for the use of supplemental oxygen for a resident who was admitted with diagnoses including shortness of breath and acute kidney failure. The resident's care plan, last updated on 5/14/24, included a problem of impaired gas exchange with a goal to maintain adequate gas exchange. The interventions specified monitoring for signs and symptoms of hypoxia and administering oxygen as ordered. However, a review of the physician orders revealed no order for supplemental oxygen use. Observations made on three separate occasions revealed that the resident was wearing oxygen via nasal cannula at 2 liters per minute. Interviews with a nurse, a nurse practitioner, and the administrator confirmed that there was no physician's order for the oxygen, and all acknowledged that there should have been an order in place. The nurse practitioner and the administrator suggested that the lack of an order might have been an oversight.

Penalty

Inspection fine: $15,646

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 secure resident medications stored in an unattended and unlocked medication cart on Wing D. During an observation conducted on May 16, 2024, from 9:50 AM to 9:56 AM, the medication cart was found parked in the hallway with its drawers facing out and the lock not engaged, as indicated by the visible red dot on the lock. No staff member was present with the cart, and four staff members, one resident, and two visitors were observed walking past the unlocked cart. Nurse #2 returned to the cart at 9:56 AM and, upon request, opened the top drawer, realizing she had left the cart unlocked. Nurse #2 acknowledged that the cart should be locked whenever not in use. The Director of Nursing (DON) confirmed in an interview that the medication cart should have been secured and locked unless the nurse was present. The DON emphasized that the nurse assigned to the cart was responsible for ensuring its security. Similarly, the Administrator stated that medication carts should not be unlocked unless the nurse was standing in front of them, and the nurse assigned to the cart was responsible for it throughout their shift.

Penalty

Inspection fine: $15,646

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's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor interventions related to medication storage, as evidenced by a deficiency cited during both the 3/23/23 and 5/17/24 surveys. Specifically, the facility was found to have an unattended and unlocked medication cart on Wing D, which was one of five medication carts observed. This issue was previously identified during the 3/23/23 recertification and complaint investigation survey, where the facility was cited for failing to keep medications secure. Despite the Administrator's statement that constant rounds and daily monitoring of medication storage rooms and carts were being conducted, the deficiency persisted, indicating a pattern of the facility's inability to sustain an effective Quality Assessment and Assurance program.