St Mary's Alzheimer's 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

The facility failed to implement infection control practices correctly for five residents reviewed for infection control, with potential impact to 37 residents on the south hall or observed during medication administration. Resident #82 was admitted with diagnoses including UTI, dementia, hypertension, and heart failure, and had orders for Levaquin and contact isolation for a UTI. Although the baseline care plan identified contact isolation precautions, observation of the resident’s room revealed no contact precaution sign posted on the door. The DON confirmed the resident was on contact precautions and stated a sign should have been posted. During medication administration observation, an LPN repeatedly failed to perform hand hygiene at required times while providing care to Residents #56, #10, #12, and #29. The LPN administered oral medications, eye drops, and a breathing treatment, removed gloves without sanitizing hands, moved between residents without hand hygiene, handled medication and nebulizer supplies, and entered and exited Resident #10’s room without sanitizing hands afterward. The LPN also handled a capsule while gloved, removed the gloves, and then administered medications without hand hygiene. The LPN verified these observations during interview. Facility policy required hand hygiene before resident contact, before preparing or handling medication, after glove removal, and after contact with resident-related surfaces.

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 insulin administration was accurately documented for a resident with dementia, type 2 diabetes mellitus, noncompliance with medication regimen, high blood pressure, and need for assistance with personal care. The physician order required Novolog 4 units subcutaneously in the morning, held for blood sugar less than 80 mg/dl. Review of the MAR showed missing documentation for the ordered insulin on multiple dates, and review of progress notes also showed no documentation related to those insulin administrations on the same dates. An LPN stated that medication administration should be documented in the MAR, that if a medication was not administered it should be documented as not administered, and that the medical team would be notified if a medication was not administered. The DON verified the missing insulin documentation, and the facility policy stated that all communication with the physician would be documented and medications would be charted on the MAR. The facility also failed to accurately document weekly skin checks for two residents. One resident had diagnoses including dementia, muscle weakness, colon cancer, anxiety, and high blood pressure, with a person-centered care plan calling for skin checks every Friday and documentation of any abnormal findings. Another resident had diagnoses including dementia, schizoaffective disorder, depression, altered mental status, heart surgery, and disorientation, with a care plan for pressure ulcer prevention and an order for weekly skin checks by a nurse. Review of the TARs showed missing documentation for scheduled skin checks for both residents on multiple dates, and review of progress notes showed no documentation for the missing skin checks. Staff interviews confirmed the expected documentation process for skin checks. An RN stated that weekly skin checks were to be documented in the TAR as an attestation that the check was completed, while the actual skin condition was to be documented as a skin evaluation in the EMR evaluation tab. An LPN gave the same explanation, stating that skin checks were to be completed weekly and documented in the TAR, with the skin evaluation completed in the EMR evaluations tab. The DON verified the missing skin checks. The facility policy titled Skin Evaluations, Weekly stated that weekly skin evaluations were to be completed by the nurse and documented in the EMR in the evaluation tab.

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 protect the privacy of a resident during personal care, resulting in a serious breach of confidentiality. A Certified Nursing Assistant (CNA) recorded a video of a resident in a vulnerable state, slouched in a shower chair with her pants around her ankles and her shirt pulled up, exposing her bare body. The video also showed a large amount of fecal matter on the floor. The CNA then posted this video on Snapchat, a social media platform, with a text overlay and emoji that demeaned the resident. This incident was reported to the facility by an anonymous caller, leading to an investigation. The resident involved had a diagnosis of Alzheimer's disease and was severely cognitively impaired, requiring maximum assistance for daily living activities. On the day of the incident, the resident experienced multiple episodes of bowel incontinence, which led to her being taken to the shower room for cleaning. During this time, the CNA recorded and shared the video without the resident's knowledge or consent, violating her privacy and dignity. Interviews with staff revealed that the CNA was known to frequently use her phone while at work, and other staff members were aware of the video being taken. The facility's policy on personal cell phone use was outdated, allowing staff to use their phones in certain areas, but not while providing personal care. The social media policy clearly stated that staff should not post any photographs or videos of residents without permission, which the CNA violated by sharing the video on Snapchat.

Removal Plan

• RN #502 and LPN #506 spoke with CNA #500 advising her of the allegation received that she posted a video on Snapchat and that they needed to see her phone. RN #502 reviewed the contents of the phone and observed the video of Resident #28. The nurses required CNA #500 to delete the video from the camera roll and the recently deleted section of her phone.
• RN #502 informed CNA #500 that she was suspended, and CNA #500 was escorted from the building.
• RN #502 assessed Resident #28. Resident #28's physician was notified of increased lethargy and loose stools and new orders to hold medications and monitor vital signs was obtained and family was updated. Resident #28 family was notified.
• The Administrator began re-education of staff in the facility regarding the social media policy, which included protecting the privacy of others, and personal cell phone use. She also interviewed staff to determine if they have witnessed or were aware of any staff taking pictures or videos of residents on their phones. There were approximately 22 as needed (PRN) staff who had not received education with a plan for staff to continue as PRN staff arrive on-site for their scheduled shifts.
• The Administrator asked CNA #500 if she had taken pictures prior or posted any videos of residents in the past. The CNA denied taking any other photos or videos of residents and no other pictures or videos involving other residents were noted on the employee's phone.
• The Administrator sent text messages to approximately 77 employees in regards to the facility social media policy, which included protecting the privacy of others, and then re-educated all employees again as they came into the facility per their schedule. Many employees worked PRN or worked one to two days a month and still required education.
• RN #511 provided re-education to 33 staff who arrived for their scheduled shift on this day on the facility social media policy, which included protecting the privacy of others, and personal cell phone.
• The Administrator began to complete audits during rounds for cell phone use. The Administrator made observations of staff on the units to ensure staff did not have cell phones out, were maintaining privacy and confidentiality during hands on care, and reviewed the cell phone audit sheets, which were completed by the floor nurses twice on each shift to monitor for staff cell phone use. The audit sheets included the date, time, unit location, whether cell phone use was observed, who was observed using their cell phone (if applicable), what corrective action was taken, and the initials of the nurse completing the form.
• Medical Director #512 was notified by Regional QA Nurse #503 of the incident involving Resident #28.
• A meeting was held with Regional QA Nurse #503, Clinical Director #513 and Medical Director #512 to discuss the incident, actions being taken by the facility, and how continued re-education and auditing/monitoring of staff cell phone use while on duty and privacy/confidentiality during care would continue daily at this time.
• CNA #500's employment was terminated.
• An AD HOC meeting via telephone conference with Medical Director #512, Director of Nursing (DON), the Administrator, and Regional QA Nurse #503 to notify Medical Director #512 of the State agency survey and Immediate Jeopardy situation. A discussion occurred related to on-going education of all staff, and the continuation of monitoring staff cell phone use and resident privacy/confidentiality during care.
• Signs were posted in resident care areas which included: no cell phone usage on the floor.
• All residents with a Brief Interview for Mental Status (BIMS) score of eight or higher were interviewed by Bookkeeper #515 revealed to Privacy/Confidentiality.
• The facility implemented a plan to continue to monitor/audit for cell phone use on the unit and ensure residents privacy was maintained during care. Audits/monitoring would be completed by the DON and/or designee by observation on the units for personal cell phone use and observation of privacy being maintained during resident care three times per day for five days a week on various shifts/times for three weeks and then three times per day on various shifts/times for three times a week for three weeks. All audits would be reviewed by the Quality Assurance and Performance Improvement (QAPI) committee to determine the need for continuation of audits.
• The DON and/or designee would interview five staff members every week for eight weeks on various shifts and in various departments on abuse policies, definitions, reporting and understanding of the facility abuse policy and social media policy. Interviews would be reviewed by the QAPI committee to determine the need for continued education.

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 protect a cognitively impaired resident from mental and emotional abuse by a staff member. A Certified Nursing Assistant (CNA) recorded a video of the resident during personal care and posted it on the social media platform Snapchat. The video showed the resident in a vulnerable state, slouched in a shower chair with her pants around her ankles and her shirt pulled up, exposing her bare body. The video also depicted a large amount of fecal matter on the floor, with a text overlay that read 'bruh' accompanied by a loudly crying face emoji. This act was deemed to have caused serious mental and emotional harm to the resident, who had a diagnosis of Alzheimer's disease. The resident involved in the incident had severe cognitive impairment and was dependent on staff for various activities of daily living, including toileting and showering. On the day of the incident, the resident experienced multiple episodes of bowel incontinence, which required assistance from the staff for cleaning. Despite the resident's condition, the CNA took a video of the resident in a state of undress and posted it online, which was considered an act of neglect and abuse by the facility staff responsible for the resident's care. The facility's policies on personal cell phone use, social media, and abuse were not adhered to by the CNA, leading to the incident. The facility's policy prohibited the use of personal cell phones in resident care areas, and the social media policy required staff to maintain the privacy and dignity of residents. The CNA's actions violated these policies, resulting in the resident's exposure to potential humiliation and emotional distress.

Removal Plan

• RN #502 and LPN #506 spoke with CNA #500 advising her of the allegation received that she posted something on Snapchat and that they need to see her phone. RN #502 reviewed the contents of the phone and observed the video of the resident. The nurses made CNA #500 delete the video from the camera roll and the recently deleted section of her phone.
• RN #502 informed CNA #500 that she was suspended, and CNA #500 was escorted from the building.
• RN #502 assessed Resident #28. Resident #28's physician was notified of increased lethargy and loose stools and new orders to hold medications and monitor vital signs was obtained and family was updated. Resident #28's family was notified.
• The Administrator began re-education of staff in the facility regarding the social media policy, which included protecting the privacy of others, and personal cell phone use. She also interviewed staff to determine if they had witnessed or were aware of any staff taking pictures or videos of residents on their phones. Education remained ongoing for PRN staff as they arrive on-site for their scheduled shifts.
• The Administrator asked CNA #500 if she had taken pictures prior or posted any videos of residents in the past and she denied stating this was her first time. No other pictures or videos involving other residents were noted on the phone.
• The Administrator sent text messages to approximately 77 employees in regards to social media policy, which included protecting the privacy of others, and then re-educated all employees again as they came into the facility per their schedule.
• RN #511 provided re-education to 33 staff who arrived for their scheduled shift on the social media policy, which included protecting the privacy of others, and personal cell phone use.
• The Administrator began to complete audits during rounds for cell phone use. The Administrator made observations of staff on the units to ensure staff did not have cell phones out, were maintaining privacy and confidentiality during hands on care, and reviewed the cell phone audit sheets, which were completed by the floor nurses twice on each shift to monitor for staff cell phone use. The audit sheets included the date, time, unit location, whether cell phone use was observed, who was observed using their cell phone, what corrective action was taken, and the initials of the nurse completing the form.
• Medical Director #512 was notified by Regional QA Nurse #503 of the incident involving Resident #28.
• A meeting was held with Regional QA Nurse #503, Clinical Director #513 and Medical Director #512 to discuss the incident, actions being taken by the facility, and how continued re-education and auditing/monitoring of staff cell phone use while on duty and privacy/confidentiality during care would continue daily.
• CNA #500's employment was terminated.
• An AD HOC meeting via telephone conference with Medical Director #512, Director of Nursing (DON), the Administrator, and Regional QA Nurse #503 to notify Medical Director #512 of the State agency Immediate Jeopardy. A discussion was held regarding education of all staff, and the continuation of monitoring staff cell phone use and resident privacy/confidentiality during care.
• Signs were posted in resident care areas that stated: no cell phone usage on the floor.
• Staff re-education was provided on the facility abuse policy and the relation to the social media policy in-person or via phone conversation by facility department heads.
• All residents with a Brief Interview for Mental Status (BIMS) score of eight or higher were interviewed by Bookkeeper #515 related to Privacy/Confidentiality.
• Corporate QA Director #514 re-educated the Administrator on the facility abuse policy and the reasonable person concept. The reasonable person concept would be utilized for future investigations. The DON was also knowledgeable of the reasonable person concept and verbalized understanding of reporting requirements to the State agency. The facility implemented a plan for Corporate QA office staff to monitor abuse allegations on an on-going basis.
• Regional QA Nurse #503 added an addendum to the facility SRI to reflect the incident/allegation was substantiated.
• The facility implemented a plan to monitor/audit for cell phone use on the unit and ensure all residents privacy was maintained during care. Audits/monitoring would be completed by the DON and/or designee by observation on the units for personal cell phone use and observation of privacy being maintained during resident care three times per day for five days a week on various shifts/times for three weeks and then three times per day on various shifts/times for three times a week for three weeks. All audits would be reviewed by the Quality Assurance and Performance Improvement (QAPI) committee to determine the need for continuation of audits. In addition, the DON and/or designee would interview five staff members every week for eight weeks on various shifts and in various departments on abuse policies, definitions, reporting and understanding of the facility abuse policy and social media policy. Interviews would be reviewed by the QAPI committee to determine the need for continued education.

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 effectively implement its abuse policy, resulting in a situation of abuse when a CNA took a video of a resident during personal care and posted it on social media. The video showed the resident, who had Alzheimer's disease, in a vulnerable state with her bare body exposed and fecal matter on the floor. The facility initially concluded the incident was unsubstantiated because the resident was unaware of the incident, despite the reasonable person concept indicating that any reasonable person would have suffered serious mental or emotional harm from such a video being taken and shared. The resident involved had severe cognitive impairment and was dependent on staff for personal care due to Alzheimer's disease and other conditions. On the day of the incident, the resident experienced incontinence and was taken to the shower room for cleaning. During this time, the CNA recorded the resident and shared the video on Snapchat, which was later reported to the facility by an anonymous caller. The facility's investigation initially failed to recognize the incident as abuse, despite the clear violation of the resident's privacy and dignity. Interviews with staff revealed that the CNA was known to frequently use her phone during work hours, and other staff members were present during the incident but did not intervene. The facility's outdated policy on personal cell phone use contributed to the failure to prevent the incident. The facility's policies on social media and abuse prevention were not effectively enforced, leading to the CNA's inappropriate actions and the subsequent failure to recognize and report the incident as abuse.

Removal Plan

• RN #502 and LPN #506 spoke with CNA #500 advising her of the allegation received that she posted something on Snapchat and that they need to see her phone. RN #502 reviewed the contents of the phone and observed the video of Resident #28. The nurses made CNA #500 delete the video from the camera roll and the recently deleted section of her phone.
• RN #502 informed CNA #500 she was suspended, and CNA #500 was escorted from the building.
• RN #502 assessed Resident #28. Resident #28's physician was notified of increased lethargy and loose stools and new orders to hold medications and monitor vital signs was obtained and family was updated. Resident #28's family was notified.
• The Administrator began re-education of staff in the facility regarding the social media policy, which included protecting the privacy of others, and personal cell phone use. She also interviewed staff to determine if they have witnessed or were aware of any staff taking pictures or videos of residents on their phones. There were approximately 22 as needed (PRN) staff who had not received education with education on-going as PRN staff arrived on-site for their scheduled shifts.
• The Administrator asked CNA #500 if she had taken pictures prior or posted any videos of residents in the past. The CNA denied taking other pictures or posting videos of other residents. No other pictures or videos involving other residents were noted on the phone.
• The Administrator sent text messages to approximately 77 employees (all staff members for which the Administrator had cell phone numbers, out of 118 staff) in regards to social media policy, which included protecting the privacy of others, and then re-educated all employees again as they came into the facility per their schedule. PRN staff and staff who worked one to two days a month would be educated as they arrived to work.
• RN #511 provided re-education to 33 staff who arrived for their scheduled shift related to the facility social media policy, which included protecting the privacy of others, and personal cell phone use.
• The Administrator began to complete audits during rounds for cell phone use. The Administrator made observations of staff on the units to ensure staff did not have cell phones out, were maintaining privacy and confidentiality during hands on care, and reviewed the cell phone audit sheets, which were completed by the floor nurses twice on each shift to monitor for staff cell phone use. The audit sheets included the date, time, unit location, whether cell phone use was observed, who was observed using their cell phone (if applicable), what corrective action was taken, and the initials of the nurse completing the form.
• Medical Director #512 was notified by Regional QA Nurse #503 of the incident involving Resident #28.
• A meeting was held with Regional QA Nurse #503, Clinical Director #513 and Medical Director #512 to discuss the incident, actions being taken by the facility, and how continued re-education and auditing/monitoring of staff cell phone use while on duty and privacy/confidentiality during care would continue daily at this time.
• CNA #500's employment was terminated.
• An AD HOC meeting via telephone conference with Medical Director #512, Director of Nursing (DON), the Administrator, and Regional QA Nurse #503 was held to notify Medical Director #512 of the State agency Immediate Jeopardy. A discussion was held regarding on-going education of all staff, and the continuation of monitoring staff cell phone use and resident privacy/confidentiality during care.
• Signs were posted in resident care areas which stated: no cell phone usage on the floor.
• Re-education on the facility abuse policy and the relation to the social media policy was completed with all staff in-person or via phone conversation by facility department heads.
• All residents with a Brief Interview for Mental Status (BIMS) score of eight or higher, Residents #8, #24, #36, #43, #54, #67, #71, #72, and #73, were interviewed by Bookkeeper #515 related to Privacy/Confidentiality.
• Corporate QA #514 re-educated the Administrator on the facility abuse policy and reasonable person concept. The reasonable person concept would be utilized for future investigations. The DON was also knowledgeable of the reasonable person concept and verbalized understanding if she was required to report an SRI. The facility implemented a plan for Corporate QA office staff to monitor abuse allegations on an on-going basis.
• Regional QA Nurse #503 completed an addendum for the facility SRI involving the incident with Resident #28. The addendum noted the allegation of abuse was substantiated.
• The facility implemented a plan to monitor/audit for cell phone use on the unit and ensure residents privacy was maintained during care. Audits/monitoring would be completed by the DON and/or designee by observation on the units for personal cell phone use and observation of privacy being maintained during resident care three times per day for five days a week on various shifts/times for three weeks and then three times per day on various shifts/times for three times a week for three weeks. All audits would be reviewed by the Quality Assurance and Performance Improvement (QAPI) committee to determine the need for continuation of audits.
• The DON and/or designee would interview five staff members every week for eight weeks on various shifts and in various departments on abuse policies, definitions, reporting and understanding of the facility abuse policy and social media policy. Interviews would be reviewed by the QAPI committee to determine the need for continued education.

Penalty

Inspection fine: $66,973

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 harmful cleaning chemicals were not accessible to severely cognitively impaired residents. During an observation, it was noted that a floor technician left a cart unattended in the hallway with four spray bottles of cleaning chemicals in an open pocket. These chemicals included Crew Restroom & Surface SC Non-Acid Disinfectant Cleaner, Virex two 256 One-Step Disinfectant Cleaner, Fantasik, and Clorox Germicidal Bleach. The floor technician confirmed that he had left the cart in the hallway while cleaning resident rooms. Interviews and reviews of safety data sheets revealed that these chemicals posed significant risks, such as causing severe skin burns, serious eye damage, and being harmful if swallowed. The facility's policy required that all cleaning agents be secured in a housekeeping cart when not in use. The failure to adhere to this policy had the potential to affect 36 residents identified as both mobile and severely cognitively impaired, out of a total facility census of 76.