Ellen Memorial Rehabilitation And Healthcare Cente

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 protect a resident from neglect by not following the resident’s updated care plan requiring two-person assistance and use of a mechanical stand-up lift for transfers. The resident had a history of right-sided hemiplegia/hemiparesis following a stroke but was documented as cognitively intact with a BIMS score of 15. A quarterly MDS showed the resident had previously been independent with ADLs, including transfers, ambulation, and toileting, and the initial care plan reflected independence with a rollator walker for transfers and ambulation. Subsequently, therapy documentation showed a decline in the resident’s functional mobility and increased left hip pain. On reevaluation, therapy noted the resident had recently refused attempts to stand and requested use of a standing lift for transfers. A therapy progress note documented that the resident remained in bed and declined to attempt standing, and the therapist downgraded the resident’s assistance level from independence with a rollator walker to requiring a stand-up lift due to the inability to assess safe ambulation and transfers. The care plan was updated to require use of a stand-up lift with assistance of two staff members for transfers and ambulation with a roller walker and gait belt with assistance of two staff members. Despite these updated care plan requirements, a nursing progress note documented that the resident experienced a witnessed fall in the bathroom while ambulating with one nurse aide using a roller walker. The resident fell while turning to sit on the toilet and was found sitting on the floor with the left foot twisted backward at the ankle, after which the resident complained of ankle and foot pain. Facility investigative documentation and staff statements indicated that the resident was transferred and ambulated without the required level of assistance and without use of the stand-up lift as specified in the care plan. As a result of this failure to follow the care plan interventions, the resident sustained a left ankle fracture that required evaluation, treatment, and subsequent surgical repair. Facility-provided statements further described the circumstances leading to the fall. One nurse aide reported responding to the resident’s call bell for bathroom assistance and documented that another aide had told the resident to prove herself by using the walker. The responding aide stated she told the resident that this was not the way the resident was supposed to transfer anymore, but the resident insisted on using the walker. The aide reported that the resident ambulated with the walker until turning to sit on the toilet, at which point the resident began to fall; the aide attempted to guide the resident to the floor but the resident landed sitting on her left foot. In a subsequent interview, this aide confirmed she was aware that the resident’s transfer status required assistance of two staff members with a stand-up lift for transfers and two-person assistance for ambulation with a roller walker, and acknowledged that the resident was ambulated and transferred without the required assistance, resulting in the fall and injury. Medical records from the hospital documented that imaging revealed a comminuted fracture of the medial malleolus and a laterally displaced oblique fracture of the lateral malleolus of the left ankle, with an impression of medial and lateral malleolar fractures. The resident received narcotic pain medication and a splint and wrap were applied. Subsequent orthopedic consultation records described the fracture as a closed, displaced lateral malleolus fracture and later as a left bimalleolar ankle fracture, characterized as unstable and requiring surgical intervention with ORIF. Nursing documentation confirmed the resident was transferred for surgery and returned following ORIF of the left ankle. The facility’s investigation, as confirmed by the Nursing Home Administrator, determined that the nurse aide did not follow the resident’s care plan requiring two-person assistance for ambulation and transfers, which constituted neglect under the facility’s abuse and neglect policy.

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 promptly notify a resident's responsible party of a significant change in condition, specifically the resident's transfer to the hospital. According to the facility's policy, notification of the resident, their physician, and their representative is required when there is a change in condition, including transfers or discharges. Review of the clinical record showed that the resident, who had diagnoses including cerebral vascular disease, anxiety, and high blood pressure, and was assessed as cognitively intact, was transferred to the hospital for evaluation and treatment. However, there was no documentation that the responsible party was notified of this transfer. Interviews with the Director of Nursing and the Nursing Home Administrator confirmed that the responsible party was not informed of the hospital transfer. The deficiency was identified through review of clinical records, facility policy, and staff interviews, and was found to be in violation of both facility policy and state regulations regarding timely notification of changes in resident condition.

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 provide necessary care and services to a resident following a significant change in condition. The resident, who had a history of cerebral vascular disease, anxiety, and hypertension, experienced an elevated temperature and dysuria. Despite the physician ordering a urinalysis and urine culture, there was no evidence that the facility ensured timely receipt, review, or action on the test results. When the laboratory reported conflicting results and requested a new specimen, the facility did not ensure timely completion of the reordered testing. Abnormal urinalysis findings and persistent fevers were documented, but the facility did not ensure timely receipt of the culture and sensitivity results needed to guide treatment. The resident continued to experience elevated temperatures, and it was not until several days later that the physician was notified again and additional diagnostic tests were ordered. Ultimately, the resident was found to have a significant infection and impaired kidney function, requiring hospitalization for acute kidney injury. Additionally, the facility failed to identify and address the resident's inadequate fluid intake during this period. The resident's estimated daily fluid requirement was documented, but daily intake records showed that the resident consistently failed to meet these needs over a two-week period. There was no evidence that the facility reassessed the resident's hydration status, implemented interventions to increase fluid consumption, or notified the physician of the ongoing inadequate intake, even as the resident was experiencing infection and persistent fever. The combination of delayed follow-up on diagnostic testing, lack of timely intervention for abnormal findings, and failure to monitor and address inadequate fluid intake contributed to the resident's decline and subsequent hospitalization. The facility did not meet regulatory requirements for timely assessment, monitoring, and intervention in response to a significant change in condition, nor did it maintain accurate and complete records as required.

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 provide timely laboratory services and appropriate follow-up for a resident who was admitted with diagnoses including cerebral vascular disease, anxiety, and hypertension. The resident developed an elevated temperature and dysuria, prompting a physician order for urinalysis and urine culture and sensitivity. Although the specimen was collected and sent to the laboratory, there was no evidence that the urinalysis results were received or reported to the facility. Subsequently, the laboratory reported conflicting results and requested a new specimen, which was collected and sent, but seven days later, the culture and sensitivity results had still not been completed or reported. The facility did not ensure follow-up with the laboratory regarding the missing results. During this period, the resident's condition worsened, with documentation of increased temperature and feeling unwell. Additional laboratory tests were ordered, including urinalysis, culture and sensitivity, CBC, and CMP. The results received indicated significant infection and impaired kidney function, leading to the initiation of IV fluids and transfer to the hospital for acute kidney injury. At the time of the survey, there was no documentation that the facility had followed up with the laboratory regarding the delayed results, and the Director of Nursing was unable to provide evidence of timely follow-up.

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 thoroughly investigate an incident of unknown origin involving a resident who was found to have more than 30 potassium chloride tablets impacted in the rectum. The resident, who was cognitively intact and required staff assistance with activities of daily living, was transferred to the hospital after experiencing nausea and loose stools. Hospital evaluation revealed numerous circular foreign bodies in the rectum, identified as potassium chloride tablets, and the resident denied inserting the medications himself. Upon return to the facility, there was no documented evidence that an investigation was initiated to determine the root cause of the incident or to rule out abuse, neglect, or mistreatment. The facility's Abuse Policy required that incidents of unknown origin be investigated as potential abuse until a root cause could be identified. However, there was no documentation of interviews or witness statements from staff who administered medications to the resident during the relevant period, nor was there an interview or written statement from the resident to assess for possible mistreatment. Additionally, the facility did not document any attempt to determine how the resident became impacted with the pills or whether any staff had harmed him or administered medication inappropriately. Subsequent to the resident's return, another incident occurred where multiple pills were found on the floor at the resident's bedside, and a facility investigation report was completed for this later event. However, the initial incident involving the rectal impaction of pills was not investigated in accordance with facility policy or regulatory requirements. The Director of Nursing and Nursing Home Administrator confirmed that a timely and comprehensive investigation was not conducted for the original incident.

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 revise a comprehensive, person-centered care plan for a resident with Alzheimer's disease and muscle weakness. The resident's POLST form, completed with the responsible party, indicated a change to a do-not-resuscitate (DNR) status and elected comfort care measures, including selective antibiotic use and no artificial hydration or nutrition. Despite these updates being documented in the physician's orders and progress notes, the resident's care plan was not revised to reflect these specific medical treatment goals. The deficiency was confirmed by the Director of Nursing and the Social Worker, who acknowledged that the care plan did not incorporate the resident's preferences for comfort measures only, antibiotics for comfort, and the decision to forego artificial hydration and nutrition. This oversight was identified during a review of the resident's clinical records and staff interviews, highlighting a failure to align the care plan with the resident's updated medical treatment goals as outlined by the POLST form and the responsible party's instructions.

Plan Of Correction

1. Resident 67's comprehensive care plan has been updated to reflect the POLST, MD orders, progress notes and resident/representative instructions. 2. Residents POLST forms have been reviewed for conformity with MD orders, progress notes and resident/representative instructions. The care plans have the appropriate interventions and goals to meet their individual needs. 3. Facility procedures for developing comprehensive care plans have been reviewed/revised to assure MD orders, progress notes and resident/representative instructions represented on the POLST are included on the comprehensive care plan. The procedures have been in-serviced to the care planning team. 4. The NHA/designee will audit 5 random charts per week to assure MD orders, progress notes and resident/representative instructions represented on the POLST are included on the comprehensive care plan. The audit will be turned in to the QA team for review. 5. February 18, 2025

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 individualized approaches to prevent declines in bowel continency and restore normal bowel function for a resident. The facility's policy requires that residents with potential for improved continence be placed on a retraining program. Upon admission, re-admission, significant changes, or after urinary catheter removal, a bowel and bladder diary should be completed for at least three days to assess the resident's continence status. However, for one resident, who was frequently incontinent of both bowel and bladder, the facility did not evaluate the resident's bowel and bladder habits to develop an individualized toileting retraining program. The resident, admitted with diagnoses including hypertension, anxiety, and recurrent urinary tract infections, required partial/moderate assistance with activities of daily living, including toilet transfer and toileting hygiene. Despite a continence evaluation recommending routine toileting and checks, there was no evidence that the recommended program was implemented. This lack of action led to the deficiency, as the facility did not adhere to its policy of evaluating and implementing a toileting program to manage the resident's incontinence.

Plan Of Correction

1. Resident 65 has started a bowel/bladder diary to evaluate continence and provide a proper training program for bowel/bladder habits. Results of the program have been placed on the cardex and put on the comprehensive care plan. 2. Residents who are identified as having the potential to improve their continence will be placed on a retraining program. Residents will be assessed upon admission, readmission quarterly and annually. 3. The Bowel and bladder policy has been reviewed/revised to assure residents who are identified as having the potential to improve continence are placed on a retraining program. The policy has been in-serviced to licensed and direct care staff. 4. The DON/designee will audit 5 residents (admits, readmits, sig change, annual) to assure that residents that have the potential to improve continence are placed on a retraining program. The audit will be turned in to the QA team for review. 5. February 18, 2025

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 coordination of care and services between the facility and the hospice agency for two residents. Resident 69, who was admitted with diagnoses including dementia and Alzheimer's disease, was placed into hospice care for end-stage Alzheimer's disease. However, the resident's care plan, last revised on November 25, 2024, did not reflect the necessary coordination of services between the facility and the hospice agency to meet the resident's daily and terminal care needs. Similarly, Resident 7, admitted with a diagnosis of dementia, was also placed into hospice care for end-stage dementia. The care plan for Resident 7, last revised on December 10, 2024, similarly failed to reflect coordination of services between the facility and the hospice agency. An interview with the director of nursing confirmed that the care plans for both residents were not coordinated with hospice services, indicating a deficiency in the facility's coordination of care.

Plan Of Correction

1. Comprehensive care plans for Residents 69 and 7 have been revised so that the facility and hospice care plans are integrated to meet the resident's care needs. 2. Residents/Representatives electing the hospice benefit will have care plans integrated with hospice to meet the resident's care needs. 3. The coordination of hospice service policy has been reviewed/revised to assure that care and service between the facility and Hospice Agency is integrated. PCC will be contacted for care plan information to better our electronic care planning. The policy will be in-serviced to the IDT. 4. The NHA/designee will audit residents on hospice weekly to assure hospice and facility care plans are integrated and promote to meet the resident's care needs. 5. February 18, 2025

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 meet the required nurse aide to resident ratios on 13 out of 63 reviewed shifts. Specifically, the facility did not provide the minimum number of nurse aides needed for the day, evening, and night shifts as per the regulation effective July 1, 2024. The deficiency was identified through a review of the facility's weekly staffing records, which showed that on multiple dates, the number of nurse aides on duty was below the required ratios based on the facility's census. For instance, on October 17, 2024, the night shift had 6.87 nurse aides instead of the required 6.93 for a census of 104 residents. Similarly, on November 23, 2024, the night shift had only 5.80 nurse aides, falling short of the required 6.93 for the same census. The deficiency was confirmed during an interview with the Nursing Home Administrator, who acknowledged that the facility did not meet the required staffing ratios on the specified dates. No additional higher-level staff were available to compensate for the staffing shortfall.

Plan Of Correction

5520 1. The facility cannot retroactively correct nurse aide staffing ratios for the past. 2. The facility will review nurse aide ratios daily to provide care according to Pennsylvania regulation on staffing. (1-10; 1-11; 1-15) 3. Regulations for nurse aide ratios have been reviewed by facility management. Facility management will project ratios daily to have staff set according to guidelines. 4. Nursing will track ratios daily and provide a copy of the numbers to the administrator. The numbers will be provided to the QA team to track compliance. 5. February 18, 2025

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 meet the required licensed practical nurse (LPN) to resident ratios on 13 out of 63 shifts reviewed. Specifically, the facility did not provide the minimum number of LPNs needed for the day, evening, and night shifts on several dates between October 2024 and January 2025. For instance, on October 17, 2024, the facility had 4.00 LPNs on the day shift, whereas 4.16 were required for a census of 104 residents. Similar deficiencies were noted on other dates, with the facility consistently falling short of the required LPN staffing levels. The report indicates that no additional higher-level staff were available to compensate for the deficiency in LPN staffing on the mentioned dates. An interview with the Nursing Home Administrator on January 9, 2025, confirmed the facility's failure to meet the required LPN to resident ratios. This deficiency was identified through a review of the facility's weekly staffing records and staff interviews, highlighting a pattern of inadequate staffing levels that persisted over several months.

Plan Of Correction

1. The facility cannot retroactively correct LPN staffing ratios for the past. 2. The facility will review LPN ratios daily to provide care according to Pennsylvania regulation on staffing. (1-25; 1-25; 1-40) 3. Regulations for LPN ratios have been reviewed by facility management. Facility management will project ratios daily to have staff set according to guidelines. 4. Nursing will track LPN ratios daily and provide a copy of the numbers to the administrator. The numbers will be provided to the QA team to track compliance. 5. February 18, 2025

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 consistently meet the state regulation requiring a minimum of 3.2 hours of direct resident care per resident per day. A review of the facility's staffing levels revealed multiple dates where the nursing care hours fell below the required minimum. Specifically, on several occasions between October 2024 and January 2025, the facility provided between 2.90 and 3.17 hours of direct care per resident, which is below the mandated 3.2 hours. This deficiency was confirmed during an interview with the Nursing Home Administrator on January 9, 2025.

Plan Of Correction

5640 1. The facility cannot retroactively correct nursing PPDs for the past. 2. The facility will review nursing PPD daily to provide care according to Pennsylvania regulation on staffing (3.20 hours). 3. Regulations for nursing PPD have been reviewed by facility management. Facility management will project PPD daily to have staff set according to guidelines. 4. Nursing will track PPD daily and provide a copy of the numbers to the administrator. The numbers will be provided to the QA team to track compliance. 5. February 18, 2025

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 three residents were free from physical abuse. Resident 73, who was severely cognitively impaired due to alcohol-induced persisting dementia, was scratched and bruised by Resident 74. Resident 74, who had Alzheimer's disease and displayed aggressive behaviors, was noted to have physically attacked Resident 73 on multiple occasions. Despite interventions in place, Resident 74's aggressive behavior was not adequately managed, leading to physical abuse of Resident 73 on May 10, 2024, resulting in a scratch and bruising on her left forearm. Resident 65, who was severely cognitively impaired due to dementia, was slapped by Resident 74 in the hallway. The incident was witnessed by a nurse aide, and although Resident 65 did not sustain visible injuries or complain of pain, the facility failed to protect Resident 65 from physical abuse. Resident 74's aggressive behavior continued to be a problem, as evidenced by multiple documented incidents of physical aggression towards other residents. Resident 89, who was moderately cognitively impaired and had heart failure, was physically abused by Resident 80, who had severe cognitive impairment due to dementia. Resident 80 entered Resident 89's room, went through his belongings, shoved him, and hit him with a reaching-assistance device. Although Resident 89 did not initially report pain, he later complained of shoulder pain. The facility's failure to manage Resident 80's aggressive behavior resulted in physical abuse of Resident 89.

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 provide an ongoing program of activities designed to meet the needs, interests, and functional abilities of residents, including three residents out of 21 sampled. Resident 74, who was admitted with Alzheimer's disease and severe cognitive impairment, had a care plan that included preferences for activities such as gardening, watching specific TV shows, and crafting. However, there was no documented evidence that these preferred activities were provided or that the resident participated in them. The records showed minimal participation in reading activities and no indication of encouragement or prompting to participate in other activities, with the resident often wandering or in bed during activity opportunities. Resident 77, admitted with unspecified dementia and severe cognitive impairment, had a care plan addressing socially inappropriate behaviors and preferences for small group activities and sensory activities. Despite this, the activity participation logs revealed limited participation in activities, and observations showed that the resident was often wandering or in other residents' rooms instead of engaging in scheduled activities. The facility's activities calendar and staff schedules indicated a lack of consistent activities staff during evening shifts, which are crucial for managing dementia behaviors. Resident 80, also severely cognitively impaired, had a care plan that included preferences for music, reading, and outdoor activities. However, the activity participation records showed no evidence of participation in these preferred activities, with the resident often wandering, napping, or refusing activities. The facility failed to provide an individualized activities program and did not accurately monitor the residents' participation and response to activities, leading to inadequate and inappropriate activities programming for these residents.

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 accurately monitor and document fluid restrictions prescribed for two residents, leading to deficiencies in maintaining fluid balance and adequate hydration. Resident 35, diagnosed with heart failure and hyponatremia, had a physician's order for a 1500 ml per day fluid restriction. However, the facility's Medication Administration Record (MAR) and Documentation Survey Reports from February to mid-March 2024 did not show consistent documentation of the fluids provided by nursing staff, failing to ensure compliance with the physician's order and the resident's hydration needs. The Director of Nursing (DON) confirmed the lack of documentation during an interview on March 15, 2024, in the presence of the Nursing Home Administrator (NHA). This failure was acknowledged as a deficiency in maintaining the resident's clinical condition and hydration status as required by the physician's order and facility policy. Similarly, Resident 43, diagnosed with congestive heart failure, had a physician's order for a 2000 ml per day fluid restriction. The resident's care plan included specific fluid allocations for dietary and nursing staff, along with monitoring for signs of fluid overload. However, the facility's Documentation Survey Reports for February and March 2024 did not provide evidence of accurate recording and accounting of the resident's daily fluid intake. The Registered Dietitian's documentation from February 20 to March 7, 2024, also failed to show compliance with the prescribed fluid restriction and adequacy for hydration. The DON confirmed on March 15, 2024, that the facility did not total and calculate the resident's daily fluid intake, failing to meet the physician's prescribed fluid restriction and hydration needs. These deficiencies highlight the facility's failure to follow its own policy on fluid restrictions, which mandates that nursing staff obtain and verify physician's orders, document fluid intake accurately, and ensure compliance with the prescribed fluid restrictions. The lack of proper documentation and monitoring for both residents resulted in non-compliance with physician orders and inadequate hydration management, as confirmed by the DON and NHA during the survey interviews.

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 provide the necessary treatment and services to maintain the highest practicable level of mental, physical, and psychosocial well-being for three residents diagnosed with dementia. Resident 74 exhibited socially inappropriate behaviors such as hitting, punching, and swinging at staff. Despite documented incidents of increased aggression and wandering, the facility did not implement an individualized care plan that included purposeful and meaningful activities based on the resident's past history and preferences. This lack of individualized care led to repeated incidents of aggression and wandering, impacting both the resident and others in the facility. Resident 80 also displayed significant behavioral issues, including verbal aggression, cursing, and wandering into other residents' rooms. Despite multiple progress notes documenting these behaviors and the ineffectiveness of redirection and other interventions, the facility did not develop an individualized care plan that incorporated the resident's interests, such as music and car magazines. The resident's behavior continued to escalate, leading to frequent disruptions and safety concerns for both the resident and others. Resident 77 exhibited behaviors such as rummaging through other residents' belongings, disrobing in public, and physical and verbal aggression. Despite these documented behaviors and an incident involving inappropriate physical contact with another resident, the facility did not implement effective individualized interventions. The resident continued to display escalating dementia-related behaviors, and the facility's interventions were not fully effective in preventing these behaviors. The Director of Nursing confirmed that the interventions developed were not effective in addressing the residents' needs.

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 their established procedures for thoroughly investigating an injury of known source, a fractured leg, sustained by one resident. The facility's abuse prohibition policy mandates that incidents of unknown origin be investigated as abuse until the root cause is identified. However, the facility did not follow these procedures. The resident, who was severely cognitively impaired and required staff assistance for daily activities, was found to have a fractured leg after exhibiting pain and tenderness in the right ankle. Despite the severity of the injury, the facility did not conduct a thorough investigation to rule out abuse, neglect, or mistreatment as potential causes. The clinical records and witness statements revealed that the resident was fine during the shift on the day before the injury was discovered. However, there was no documented evidence that the facility interviewed additional staff members, including those from other shifts that cared for the resident prior to the injury. The facility also did not investigate potential causes of the injury that may have occurred during the day of the injury. This lack of thorough investigation is a direct violation of the facility's abuse prohibition policy. The Director of Nursing confirmed that the facility planned to educate staff on the use of the mechanical lift to rule out potential staff technique as a cause of the injury. However, there was no documented evidence that this education was provided. The failure to conduct a thorough investigation into the resident's serious injury of unknown origin to rule out abuse, neglect, or mistreatment was confirmed by the Director of Nursing.

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 provide necessary behavioral health care to Resident 5, who had diagnoses including PTSD, anxiety, and depression. The resident's care plan identified potential for verbal and physical aggression and included various interventions. However, the care plan did not identify interventions to determine the root cause of the behaviors or effective strategies for staff to employ when the resident exhibited these symptoms. The care plan was not reviewed for continued adequacy and effectiveness in meeting the resident's mental health care needs. The resident's clinical records revealed multiple instances of aggressive and inappropriate behavior, including refusing care, damaging another resident's property, and making derogatory gestures towards staff. Despite these behaviors, there was no documented evidence of follow-up psychiatric services or effective interventions. The facility's documentation showed repeated behaviors with unchanged or ineffective interventions, and no revisions were made to address the resident's needs. Interviews with staff and the resident indicated that the resident's behaviors were frequently discussed but not adequately addressed. The facility was unable to provide evidence that necessary care and services were provided to meet the resident's behavioral health needs. The lack of an interdisciplinary approach and timely behavioral health care contributed to the deficiency in promoting the resident's highest practicable physical and psychosocial well-being.