Nhc Healthcare, Smithville

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 resubmit a Pre-Admission Screening and Resident Review (PASRR) to include an active mental health condition for a resident upon admission. The facility's policy requires screening patients before admission to determine if they have a mental illness, intellectual or developmental disability, or related condition, and to refer any patient for a Level II resident review upon a significant change in status or condition. However, the facility did not adhere to this policy for a resident who was admitted with diagnoses including Dementia, Anxiety, and Psychotic Disorder with Delusions. The PASRR Level I Screen Outcome did not include the Psychotic Disorder with Delusions as an active mental health diagnosis, which was confirmed by the Assistant Director of Nursing (ADON) during an interview. The resident was admitted with severe cognitive impairment, as indicated by a score of 6 on the Brief Interview for Mental Status (BIMS) assessment. The comprehensive care plan for the resident noted psychiatric conditions and the risk for complications related to the Psychotic Disorder with Delusions. Despite these documented conditions, the PASRR was not updated to reflect the active diagnosis of Psychotic Disorder with Delusions, which was an oversight acknowledged by the ADON. This failure to resubmit the PASRR with the correct diagnosis represents a deficiency in the facility's adherence to its own policies and regulatory requirements.

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 the accuracy of the medical record for one resident, identified as Resident #37, among 25 residents reviewed. The deficiency was identified through a review of the facility's policy on documentation, medical record review, and staff interviews. Resident #37, who was admitted with multiple diagnoses including Hypertensive Heart Disease with Heart Failure and Malnutrition, had a comprehensive care plan indicating a risk for weight fluctuations. The medical record showed a significant weight discrepancy, with a recorded weight of 221 lbs. on January 30, 2025, which was inconsistent with the resident's typical weight range in the 170s. Interviews with the Registered Dietician, Restorative Nurse, and Family Nurse Practitioner confirmed the inaccuracy of the 221 lbs. weight entry, suggesting it was not plausible even with fluid overload. The LPN mentioned that the electronic documentation system provides a warning for out-of-range weights and allows for comparison with previous weights, indicating a potential oversight in verifying the weight. The CNA who recorded the weight acknowledged the discrepancy and attempted a reweigh, but the corrected weight was not saved in the system. The Assistant Director of Nursing confirmed the expectation for accurate documentation and acknowledged the error in the recorded weight.

Penalty

Inspection fine: $228,51140 days payment denial

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 environment free from abuse for several residents, leading to multiple incidents of abuse and neglect. One incident involved a cognitively impaired female resident who wandered into the room of an alert male resident with a history of psychiatric disorders. The male resident, who was known to have delusions and aggressive behaviors, physically assaulted the female resident by hitting her on the head and back. This incident was not isolated, as the same male resident was also verbally abusive to another cognitively impaired female resident in a separate incident in the dining room. The facility's failure to recognize and intervene in the male resident's continued abusive behavior placed the involved residents in immediate jeopardy. The staff did not adequately monitor or redirect the wandering residents, nor did they effectively manage the male resident's known behavioral issues. The facility's policies on abuse prevention and intervention were not properly implemented, as evidenced by the lack of immediate corrective actions and failure to report the incidents to the appropriate authorities. Additionally, the facility did not report or adequately address a separate altercation between two other residents, which resulted in a physical injury. This incident, although not rising to the level of immediate jeopardy, further highlights the facility's systemic issues in managing resident interactions and ensuring a safe environment. The lack of timely reporting and intervention in these cases demonstrates a significant deficiency in the facility's ability to protect residents from abuse and neglect.

Removal Plan

• A stop sign was placed on Resident #1's room to intervene wandering behavior.
• The staff were trained on abuse policy and procedures.
• The staff should be with Resident #2 during mealtimes.
• A Velcro stop sign was affixed to Resident #1's doorway.
• The Quality Assurance Performance Improvement (QAPI) will oversee question and answers regarding abuse policy and procedures.
• The staff will monitor patients for behaviors that may increase their risk for physical abuse.
• The QAPI committee will confirm compliance with Stop Sign usage.
• Both residents will continue to be seen by Psych services.

Penalty

Inspection fine: $228,51140 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide adequate supervision to prevent accidents for two residents, resulting in significant incidents. One resident, who was cognitively impaired and assessed as an elopement risk, managed to exit the facility due to a malfunctioning door alarm system. This resident, wearing a wander guard bracelet, left the facility unnoticed by staff and walked to a nearby house, where a former employee recognized her and returned her to the facility. The staff were unaware of her absence, and upon her return, she reported falling outside, which resulted in a small laceration on her tongue. Another resident, who was a high fall risk and on blood thinners, experienced a witnessed fall that resulted in a head injury. Despite the fall, there was a lack of appropriate care plan interventions to prevent further falls, and the resident's condition deteriorated over the following days, leading to his death. The care plan interventions were not suitable for the resident's cognitive impairment, as he was unable to remember to ask for assistance or use non-skid footwear, which were part of the care plan. The facility's policies and procedures for incidents and missing patients were not effectively implemented, as evidenced by the lack of documentation and awareness of the residents' whereabouts. The failure to ensure the functionality of the door alarm system and the inadequacy of the care plans contributed to the immediate jeopardy situation, resulting in actual harm to the residents.

Penalty

Inspection fine: $228,51140 days payment denial

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 implement a comprehensive person-centered care plan for two residents, resulting in actual harm for one of them. Resident #5, who had severe cognitive impairment with a BIMS score of 4, was on anticoagulant medication and required extensive assistance with mobility. Despite these needs, the care plan interventions were not appropriate, as they relied on the resident's ability to remember to ask for assistance and use non-skid footwear, which was not feasible given the resident's cognitive status. This inadequacy in the care plan led to two identical fall incidents where Resident #5 fell from a wheelchair, sustaining head injuries. The first fall occurred on 11/18/2023, where Resident #5 was witnessed leaning over in a wheelchair and fell, resulting in an abrasion on the forehead. The care plan was not updated appropriately to prevent further falls, and the same incident repeated on 1/23/2024. After the second fall, Resident #5 exhibited signs of neurological decline, including hypotension, slurred speech, and increased confusion, which were not adequately addressed in the care plan. The resident's condition continued to deteriorate, leading to their death on 1/26/2024. Resident #7 also had a deficient care plan. With a BIMS score of 6, indicating severe cognitive impairment, the care plan included interventions that required the resident to understand and comply with the plan of care, which was unrealistic given their cognitive status. The resident exhibited delusions, physical behaviors towards others, and wandering, yet the care plan did not adequately address these behaviors. The facility's failure to tailor the care plans to the residents' cognitive abilities and needs resulted in inadequate care and supervision.

Penalty

Inspection fine: $228,51140 days payment denial

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 report allegations of abuse within the required 2-hour timeframe for four residents and did not complete the 5-day investigation report for two residents. The facility's policy mandates immediate reporting of any suspected abuse, neglect, or misappropriation of property, but this was not adhered to in several instances. For example, Resident #1, who has a history of mental illness, was involved in a verbal altercation with Resident #7, who has severe cognitive impairment. The incident was not reported as required, and staff interviews revealed that the verbal abuse was not communicated to the appropriate authorities. Another incident involved Resident #6, who sustained a minor injury when his roommate, Resident #8, pushed a bedside table that accidentally hit Resident #6's knee. Despite the injury and the aggressive behavior exhibited by Resident #8, the incident was not reported in a timely manner. Interviews with staff indicated a lack of awareness and communication regarding the incident, and the Social Service Director was not informed until much later. Additionally, an altercation between Residents #3 and #4 was reported to the state agency, but the final investigation report was not submitted until nearly a year later. This delay in reporting and investigation completion highlights a significant deficiency in the facility's adherence to its own policies and federal and state regulations regarding the reporting and investigation of abuse allegations.

Penalty

Inspection fine: $228,51140 days payment denial

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 competent and proficient nursing staff to ensure residents' safety and maintain their highest practicable physical well-being. This deficiency was evident in the case of three residents. Resident #5, who had severe cognitive impairment and was on long-term anticoagulant therapy, experienced a fall resulting in a head injury. The care plan interventions were not appropriate for his cognitive level, as they relied on his ability to ask for assistance, which he could not do. Furthermore, the nurse failed to communicate the risks associated with the fall and the resident's anticoagulant use to the conservator, leading to a lack of appropriate medical response. Additionally, the facility did not adequately address resident-to-resident altercations. Resident #1, who had no cognitive impairment but experienced delusions, was involved in a verbal altercation with Resident #7, who had severe cognitive impairment. The altercation was not reported as verbal abuse, and the staff failed to notify the abuse coordinator or conduct a follow-up. Similarly, Resident #6, who had intact cognition, was physically harmed by Resident #8, who had poor memory and behavioral issues. The incident was not reported accurately, and the staff did not take appropriate measures to prevent further harm. The facility also failed to conduct yearly performance evaluations for licensed nurses, which is crucial for maintaining clinical competency. The Director of Nursing did not perform these evaluations for three of the five nurse files reviewed, with the last evaluations dating back to 2018. This lack of oversight contributed to the deficiencies in care and communication observed in the facility, as staff were not adequately assessed or guided in their roles.

Penalty

Inspection fine: $228,51140 days payment denial

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 conduct yearly performance evaluations for two Certified Nurse Assistants (CNAs), identified as CNA MM and CNA NN, as required by their job descriptions. The job description for the Director of Nursing (DON) includes the responsibility to promote and delegate accountability for maintaining an effective performance appraisal system for nursing staff, including CNAs. However, a review of personnel files revealed that CNA MM, hired on June 16, 2020, and CNA NN, hired on December 7, 2021, did not have performance evaluations completed over the last year. Interviews conducted during the investigation revealed that the facility had suspended performance evaluations during the COVID-19 pandemic in 2020-2021. The DON and Accounts Payable QQ acknowledged that performance evaluations were postponed due to the pandemic, but efforts to resume them began in the middle of 2023. The Administrator confirmed that the performance improvement evaluations were not conducted during the pandemic, and tracking of evaluations was only reintroduced as part of the annual plan in 2023.

Penalty

Inspection fine: $228,51140 days payment denial

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 Assurance Performance Improvement (QAPI) committee failed to effectively monitor and implement plans of action following a resident-to-resident abuse incident. The incident involved Resident #2 wandering into Resident #1's room, where Resident #1 struck Resident #2. Although immediate intervention was provided, and measures such as increased observation and a stop sign on Resident #1's room were implemented, the QAPI committee did not adequately oversee these actions. The facility's investigation revealed that staff were trained on abuse policy and procedures, and the QAPI committee was tasked with overseeing compliance. However, discrepancies were found in the Performance Improvement Plans (PIPs) related to staff education and monitoring. Several PIPs lacked employee signatures, and some staff members denied participating in the training sessions, indicating that their names were falsely recorded. This lack of proper documentation and verification undermined the facility's ability to ensure staff accountability and compliance with the implemented measures. Interviews with staff, including a CNA and an LPN, confirmed that their signatures were not on the PIP documents, and they were unaware of the training content. The Director of Nursing (DON) and the Administrator were unable to provide adequate documentation or verification of increased observation for Resident #2, as initially planned. The Administrator cited HIPAA concerns as a reason for the lack of identifiable information, but this approach hindered the facility's ability to verify staff participation and accountability in the training process.