Purehealth Transitional Care At Thr Arlington

Penalty

Inspection fine: $60,540

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 immediately consult with a resident's physician and notify the resident representative when there was a significant change in the resident's condition or a need to alter treatment. Specifically, the facility did not notify the physician when the resident's vital signs were abnormal over several days, despite documentation and reports from staff and family that the resident was lethargic and fatigued. The resident was ultimately sent to the hospital after the family alerted a nurse to critically low blood pressure, where the resident was diagnosed with sepsis from a UTI. The resident involved was an elderly female with a history of multiple medical conditions, including fractures, hypertension, chronic pain syndrome, atrial fibrillation, repeated falls, and reduced mobility. Her care plan did not include a focus on urinary incontinence, risk for UTI, or hypertension. Medication administration records showed that antihypertensive medications were held multiple times due to low blood pressure, but there was no documentation that the physician was notified of these abnormal readings. Staff interviews revealed that the resident was observed to be lethargic and fatigued throughout the week, with these concerns reported by both staff and family, but not escalated to the physician. Interviews with facility staff, including the DON, nurses, and CNAs, indicated a lack of clarity and consistency regarding when to notify the physician of abnormal vital signs and changes in condition. The facility's policy required prompt notification of the physician and resident representative for significant changes, but this was not followed. The physician confirmed he was not notified of the abnormal vital signs prior to the resident's transfer to the hospital. The failure to notify the physician and the resident's representative of significant changes in condition was identified as a deficiency by surveyors.

Removal Plan

• Inform the Medical Director of the Immediate Jeopardy.
• In-service licensed staff on notifying physician of abnormal vital signs when accompanied by symptoms and standard disease related clinical interventions by the licensed nurse are not successful.
• Train staff on notifying the physician of abnormal vital signs when accompanied by symptoms and standard disease related clinical interventions by the licensed nurse are not successful, assessing a resident for change of condition, and notifying physician of change in conditions.
• Review all patients for documented low blood pressure. If a patient is noted to have blood pressures outside of the specified order parameters, notify the MD or NP. If neither are available, or in an emergent situation, contact emergency services (911).
• In-service ADON, Administrator, Medical Records, and Wound Care Nurse on notifying physician of change of condition and assessing the patient for change in condition and identifying a major decline or improvement in the resident's status.
• Initiate staff (LVN, RN, CNA) in-servicing on notifying of changes in condition and quality of care. Any staff who have not received in-servicing will not be permitted to work until in-servicing has been completed. In-servicing will be on-going for PRN, new staff, staff on leave, agency (if applicable).
• If a CNA obtains abnormal vital signs they will notify their charge nurse immediately. Charge nurse will then re-assess resident and re-take vital signs. The physician is to be notified of abnormal vital signs when accompanied by symptoms and standard disease related clinical interventions by the licensed nurse are not successful.
• Notify the physician of abnormal vital signs when accompanied by symptoms and standard disease related clinical interventions by the licensed nurse are not successful, based upon direction of the medical director.
• Define abnormal vital signs as: Systolic BP less than 90, Diastolic less than 50, Systolic greater than 180, Diastolic greater than 100, Heart rate less than 50, Heart rate greater than 130.
• ADON/DON/designee will review the exception report for low blood pressures with systolic blood pressures less than 90 and diastolic less than 50. Review will occur daily for 2 weeks, then 5 times weekly for 6 weeks, and then 3 times weekly for 4 weeks.

Penalty

Inspection fine: $60,540

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 treatment and care in accordance with professional standards, the resident's care plan, and the resident's preferences for one resident reviewed for quality of care. Specifically, the facility did not document assessments or notify the physician when the resident's vital signs were abnormal over several days, despite clear parameters in the physician's orders for when to hold antihypertensive medications and when to notify the physician. The resident's blood pressure and heart rate were repeatedly below the specified thresholds, and antihypertensive medications were held accordingly, but there was no documentation of physician notification or further assessment. Additionally, staff and the resident's family expressed concerns about the resident's lethargy and fatigue throughout the week, but these concerns were not adequately addressed or escalated. The resident involved was an elderly female with a history of multiple fractures, hypertension, atrial fibrillation, chronic pain, and repeated falls. Upon admission, she required assistance with mobility and activities of daily living and had occasional urinary incontinence. During her stay, her blood pressure and heart rate were frequently low, and she exhibited increasing lethargy and fatigue, as noted by therapy staff, family, and in some nursing documentation. Despite these symptoms and abnormal vital signs, there was no evidence that the physician was notified or that further interventions were implemented until the resident's condition became critical. On the day her condition significantly worsened, the resident's family measured a critically low blood pressure and alerted nursing staff, who then assessed the resident and found her to be lethargic and minimally responsive. Only at this point was the physician notified, and the resident was transferred to the hospital, where she was diagnosed with sepsis from a urinary tract infection. Interviews with staff revealed inconsistent understanding and application of protocols for notifying the physician of abnormal vital signs and changes in condition, and the facility did not have a policy on blood pressure assessments. The deficiency was identified as Immediate Jeopardy due to the failure to ensure timely treatment and care in accordance with orders and standards of practice.

Removal Plan

• Inform the Medical Director of the Immediate Jeopardy.
• In-service licensed staff on notifying physician of abnormal vital signs when accompanied by symptoms and standard disease related clinical interventions by the licensed nurse are not successful.
• Train staff on notifying the physician of abnormal vital signs when accompanied by symptoms and standard disease related clinical interventions by the licensed nurse are not successful, assessing a resident for change of condition, and notifying physician of change in conditions.
• Review all patients for documented low blood pressure. If a patient is noted to have blood pressures outside of the specified order parameters, notify the MD or NP. If neither are available, or in an emergent situation, contact emergency services (911).
• In-service ADON, Administrator, Medical Records, and Wound Care Nurse on notifying physician of change of condition and assessing the patient for change in condition and identifying a major decline or improvement in the resident's status.
• Initiate staff (LVN, RN, CNA) in-servicing on notifying of changes in condition and quality of care. Any staff who have not received in-servicing will not be permitted to work until in-servicing has been completed. In-servicing will be on-going for PRN, new staff, staff on leave, agency (if applicable).
• If a CNA obtains abnormal vital signs they will notify their charge nurse immediately. Charge nurse will then re-assess resident and re-take vital signs. The physician is to be notified of abnormal vital signs when accompanied by symptoms and standard disease related clinical interventions by the licensed nurse are not successful.
• Notify the physician of abnormal vital signs when accompanied by symptoms and standard disease related clinical interventions by the licensed nurse are not successful, based upon direction of the medical director.
• Define abnormal vital signs as: Systolic BP less than 90, Diastolic less than 50, Systolic greater than 180, Diastolic greater than 100, Heart rate less than 50, Heart rate greater than 130.
• ADON/DON/designee will review the exception report for low blood pressures with systolic blood pressures less than 90 and diastolic less than 50. Review will occur daily for 2 weeks, then 5 times weekly for 6 weeks, then 3 times weekly for 4 weeks.

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 a resident, who was unable to carry out activities of daily living (ADLs), received necessary services to maintain personal hygiene. Patient #1, a male with diagnoses including morbid obesity, reduced mobility, heart failure, peripheral vascular disease, and urogenital implants, was admitted for rehabilitation. Despite requiring assistance for most ADLs and being dependent on staff for mobility, the facility did not consistently provide showers, bed baths, or oral care according to the ADL schedule. Patient #1 reported that during his 10-day stay, he never received a full shower or bed bath, only having his lower legs and abdomen wiped with a wet wipe once. Although he initially refused to use a mechanical lift due to anxiety, he later agreed, but staff still did not attempt to transfer him for a shower or provide a bed bath. He also expressed concerns about not being provided with toiletries or a setup for oral care, which made him feel ashamed and unclean. Interviews with CNAs revealed inconsistencies in documentation and care provision, with one CNA admitting to marking tasks as not applicable by mistake and another acknowledging short-staffing issues that prevented scheduled showers or baths. The facility's policy on ADLs stated that residents unable to carry out these activities independently should receive necessary services to maintain personal hygiene. However, interviews with the Interim DON and Administrator highlighted a lack of adherence to this policy, as staff were expected to document all encounters and offer alternatives if a patient refused care. The failure to provide proper ADL care placed patients at risk for skin breakdown, dignity issues, and infection, as noted by the Interim DON.

Penalty

Inspection fine: $57,608

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 the services provided met professional standards of quality for a resident who required post-surgical care. The resident was admitted with a stomach drain tube to manage an abscess, but the nursing staff, including RN A and LVN C, did not obtain a doctor's order for the drain care. From the time of admission, the resident's post-surgical site, stomach drain tube, and output were not documented, leading to the resident's hospitalization due to an infection. The nursing staff involved were not trained on how to manage the drain, and they were unaware of the necessity to obtain an order for the drain. The resident, an elderly woman with multiple diagnoses including encephalopathy, acute duodenal ulcer with perforation, and atrial fibrillation, was admitted to the facility with severe cognitive impairment. Despite these conditions, there was no evidence of stomach tube drain care or monitoring of output in her order summary. The admission assessment by RN A did not reflect the presence of any drains, and progress notes did not indicate any care for the drainage tube by the nursing staff. Interviews with the resident's family and various staff members revealed a lack of awareness and training regarding the management of the drain, which contributed to the oversight. The facility's admission process was not followed, as the ADON was not notified of the resident's drain tube until it was too late. The wound care nurse, who was expected to perform a skin assessment on all new residents, failed to do so, which was one of the reasons for their termination. The DON acknowledged the failure to obtain care orders for the drain and recognized the risk of infection due to this oversight. The lack of training and communication among the nursing staff, as well as the absence of a proper assessment and documentation process, led to the deficiency in care for the resident.

Penalty

Inspection fine: $57,608

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 a resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices. Specifically, the facility did not document or properly assess, monitor, and treat the resident's stomach drain tube and drainage bag upon admission. The oversight was discovered when the resident's family mentioned the stomach tube drainage to the physician, leading to the resident's hospitalization due to an infection four days later. The resident, an elderly woman with severe cognitive impairment and multiple medical conditions, was admitted to the facility without any documented orders for her stomach tube or drainage bag. The facility's admission assessment and subsequent care plans failed to address the presence of the drain. Despite the resident experiencing pain and the family raising concerns about the lack of drainage, the facility did not take appropriate action to obtain necessary orders or provide adequate care for the drain. Interviews with facility staff revealed a lack of communication and responsibility in obtaining and following up on care orders for the resident's drain. The admitting nurse did not verify the presence of orders, and subsequent caregivers did not take steps to rectify the situation. The facility physician was aware of the drain but did not ensure that proper orders were in place, leading to a delay in addressing the resident's condition and ultimately resulting in the resident's hospitalization for an infection related to the drain.

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 all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation was made. Specifically, the facility did not report an unwitnessed fall with injury to the head by unknown source for a resident on 03/16/24. This failure could place residents at risk of not receiving timely investigations and reporting of injuries of unknown source. The resident involved was an elderly male with severe cognitive impairment, as indicated by a BIMS score of 3. He had multiple diagnoses, including cerebral ischemia, dehydration, unspecified dementia, muscle wasting, fall from bed, reduced mobility, altered mental status, and weakness. On the night of the incident, the resident was found on the floor with a large swelling and a laceration on the back of his head, as well as a skin tear and swelling on his left leg. The resident was transferred to the emergency room due to the severity of his injuries and the inability to stop the bleeding because of blood thinners. Interviews with staff revealed that the incident was not reported to the Director of Nursing (DON) or the administrator immediately. The DON was notified two days later, and the administrator delayed reporting the incident to the State Agency until after being interviewed by a State surveyor. The facility's policy requires that all alleged violations be reported immediately, but this protocol was not followed in this case. The delay in reporting could have affected the resident's timely medical attention and the thoroughness of the investigation.

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 Resident #139 received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices. Resident #139, a male with a history of encephalopathy, muscle wasting, hypertension, and dysphagia, experienced a significant decline in condition between 03/14/24 and 03/19/24. Despite noticeable changes in his cognitive and physical abilities, the facility did not adequately identify or address these changes in a timely manner. The resident's family and staff observed a marked decline in his ability to perform activities he previously managed, such as completing puzzles and supporting himself physically, but these observations were not promptly acted upon by the facility's medical team. On 02/22/24, Resident #139 experienced a fall, which was assessed by the staff, and no immediate concerns were noted. However, subsequent observations and interviews revealed a significant cognitive and physical decline that was not properly documented or addressed. The resident's family reported a noticeable decline in his cognitive abilities 2-3 days after the fall, and staff members observed a decline in his physical abilities, such as his inability to support himself and requiring assistance with drinking. Despite these observations, the primary physician did not see the resident until 03/25/24, and the Director of Nursing (DON) and other staff members did not take immediate action to address the resident's deteriorating condition. Interviews with various staff members, including the DON, RN G, and PT F, indicated that there were clear signs of Resident #139's decline, but these were not consistently communicated or acted upon. Progress notes from 03/02/24 indicated a change in the resident's condition, but subsequent notes from 03/03/24 to 03/19/24 did not reflect any issues or changes. It was only on 03/21/24 that a change in condition related to hypertension and increased confusion was documented, and appropriate medical intervention was recommended. This delay in recognizing and addressing the resident's decline highlights a failure in the facility's care and monitoring processes.

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 accurate administration of medications for a resident, leading to the administration of an incorrect dose of Acetaminophen. Specifically, RN A administered a 500 mg tablet of Acetaminophen instead of the prescribed 325 mg tablet to a resident. The resident, who was admitted with a displaced tri malleolar fracture, depression, and anxiety disorder, reported the error to the state surveyor and provided a saved tablet as evidence. The resident's care plan and physician orders specified the correct dosage, but the medication administration record showed discrepancies in the doses given by RN A. During interviews, RN A denied administering the wrong dose and claimed to have given the correct 325 mg tablets. However, documentation and the Director of Nursing (DON) confirmed that RN A was on duty and administered the last dose of Acetaminophen at 5:17 PM. The DON also revealed that the 325 mg and 500 mg Acetaminophen tablets were stored next to each other in the medication cart, which may have contributed to the error. The facility's policy on medication errors was reviewed, highlighting the need for accurate medication administration and reporting of adverse consequences.