The Heights Of League City

Penalty

Fine: $18,860

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 consult with a resident’s physician when there was a significant change in the resident’s physical, mental, or psychosocial status. The resident was an adult male with multiple serious diagnoses, including Type 2 diabetes, cardiac implants and grafts, morbid obesity, hypertension, and a prior cerebral infarction, and was documented as full code. His care plan directed staff to monitor vital signs and report all changes in condition to a doctor. On one day, his blood pressure readings taken by a medication aide were 89/59 at 2:31 p.m. and 86/57 at 7:08 p.m., which were hypotensive. There was no documentation that a Change in Condition (CIC) assessment was completed that day, and no progress notes indicated that the physician had been notified of these low blood pressure readings or of any change in condition. Staff interviews and records showed that the resident’s condition had changed over the same period without appropriate escalation to a provider. CNAs reported that the resident, who was normally alert, communicative, and active on his computer, slept most of the day and night, was very sleepy, did not eat breakfast or lunch except for one cup of pudding, and had minimal verbal communication, sometimes only nodding his head with eyes closed and heavy breathing. A CNA stated he informed the floor nurse that the resident had not eaten and was very sleepy but could not recall the nurse’s name or what action was taken. A medication aide stated he held the resident’s blood pressure medication due to low blood pressure and told an unidentified nurse, but he could not say which nurse or what the nurse’s response was. The nurses who worked those shifts stated they were not informed of the low blood pressure readings or the resident’s poor intake and increased sleepiness. The following morning, an LVN entering the resident’s room found him drowsy, barely speaking, with an untouched breakfast tray, clammy to the touch, and with a low blood pressure of 75/54. The LVN documented that the resident was unresponsive to a sternal rub and was sent out due to an acute change in condition, hypotension, increased work of breathing, and unresponsiveness; EMS, the provider, the DON, and family were notified at that time. Subsequent hospital information obtained by surveyors indicated the resident was admitted to ICU for unresponsiveness, required multiple rounds of CPR after his heart stopped, and was diagnosed with a blood infection, septic shock, mucus in his lungs, and an acute stroke, with a blood sugar of 63. The resident’s primary medical doctor reported that when he saw the resident at the hospital, the resident had vomit around his mouth, appeared to have been deteriorating for hours, and had technically passed away twice but was resuscitated. The facility’s DON confirmed that per policy, providers should be informed of all significant changes, and that CNAs and medication aides were expected to report changes to nurses, who in turn were to notify the provider and document the change in condition, which did not occur in this case. An Immediate Jeopardy was identified related to this failure to notify the physician of the significant change in condition.

Removal Plan

• Removed medication aide #1 from assignment pending completion of in-service training on Medication Administration, reporting abnormal vital signs to charge nurse, Abuse/Neglect, and Residents Rights.
• Counseled medication aide #1 and issued a written performance action for failure to report low blood pressure readings to the charge nurse.
• Re-educated all licensed nurses on the expected change-in-condition process: evaluation/assessment, documentation (vital signs and Change in Condition assessment/progress note), reporting to the medical provider, notification of resident representative, and ensuring all steps are documented in the EHR.
• Required licensed nurses to review medication aide vital sign forms to identify abnormal vital signs, re-assess residents, implement interventions, notify the medical provider and resident representative, and document actions in the EHR.
• Required nurses to report identified/suspected changes in condition to the oncoming nurse during shift handoff to ensure continuity of reporting.
• Prohibited any nursing staff (full-time, part-time, PRN, or on leave) from working their next assigned shift until all required in-service training was completed.
• Educated all certified medication aides on medication administration (rights of medication administration) and the requirement to notify the charge nurse of any abnormal vital signs.
• Educated all team members on the Stop and Watch process for subtle changes in condition and expectations for use.
• Required Stop and Watch forms to be completed in the EHR and/or on paper, communicated to the nurse, and paper forms turned in to the charge nurse for nurse follow-up assessment and notifications.
• Required nurses to provide a copy of the Stop and Watch paper form to the Director of Nursing Services.
• Required all nursing team members to notify the DON when a change in condition is identified and Stop and Watch is completed, including confirmation that assessment and provider/representative notifications were made.
• Made blank Stop and Watch forms readily available at the nurse's station.
• Placed a copy of the Stop and Watch form in the Plan of Removal/Abatement binder for state surveyor review.
• Completed a 100% audit of all residents to identify any residents with a change in condition and ensured appropriate assessments, provider communication, orders, documentation, representative notification, and updates to the 24-hour communication report.
• Provided education to all nursing team members on Abuse/Neglect and Residents Rights.
• Ensured all PRN/on-leave nursing staff are in-serviced prior to working their next shift and that administrative nursing staff provide in-service/education prior to staff working.
• Ensured all residents receive appropriate care after a change in condition.
• Conducted an ad hoc meeting with the Administrator, DON, and Medical Director to address the immediacy issue related to F580 and the plan of removal to lift immediate jeopardy.
• Required certified medication aides to handwrite all vital signs on the designated vital sign form/log and turn it in to the charge nurse.
• Placed a copy of the medication aide vital sign form/log in the Abatement/Plan of Removal binder for state surveyor review.
• Ensured Stop and Watch forms were available in designated locations for staff access and use.
• Required DON notification by phone when a Stop and Watch form is completed and a change in condition is identified.

Penalty

Fine: $18,860

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 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 when there was a clear change in condition. The resident was an adult male with Type 2 diabetes, cardiac implants and grafts, morbid obesity, hypertension, and a prior cerebral infarction, and was documented as full code. His care plan directed staff to monitor vital signs and report all changes in condition to a physician. On the day in question, a medication aide documented hypotensive blood pressure readings of 89/59 at 2:31 p.m. and 86/57 at 7:08 p.m., but there was no corresponding change-in-condition assessment completed that day, and the low readings were not effectively communicated to the licensed nurses responsible for his care. Throughout that day and night, multiple staff observed and described significant deviations from the resident’s usual baseline without ensuring appropriate nursing assessment and provider notification. A CNA working the day shift reported that the resident, who normally liked to play on his computer, slept most of the day and did not eat breakfast or lunch except for one cup of vanilla pudding; he stated he told the floor nurse but could not recall who it was or what action was taken. Another CNA on the night shift stated the resident was “out of it,” barely spoke, slept most of the shift despite usually staying up late, had heavy breathing, and only nodded his head with eyes closed in response to questions; she reported communicating these concerns to the night nurse and checking on him several times. The medication aide on the 2:00 p.m. – 10:00 p.m. shift acknowledged that the resident’s blood pressure was low and that he held the resident’s blood pressure medication, but he could not clearly identify which nurse he informed or what the nurse’s response was. Licensed nurses on both shifts reported that they were not made aware of the resident’s low blood pressure readings or his refusal of meals. The day-shift LVN stated she received no notifications from CNAs or medication aides that the resident had low blood pressure or had not eaten, and she indicated she would have contacted the provider if she had known of a systolic reading of 86. The night-shift LVN stated she checked on the resident several times, received nods or brief verbal responses, and did not recognize a change in behavior; she also stated she was told by a CNA that the resident had not eaten breakfast or lunch but believed that CNA had already informed the day nurse. Neither LVN had knowledge of the documented hypotensive readings. The following morning, another LVN found the resident barely responsive, clammy, with an untouched breakfast tray, a blood pressure of 75/54, and unresponsiveness to a sternal rub, at which point EMS was called and the resident was sent to the hospital. Hospital staff and the primary medical doctor later described the resident as having been deteriorating for hours, with findings including blood infection, septic shock, mucus in the lungs, hypoglycemia, and an acute stroke, and he required multiple rounds of CPR. The facility’s own policy titled “Change in Resident Condition” required that when there was a significant change in a resident’s physical, mental, or psychosocial status, the medical provider should be contacted. The DON stated that when the medication aide identified low blood pressure, he should have notified the nurse immediately, and that CNAs and medication aides were expected to provide verbal updates to nurses, who in turn were responsible for notifying the provider, completing documentation, and ensuring oversight. In this case, despite documented hypotension, decreased intake, increased sleepiness, and altered responsiveness over many hours, there was a breakdown in communication and follow-through: the low blood pressure readings were not effectively reported to the LVNs, no change-in-condition assessment was completed on the day of the abnormal readings, and the provider was not contacted about the resident’s change in condition until the following morning when he was found unresponsive and required emergency transfer. The primary medical doctor later stated that the resident was found unresponsive to a hard sternal rub with low blood pressure and vomit around his mouth, and that he appeared to have been deteriorating for hours. A hospital registered nurse reported that the resident was admitted due to unresponsiveness, required three rounds of CPR because his heart stopped, and imaging and cultures showed an infarct and blood infection. A hospital nurse practitioner stated that the resident was positive for a blood infection, septic shock, mucus in the lungs, hypoglycemia, and an acute stroke, and that his unresponsiveness was caused by multiple factors. The resident’s family member reported that his mind had been very sharp despite prior stroke-related mobility issues and expressed gratitude that the LVN who found him unresponsive returned to check on him, stating that this likely saved his life. These findings collectively demonstrate that staff did not act in accordance with the resident’s care plan and facility policy regarding timely recognition, assessment, and reporting of a significant change in condition.

Removal Plan

• Removed medication aide #1 from his assignment pending completion of in-service training on Medication Administration, Reporting of Abnormal Vital Signs to the charge nurse, Abuse/Neglect, and Residents Rights.
• Counseled medication aide #1 and issued a written performance action related to failure to report low blood pressure readings to the charge nurse.
• Re-educated all licensed nurses on the expected change-in-condition process, including: evaluation/assessment; documenting findings (vital signs and Change in Condition assessment/progress note); reporting changes to the medical provider; notifying the resident representative; documenting all actions in the EHR; reviewing medication aide vital sign forms for abnormalities with reassessment/interventions; reporting changes to the oncoming nurse during handoff.
• Required that no nursing staff work their next assigned shift until all required in-service training is completed.
• Educated all certified medication aides on medication administration (five rights) and the requirement to notify the charge nurse of any abnormal vital signs.
• Educated all team members on the Stop and Watch process, including when to use it, completing it in the EHR and/or on paper, communicating it to the nurse, and turning the form in to the charge nurse for nurse follow-up.
• Required the nurse to provide a copy of the Stop and Watch paper form to the Director of Nursing Services.
• Required all nursing team members to notify the Director of Nursing when a change in condition is identified and Stop and Watch is completed, including that assessment and provider/representative notifications were made.
• Made blank Stop and Watch forms readily available at the nurse’s station and specified secure storage locations for staff use.
• Placed a copy of the Stop and Watch form in the Plan of Removal/Abatement binder for State surveyor review.
• Completed a 100% audit of all residents to identify any residents with a change in condition and ensured appropriate assessments, provider communication/orders, documentation, representative notification, and updates to the 24-hour communication report.
• Provided education to all nursing team members on Abuse/Neglect and Residents Rights.
• Ensured all nursing staff on leave/PRN are in-serviced prior to working their shift and that administrative nursing staff provide in-service/education prior to staff working their next assigned shift.
• Implemented ongoing monitoring/verification using a Change in Condition audit tool with audits to ensure compliance.
• Implemented/maintained medication aide vital sign monitoring logs and required medication aides to handwrite vital signs on the designated form and submit to the charge nurse for review.
• Conducted an ad hoc meeting with the Administrator, DON, and Medical Director to address the immediacy issue related to F684 and the plan of removal.

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 maintain all mechanical, electrical, and patient care equipment in safe operating condition, specifically regarding one of four suction machines reviewed. On the date in question, staff attempted to use the suction machine located in a resident's room to clear oral secretions, but the machine was not functioning. As a result, staff had to retrieve a suction machine from the crash cart, causing a delay in care. Multiple staff interviews confirmed that the in-room suction machine was nonfunctional at the time it was needed. The resident involved had significant medical needs, including Alzheimer's disease, dysphagia, congestive heart failure, dementia, Parkinson's disease, COPD, a gastrostomy tube, a pacemaker, and was dependent on staff for all activities of daily living. The resident was on hospice care and had a suction machine in the room as part of a hospice bundle, although there was no current physician order for suctioning at the time of the incident. The care plan and physician orders did not mention oral suctioning as an intervention or requirement for the resident. Interviews with facility leadership revealed there was no policy in place for checking or maintaining the functionality of suction machines. The Director of Nursing and Administrator both stated that whoever placed the suction machine in the room was responsible for checking it, but there was no formal process or documentation for routine equipment checks. Review of facility policies indicated a requirement for a preventive maintenance program for essential equipment, but this was not implemented for suction machines, leading to the deficiency.

Penalty

Fine: $26,685

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

Summary

A deficiency was identified in the facility's failure to ensure that an area was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which could contribute to accidents occurring. Specific actions or inactions by staff or details about the residents involved are not provided in the report. The deficiency centers on the lack of proper hazard control and insufficient supervision in the designated area, as observed by surveyors during their assessment.

Penalty

Fine: $37,880

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

Summary

A deficiency occurred when facility personnel failed to provide basic life support, including CPR, to a resident who was found unresponsive prior to the arrival of emergency medical personnel. The resident, an elderly female with diagnoses including urinary tract infection, severe obesity, hypertension, and diabetes, was readmitted to the facility and did not have a completed care plan or a clearly documented code status in the electronic health record at the time of the incident. When the resident was found unresponsive and without a pulse, the nurse on duty, LVN A, did not immediately initiate CPR or call for assistance from available staff. Instead, LVN A left the resident to check the code status in the electronic health record and a code status binder, and made multiple phone calls to hospice, the resident's representative, and the facility administrator to determine the resident's code status. This process resulted in a delay of approximately three minutes before CPR was started. Other staff members, including LVN C and LVN D, only began CPR after being informed by LVN A and after searching for the code status themselves. Multiple staff interviews revealed that they had not been trained by the facility on how to respond to an unresponsive resident or on the protocol for initiating CPR and emergency response. Record reviews and staff interviews further indicated that the facility did not have a documented CPR policy, and the existing change in condition policy did not address steps to take when a resident is found unresponsive. The failure to enter the resident's code status at admission, combined with the lack of staff training and clear protocols, contributed to the delay in initiating CPR. This deficiency was identified as Immediate Jeopardy due to the risk of harm from delayed emergency response.

Removal Plan

• Corporate nurse educated the Administrator/Director of Nursing/Assistant Director of Nursing/Social Worker on the expected practice of confirming all new admissions have advance directives elections indicated within the medical record.
• All residents should have a code status election physician's order in place upon admission.
• Any resident who has an advance directive election change should have the election documented and a physician's order should be obtained at the time the election has been voiced. DNR elections will be honored upon the resident/representative having voiced the advanced directive care election and if DNR the OOH-DNR form will be initiated and completed, then uploaded into the electronic health record.
• Licensed Nurses both on-coming, and off-going nurses will review/audit the code status designation for any new admission, re-admission and new order or changes to code status during the 24-hour report. Any identified discrepancies or absence of code status will be reported to the attending MD, DNS and/or ADMIN.
• Should there not be an election of advanced directives or code status, will result in the individual being full code until otherwise directed.
• The Administrator/Director of Nursing/Assistant Director of Nursing/Social Worker will conduct an initial review of the admission/readmission orders to validate that the advanced directive election for code status is in place. This audit will take place during the morning meeting and the RN Supervisor on duty will conduct the audit on the weekends. In the absence of the RN Supervisor on duty, the Director of Nursing or Assistant Director of Nursing will be responsible for conducting the audit to validate code status election orders are in place. Any discrepancies will be immediately clarified with the resident, authorized representative and the appropriate order will be obtained by the attending physician.
• Corporate nurse educated the Administrator/Director of Nursing/Assistant Director of Nursing on response times when performing immediate assessments/interventions for residents with changes in condition.
• Anytime a resident experiences a change in condition and it appears the heart has stopped, pulseless or not breathing, with a Full Code Order or No code status, you must immediately initiate the CPR process, until the code status is validated. The other present licensed nurses in the community must assist with the change in condition by immediately verifying code status, calling 911, notifying MD and RP. As well as assisting with the required paperwork for a hospital transfer.
• The Administrator/Director of Nursing/Assistant Director of Nursing conduct re-education with the identified nurses as well as all other licensed nurses regarding the expected practice of confirming all new admissions, re-admissions have advance directives elections indicated within the medical record.
• All licensed nurses will receive the education regarding the process of reconciling physician orders into the electronic health record accurately and timely to include but not limited to code status upon admission, re-admission and any changes in code status election/advanced directives. No nurse will be allowed to work until the in-service training has been completed.
• DNR elections will be honored upon the resident/representative having voiced the advanced directive care election and if DNR the OOH-DNR form will be initiated and completed with physician's signatures, then uploaded into the electronic health record.
• Nurses are expected to validate the code status election within the electronic health record orders to determine code status ordered, upon identifying that a resident presents with altered signs of life, i.e. absence of detectable vital signs, no s/s of life. Nurse should immediately validate code status order in order to confirm advance directive/code status election prior to initiating CPR. After code status has been swiftly confirmed, the nurse should adhere to the code status election (Full Code = swiftly initiating CPR accordingly or DNR-do not resuscitate the nurse would swift proceed with notifications of no s/s of life to the physician and representative. If full code: The available licensed nurses within the community should assist with the code status response by swiftly verifying the code status order, implementing CPR according to the physician's order, calling 911, and notification to MD and RP, as well as assisting with the required paperwork for a hospital transfer. If you find a resident is found unresponsive, the nurse must yell for help, and then proceed to validate the code status, if the cart with the computer is at the door of the room. In the event the cart is not at the door of the room, the charge nurse must also yell for a team member to bring the computer, the crash cart, and the AED machine.
• Nurses are expected to immediately review the code status orders within the electronic health record in order to identify the resident's code status. This should be immediately with the closest nurse's station computer or closest laptop available. The nurse should respond with urgency, immediately confirming code status and implementing resuscitative measures accordingly.
• Nurses are expected to document findings, interventions/response and notifications within the medical record.
• Nurses are expected to notify the Administrator and/or Director of Nurses for all emergent events, deaths within the facility, significant changes in condition and any concerns regarding CPR emergent response as well as any resident without an identified code status election order.
• The Administrator/Director of Nursing/Assistant Director of Nursing conduct re-education with the identified nurses initially then re-education is provided to all licensed nurses regarding on response times when performing immediate assessments/interventions for residents with changes in condition.
• Director of Nursing/Assistant Director of Nursing conducted an audit to validate all orders have been entered into [facility electronic record system] accurately and timely.
• The Administrator/Director of Nursing/Assistant Director of Nursing out of an abundance of caution, provided re-education to all team members on Abuse /Neglect and Residents Rights.
• Going forward the identified trainings above will also be conducted with new hires accordingly.
• Community will ensure all staff on leave/agency/PRN staff are in serviced prior to working their shift.
• Community will ensure administrative nursing staff in the community to provide in-service/education prior team members working their assigned shift. These trainings will also be conducted with new hires.
• Director of Nursing/Assistant Director of Nursing conducted 100% re-education was extended to all nurses regarding the expected practice of confirming all new admissions have advance directives elections indicated within the medical record.
• All licensed nurses educated regarding the process of reconciling physician orders into the electronic health record accurately and timely to include but not limited to code status upon admission, re-admission and any changes in code status election/advanced directives.
• Nurses are expected to validate the code status election prior to initiating CPR by reviewing the code status order within the electronic health record. The nurse should immediately alert staff for assistance and all available nursing staff should immediately respond to that location. The nurse will alert staff by utilizing the call light system, phone and /or verbally calling for emergency response assistance to that location.
• Upon identifying the code status election via the physician's order, the nurse should then proceed with initiating CPR. If the person is designated as Full Code as per the code status order. The available nurses within the community should assist with the code status response by swiftly verifying the code status order, implementing CPR according to the physician's order, calling 911, and/or conducting proper notification to MD and RP, as well as assisting with the required paperwork for a hospital transfer.
• Should the resident be designated as DNR-do not resuscitate per physician's order and as per the resident's/representative's wishes, the nurse/nurses would proceed with conducting the proper notifications of no s/s of life to the physician and representative.
• In the event there is no identified code status / advanced directives CPR should be initiated. Resuscitative measures should then only be ceased upon the resident's representative's instruction to stop CPR, confirm the person wished to be DNR and as instructed by physician and/or EMS-medical response team.
• Director of Nurses/Assistant Director of Nurses will conduct training for licensed nurses, aids and medication aids regarding the process for confirming and implementing CPR. Nursing team members will not work until in-service training has been received.
• Mock Code Drills: Director of Nurses/Assistant Director of Nurses will conduct monthly mock code response of both full code and DNR on various shifts.
• Nurses are expected to document findings, interventions/response and notifications within the medical record.
• Licensed Nurses both on-coming, and off-going nurses will review/audit the code status designation for any new admission, re-admission and new order or changes to code status during the 24-hour report. Any identified discrepancies or absence of code status will be reported to the attending MD, DNS and/or ADMIN.
• Should there not be an election of advanced directives or code status, will result in the individual being full code until otherwise directed.
• Nurses are expected to notify the Administrator and/or Director of Nurses for all emergent events, deaths within the facility, significant changes in condition and any concerns regarding CPR emergent response as well as any resident without an identified code status election order.
• All Staff: Any staff member should immediately respond to a code status response with the Crash Cart along with the AED to the bedside of identified resident accordingly.
• The Administrator/Director of Nursing/Assistant Director of Nursing out of an abundance of caution, provided re-education to all team members on Abuse /Neglect and Residents Rights.
• Going forward the identified trainings above will also be conducted with new hires accordingly.
• Community will ensure all staff on leave/agency/PRN staff are in serviced prior to working their shift.
• Community will ensure administrative nursing staff in the community to provide in-service/education prior team members working their assigned shift. These trainings will also be conducted with new hires.
• Monitoring: The Administrator/Director of Nursing/Assistant Director of Nursing/Social Worker will make weekly random audits validating the electronic health record for accurate code status orders as well as appropriate OOH-DNR form within the medical record. The findings will be reviewed and reported to the QAPI committee, to validate compliance or to identify additional training needs.
• The Director of nurses/Assistant Director of Nurses will conduct weekly skills validations of order entry as well as interview nurses to review the expected practice of validating code status upon admission, validating code status order entry as well as expected process for an emergent response when a significant change in condition (absence of signs of life, no detectable vital signs) has been identified, as well as general interviews with all staff regarding expected response of responding with the crash cart to the designated room accordingly.
• Mock Code Drills: Director of Nurses/Assistant Director of Nurses will conduct monthly mock code response of both full code and DNR on various shifts.
• Director of Nurses/Assistant Director of Nurses will review all admission/re-admission orders daily in the clinical meeting to validate orders are transcribed as per required code status admission orders and will review all orders daily in the clinical meeting to validate compliance of code status election has the appropriate code status election physician's order in place.
• HR/Director of Nurses will conduct CPR certification audit.
• This corrective action plan will remain in place to ensure compliance or to identify any further training needs. Findings of those observations will be reported to the QAPI committee during monthly meeting to establish compliance or identify additional trainings and oversight is required.
• All audits will be placed in a binder and kept for review by HHSC for the revisit to validate to compliance.
• The Administrator/Director of Nursing and Medical Director conducted a Ad Hoc QAPI meeting to review this situation, and the immediate corrective action plan implemented.

Penalty

Fine: $28,235

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 when there was a significant change in the resident's physical status. Specifically, the facility did not ensure that the physician was consulted when a resident experienced shortness of breath while receiving oxygen treatment. This oversight was identified for one of the four residents reviewed for notification of changes, and it was noted that the resident did not have an order for oxygen administration documented in their records. The resident in question was a male with a history of heart failure, morbid obesity, diabetes mellitus, and atrial fibrillation. Despite being at risk for shortness of breath, there was no documented physician's order for oxygen in the resident's care plan or medical records. Interviews with nursing staff revealed confusion and uncertainty about whether the resident had an order for oxygen, and it was acknowledged that oxygen should be administered with a physician's order to ensure the appropriate dosage. Further interviews with staff, including registered nurses, licensed vocational nurses, and the Director of Nursing, highlighted a breakdown in communication and documentation processes. The resident's physician confirmed that an intermittent oxygen order was given, but it was not properly entered into the facility's electronic health record. This failure in documentation and communication could have placed the resident at risk of respiratory distress or significant decline in physical functioning.

Removal Plan

• Director of Nursing Services/Assistant Director of Nursing Services identified all residents in the community on continuous oxygen and verified accurate orders were in the electronic health record.
• Director of Nursing Services/Assistant Director of Nursing services will conduct skills validations for all licensed nurses to validate competency for inputting physician orders.
• Rehabilitation Director will be present in the morning meeting. Director of Nursing Services/Assistant Director of Nursing Services will review all residents who are on oxygen. The Audit Listing Report for residents on oxygen will be printed, and a copy given to therapy.
• Director of Nursing/Assistant Director of Nursing will provide education to all team members in therapy on notification of changes on condition to the Charge nurse/Assistant Director of Nursing/Director of Nursing.
• Director of Nursing/Assistant Director of Nursing will provide education to all direct care staff on notification of changes in condition to report to the charge nurse/Assistant Director of Nursing/Director of Nursing Services.
• Director of Nursing/Assistant Director provided education to all licensed nurses in regard to resident's changes in condition (shortness of breath, low oxygen saturations and all changes in condition).
• Community will ensure all staff on leave/agency/PRN staff are in serviced prior to working their shift.
• Community will ensure administrative nursing staff in the community to provide in-service/education prior team members working their assigned shift.
• Director of Nurses/Assistant Director of Nurses will conduct skills validations of order entry for nurses.
• Director of Nurses/Assistant Director of Nurses will review all admission/re-admission orders in the clinical meeting to validate orders are transcribed per discharge orders for the reconciliation process.
• Director of Nursing Services/Assistant Director of Nursing Services will review all residents who are on oxygen in the morning meeting. A review of residents who are on oxygen will be reviewed with the rehabilitation representative.
• Director of Nursing/Assistant Director of Nursing will validate the process of reporting changes in condition with random therapy team members.
• Director of Nursing Services/Assistant Director of Nursing Services will validate the process to implement with the notification of a change in condition from random licensed nurses.
• All the monitoring will be monitored by the Director of Nursing/Assistant Director of Nursing.
• Findings of those observations will be reported to the QAPI committee.

Penalty

Fine: $28,235

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 respiratory care and services, including oxygen administration, to a resident who required such care. The resident, who had a history of heart failure, morbid obesity, diabetes mellitus, and atrial fibrillation, was admitted with a verbal order for oxygen administration. However, this order was not documented, verified, or communicated to the staff, leading to a lack of proper implementation. As a result, the resident ambulated without oxygen, experienced a fall, became unresponsive, and subsequently died. Interviews and record reviews revealed that the resident was on PRN oxygen, but there was no formal order documented in the facility's records. The nursing staff, including the RN, LVN, and DON, were unsure about the existence of an oxygen order, and the necessary documentation was missing from the electronic health record. The resident's care plan indicated a risk for shortness of breath, but the order summary report and NEMAR did not reflect any order for oxygen administration. The deficiency was further compounded by the lack of communication and verification of the resident's needs during the admission process. The admitting nurse failed to enter the oxygen order into the computer, and subsequent chart audits did not catch this oversight. The facility's failure to ensure proper documentation and communication of the resident's oxygen needs placed the resident at risk of respiratory distress, ultimately leading to the resident's death.

Removal Plan

• Director of Nursing Services/Assistant Director of Nursing Services identified all residents in the community on continuous oxygen and verified accurate orders were in the electronic health record.
• Director of Nursing Services/Assistant Director of Nursing Services provided education to all licensed nurses for the process of reconciliation of physician orders from the discharging facility.
• Director of Nursing Services/Assistant Director of Nursing Services will conduct skills validations for all licensed nurses to validate competency for inputting physician orders.
• Rehabilitation Director will be present in the morning meeting. Director of Nursing Services/Assistant Director of Nursing Services will review all residents who are on oxygen.
• Director of Nursing/Assistant Director of Nursing will provide education to all team members in therapy on notification of changes on condition to the Charge nurse/Assistant Director of Nursing/Director of Nursing.
• Director of Nursing/Assistant Director of Nursing will provide education to all direct care staff on notification of changes in condition to report to the charge nurse/Assistant Director of Nursing/Director of Nursing Services.
• Director of Nursing/Assistant Director provided education to all licensed nurses in regard to resident's changes in condition.
• Director of Nursing/Assistant Director provided education to all direct care team members on use and access of the Kardex.
• Director of Clinical Operations provided education to the Director of Nursing Services and Assistant Director of Nursing Services on process and expectation of reconciliation of physician orders from the discharging facility.
• Community will ensure all staff on leave/agency/PRN staff are in serviced prior to working their shift.
• Community will ensure administrative nursing staff in the community to provide in-service/education prior team members working their assigned shift.
• Director of Nurses/Assistant Director of Nurses will conduct skills validations of order entry.
• Director of Nurses/Assistant Director of Nurses will review all admission/re-admission orders in the clinical meeting.
• Director of Nursing Services/Assistant Director of Nursing Services will review all residents who are on oxygen in the morning meeting.
• Director of Nursing/Assistant Director of Nursing will validate the process of reporting changes in condition with random therapy team members.
• Director of Nursing Services/Assistant Director of Nursing Services will validate the proper process of use/access of the Kardex by direct care staff.
• Director of Nursing Services/Assistant Director of Nursing Services will validate the process to implement with the notification of a change in condition from random licensed nurses.

Penalty

Fine: $28,235

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 adequate supervision and adherence to care plans, resulting in a critical incident involving a resident. The resident, who had a history of heart failure, morbid obesity, diabetes mellitus, and atrial fibrillation, required moderate assistance with mobility and was care planned to use a wheelchair for ambulation and to be transferred by two staff members using a gait belt. However, CNA C, who was unfamiliar with the resident's care needs, attempted to transfer the resident alone, leading to the resident sliding out of a shower chair and becoming unresponsive. CNA C did not follow the resident's care plan, which specified the need for two staff members during transfers and the use of a wheelchair for ambulation. Instead, the resident was allowed to ambulate with a walker, contrary to the care plan. During the transfer to the shower chair, the resident fell and subsequently became unresponsive, with signs of hypoxia observed by LVN T, who was called to the scene. Despite efforts to provide oxygen and perform CPR, the resident expired. Interviews with staff revealed a lack of awareness and understanding of the resident's care plan and the proper procedures for accessing care information via the Kardex. CNA C admitted to not knowing the resident's specific care needs and did not consult the Kardex or nursing staff for guidance. The incident highlighted deficiencies in staff training and communication regarding resident care plans and the importance of following established protocols to prevent accidents.

Removal Plan

• Director of Nursing Services/Assistant Director of Nursing Services identified all residents in the community on continuous oxygen and verified accurate orders were in the electronic health record. All residents with supplemental oxygen have orders in place in the electronic health record.
• Director of Nursing Services/Assistant Director of Nursing Services provided immediate education to all licensed nurses for the process of reconciliation of physician orders from the discharging facility.
• Director of Nursing Services/Assistant Director of Nursing Services will conduct skills validations for all licensed nurses to validate competency for inputting physician orders.
• Rehabilitation Director will be present in the morning meeting. Director of Nursing Services/Assistant Director of Nursing Services will review all residents who are on oxygen.
• Director of Nursing/Assistant Director of Nursing will provide education to all team members in therapy on notification of changes on condition to the Charge nurse/Assistant Director of Nursing/Director of Nursing.
• Director of Nursing/Assistant Director of Nursing will provide education to all direct care staff on notification of changes in condition to report to the charge nurse/Assistant Director of Nursing/Director of Nursing Services.
• Director of Nursing/Assistant Director provided education to all licensed nurses in regard to resident's changes in condition (shortness of breath, low oxygen saturations and all changes in condition).
• Director of Nursing/Assistant Director provided education to all direct care team members on use and access of the Kardex to be informed of the residents needs with activities of daily living prior to providing care of the resident.
• Director of Clinical Operations provided education to the Director of Nursing Services and Assistant Director of Nursing Services on process and expectation of reconciliation of physician orders from the discharging facility.
• Community will ensure all staff on leave/agency/PRN staff are in serviced prior to working their shift.
• Community will ensure administrative nursing staff in the community to provide in-service/education prior team members working their assigned shift.
• The Director of Nurses/Assistant Director of Nurses will conduct weekly skills validations of order entry for nurses.
• Director of Nurses/Assistant Director of Nurses will review all admission/re-admission orders daily in the clinical meeting to validate orders are transcribed per discharge orders for the reconciliation process.
• Director of Nursing Services/Assistant Director of Nursing Services will review all residents who are on oxygen in the morning meeting.
• Director of Nursing/Assistant Director of Nursing will validate the process of reporting changes in condition with random therapy team member.
• Director of Nursing Services/Assistant Director of Nursing Services will validate the proper process of use/access of the Kardex by direct care staff.
• Director of Nursing Services/Assistant Director of Nursing Services will validate the process to implement with the notification of a change in condition from random licensed nurses.
• All the monitoring will be monitored by the Director of Nursing/Assistant Director of Nursing.
• This plan will remain in place to ensure compliance or to identify any further training needs.

Penalty

Fine: $28,235

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 therapeutic diet was prescribed and administered as ordered by the attending physician for a resident with multiple health conditions, including heart failure, morbid obesity, diabetes mellitus, and atrial fibrillation. The resident was supposed to be on a cardiac diet with specific restrictions, including 2 GM sodium, low fat, and low cholesterol. However, the diet order was not transcribed correctly, leading to the resident receiving a regular diet instead. The Director of Nursing (DON) and Licensed Vocational Nurse (LVN) involved in the resident's care did not verify the diet order with the physician, resulting in the incorrect diet being entered into the facility's computer system. The Dietary Manager also failed to cross-check the diet order with the physician's order on the computer, leading to the resident receiving meals that did not adhere to the prescribed cardiac diet. This oversight was not identified until after the resident's death in the facility. Interviews with facility staff revealed a lack of communication and verification processes regarding diet orders. The LVN admitted to incorrectly transcribing the diet order, and the Dietary Manager acknowledged not consulting with nursing staff to resolve discrepancies. The Administrator confirmed that the failure to provide the correct diet could have adversely affected the resident's health. The facility's policy on therapeutic diets emphasized the importance of providing residents with the appropriate nutritive content as prescribed, which was not adhered to in this case.

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 conduct accurate and comprehensive assessments for several residents, leading to deficiencies in their care. Resident #4 was not properly assessed for her mental diagnoses and hearing difficulties. Despite having a history of bipolar disorder and being scheduled for an audiology appointment, her assessments did not reflect these issues, and she experienced communication difficulties due to hearing problems. Interviews with staff confirmed that her hearing issues were known but not accurately documented in her assessments. Resident #7 was not assessed for her mental illness and oral health issues. Although she had a history of mental health conditions and reported pain in her gums, her MDS assessment did not reflect these concerns. The social worker confirmed that a dental appointment was scheduled, but the MDS coordinator admitted to being new to the process and still learning, which may have contributed to the oversight. Resident #34's assessment failed to document her bipolar disorder, despite her history of the condition. This omission could delay necessary services. Similarly, Resident #97's oral health issues were not accurately recorded, as she reported problems with her dentures that were not reflected in her MDS assessment. The facility's policy requires comprehensive assessments within 14 days of admission and at regular intervals, but these were not adequately conducted, leading to potential delays in care and services.

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 comprehensive, resident-centered care plans were reviewed and revised by the interdisciplinary team after each assessment for several residents. Specifically, the care plans for seven residents were not updated to reflect their current needs and conditions. For instance, Resident #4's care plan did not include her cognitive loss, dementia, communication issues, and dental care needs, despite these being identified in her admission MDS assessment. Similarly, Resident #7's care plan lacked updates for cognitive function, visual function, psychosocial well-being, and dental care, which were triggered in her annual MDS assessment. Additionally, Resident #48's care plan did not reflect her DNR status, and the care plans for Residents #13, #48, and #53 did not specify the level of assistance required for ADLs, despite their dependence on staff assistance. Resident #10's care plan included an order for a brace/splint to be applied to her left foot, but this was not implemented, as observed during multiple checks. Interviews with staff revealed a lack of awareness and communication regarding these care plan requirements, contributing to the deficiencies. The report highlights that these failures placed residents at risk of not having their needs met and not receiving appropriate individualized care. Interviews with the MDS Coordinator and the Administrator confirmed that the care plans should have been accurate and updated to ensure proper care. The facility's policy on comprehensive care plans emphasized the need for ongoing assessments and revisions, which were not adhered to in these cases.

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 expired medications were removed from the medication room and medication carts, as observed during a survey. Expired medications, including Meclizine Chewable, Prenatal multivitamins, Optimum Vitamin A, Calcium 600 +D, Enema saline laxative, Sore throat spray, and Docusate Calcium, were found in the medication room. Additionally, several medications on the 600 Hall medication cart, such as Famotidine and Ammonium Lactate lotion, were expired or not dated when opened. Interviews with staff revealed a lack of clarity regarding responsibility for checking and removing expired medications, with some staff unsure of who was responsible for these tasks. Further observations revealed expired medications on the 400 Hall medication cart and undated open medications on the 100 and 200 Hall medication carts. Interviews with the Director of Nursing (DON) and unit managers confirmed that expired medications should have been removed and stored in a designated area for destruction. The DON acknowledged that the expired drugs could be mistakenly administered to residents, potentially leading to ineffective treatment and gastrointestinal issues. The facility's central supply clerk, who was responsible for checking the medication room, was newly hired and on vacation, contributing to the oversight.

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 electronically transmit the Minimum Data Set (MDS) assessments within the required 14-day period after completion for three residents, leading to a deficiency in compliance with CMS regulations. Specifically, the facility did not complete and transmit discharge MDS data for three residents, which could potentially disrupt Medicaid payments and services. The MDS coordinator acknowledged that the assessments were not completed and submitted, attributing the oversight to the records being overlooked. This failure was confirmed during interviews with the facility's Director of Nursing (DON) and Administrator, who both expressed expectations that all discharged residents' records should be closed out as per regulatory requirements. The report details the cases of three residents who were affected by this deficiency. One resident, a male with multiple diagnoses including respiratory failure and chronic kidney disease, was admitted and readmitted to the facility but did not have a discharge MDS assessment completed. Another resident, also with chronic kidney disease, was discharged home in stable condition, yet lacked a discharge MDS. The third resident, with diagnoses including muscle weakness and cognitive decline, was discharged without a completed MDS. The facility's policy and procedure on the Resident Assessment Instrument did not provide guidance on completing and encoding resident information into the CMS system, contributing to the oversight.

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 appropriate care for a resident with limited range of motion, specifically in managing a condition known as foot drop. The resident, a moderately cognitively intact female with a history of cerebrovascular disease and hemiplegia, was observed multiple times without the prescribed brace or splint for her left foot. Despite physician orders and care plans indicating the need for the brace/splint to be applied during the day and removed at bedtime, the resident was not wearing it during several observations, and there was no documentation of refusals or interventions in place. Interviews with the resident, the Restorative Nurse Aide (RNA), and the Licensed Vocational Nurse (LVN) revealed a lack of communication and adherence to the care plan. The RNA mentioned that the resident often refused the brace/splint, but there was no documentation of these refusals. The LVN and the Director of Nursing (DON) were unaware of the resident's need for the brace/splint, and the facility lacked a specific policy for managing foot drop or ensuring compliance with physician orders. This oversight placed the resident at risk for decreased mobility and worsening of her 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 appropriate incontinence care for a resident, leading to potential risks of urinary tract infections and skin breakdown. During an observation, CNA BB did not perform proper perineal care for a resident who was incontinent of bladder and bowel. Specifically, CNA BB did not open and clean the labia and failed to clean around the resident's buttocks after an incontinent episode. This improper care was observed despite CNA BB having been deemed competent in performing peri-care and hand hygiene according to skill checks. The resident involved was a female with multiple medical conditions, including acute cystitis, cerebrovascular disease, muscle wasting, bacteremia, and pressure ulcers, among others. She was moderately cognitively impaired and required extensive assistance with all activities of daily living, being always incontinent of bowel and bladder. The facility's policy on perineal care, which was not followed, required washing the perineal area from front to back, separating the labia for cleaning, and thoroughly washing the rectal area.

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 maintain a medication error rate below 5%, with a reported rate of 14.28% due to four errors out of 28 opportunities. These errors involved a medication aide, identified as MA DD, who did not administer four prescribed medications to a resident, identified as Resident #93. The medications not administered included Ferrous Sulfate, Cholecalciferol, Gabapentin, and Carbamazepine, which were crucial for managing the resident's conditions such as epilepsy and nerve pain. Resident #93, a male with a history of dysphagia, epilepsy, and dementia, was dependent on staff for personal care and had a moderately impaired cognition as indicated by a BIMS score of 9 out of 15. During a medication pass observation, MA DD was seen administering 13 medications but failed to give the four aforementioned medications. The medication administration record (MAR) inaccurately reflected that these medications were given, and there was no documentation of notifying the physician about the missed doses. Interviews with MA DD revealed that she documented the administration of medications without verifying them against the MAR, and she admitted to forgetting to administer some medications. The Director of Nursing (DON) and the Administrator confirmed that medications should be administered as ordered and acknowledged the potential reduction in therapeutic efficacy due to missed doses. The facility's policies on medication administration emphasize verifying medication details and documenting accurately, which were not adhered to in this instance.

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 did not maintain an effective infection prevention program, as evidenced by the actions of CNA BB during incontinence care for a resident. The resident, a moderately cognitively intact female with a history of acute cystitis, cerebrovascular disease, and hemiplegia, required extensive assistance with activities of daily living and was always incontinent of bowel and bladder. During an observation, CNA BB failed to follow proper hand hygiene protocols. She picked up a tissue from the floor, discarded it, and then proceeded to handle clean wipes and the resident's soiled brief without changing gloves. Additionally, CNA BB applied barrier cream to the resident's chafed area without changing gloves, which is against the facility's hand hygiene policy. The facility's policy on hand hygiene emphasizes the importance of handwashing as the primary means to prevent infection spread. It requires personnel to wash or sanitize hands before and after direct contact with residents, after removing gloves, and when moving from a contaminated to a clean body site. Despite being deemed competent in peri-care and hand hygiene, CNA BB did not adhere to these protocols, potentially placing residents at risk for infection. The facility's Director of Nursing acknowledged the lapse in protocol adherence and indicated that CNA BB would be retrained.

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 incorporate recommendations from the PASARR evaluation for a resident, leading to a deficiency in the coordination of PASARR services. The resident, a female with multiple diagnoses including dysphagia, hyperlipidemia, esophageal varices, autoimmune hepatitis, and cerebral palsy, was identified as having moderate cognitive impairment and required substantial assistance for daily activities. Despite being listed as PASARR positive and eligible for specialized services, the necessary forms and documentation were not submitted in a timely manner, resulting in a delay in the provision of these services. The deficiency was further compounded by a lack of communication and coordination among the facility staff. The MDS Coordinator responsible for ensuring the submission of PASARR-related forms did not inform other staff members about the communication from the PASARR Compliance Unit. This resulted in the forms not being submitted accurately and on time. The DON and another MDS Coordinator were unaware of the issue until after the responsible MDS Coordinator had transitioned to a different role within the facility. Interviews with the involved staff revealed discrepancies in their accounts of the events. The MDS Coordinator claimed to have informed the DON and other staff members about the PASARR communication, but this was not corroborated by the others. Additionally, the MDS Coordinator expressed uncertainty about whether the forms were completed correctly, citing confusion over incorrect service listings on the original form. This lack of clarity and communication led to the resident not receiving the specialized services within the required timeframe, as outlined in the facility's PASRR policy.