Monument Healthcare Brigham City

Penalty

Inspection fine: $15,640

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 a resident with severe dementia and urinary incontinence was left in a wet brief for an extended period, resulting in a rash and excoriation to the groin area. The resident was unable to communicate her needs and relied on staff for incontinence care. On the evening in question, the assigned CNA failed to perform the required two-hour checks and did not change the resident's brief for approximately eight hours. When oncoming staff arrived, they found the resident saturated with dried and wet urine up to her shoulders, and the nurse confirmed the resident's condition and documented skin breakdown. Multiple staff interviews revealed that the CNA assigned to the resident gave conflicting accounts of when care was last provided, initially claiming to have changed the resident multiple times, then admitting she had not done so since the afternoon. The CNA also blocked other staff from entering the resident's room and yelled at a coworker who confronted her about the lack of care. Other CNAs and nurses stated that routine practice was to check and change residents at least every two hours, and that leaving a resident in a wet brief could quickly lead to skin breakdown or infection. The facility's policy required regular incontinence care and monitoring to prevent neglect and harm. Staff interviews confirmed that the resident never refused care and that there were standing orders for frequent checks due to her incontinence and cognitive impairment. The failure to provide timely incontinence care directly resulted in physical harm to the resident, as evidenced by the documented skin issues and the observations of multiple staff members.

Penalty

No penalty information released

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

Summary

The facility failed to protect a resident from abuse, resulting in an Immediate Jeopardy citation. A resident with a history of dementia and cognitive impairments was found missing by staff, and after a search, was discovered exiting a locked therapy room. The resident made statements indicating that a male staff member engaged in sexual actions with her. The therapy room was inaccessible to staff, and the resident was found pale, nauseated, and disoriented, with therapy paperwork in hand. Interviews with staff revealed that the therapy room was locked, and the resident was missing for approximately 20 minutes. Staff observed the resident exiting the therapy room, appearing sick and disoriented. The resident later disclosed to staff that she and a male staff member attempted to engage in sexual activity, which was reportedly consensual according to the resident. However, the resident's cognitive impairments raised concerns about her ability to consent. The male staff member, a Physical Therapy Assistant, was found in the facility after hours, contrary to previous instructions. Staff reported that the therapy room was usually unlocked, and the male staff member's presence in the facility after hours had been a concern. The facility's failure to ensure the safety and security of the resident, as well as the lack of access to the therapy room, contributed to the deficiency.

Removal Plan

• Resident and staff member were separated.
• Police contacted upon suspicion.
• Resident assessed; no injury noted.
• Notification to Physicians, POA, Incident reported by administrator to DHS, APS, Ombudsman.
• Resident interviewed with administrator.
• Hospital evaluation completed, no trauma noted.
• Resident care plan reviewed and updated as needed.
• Provider to assess/evaluate residents including medication review.
• Social Services wellness visits to be completed for resident and PRN.
• Behavioral health visit requested with local mental health provider.
• Therapy staff member was immediately placed on administrative leave, facility keys/badge provided to administrator.
• Therapy staff member was questioned and released by the police, pending potential charges.
• Employee file was reviewed.
• Therapy staff member will not return to the facility.
• Regional Director of Operations spoke to Therapy Regional Director and informed him that staff are not to stay in the facility after normal business hours without the approval of the facility administrator.
• Facility will ensure the therapy staff working in the facility have background checks (DACS) that are connected to the facility.
• All residents interviewed by administrator/designee to assess potential for abuse/neglect allegations.
• Locks will be removed from all doors and/or Master Key accessible to charge nurse on medication cart.
• Staff Members will not remain in the facility after normal business hours without the approval of the facility administrator.
• Administrator, DON and RNC reviewed Abuse & Neglect Policy.
• Administrator, DON and IDT were educated by RNC regarding Abuse & Neglect Policy.
• Administrator/DON/designee will complete Abuse & Neglect education with all staff.
• Education including post-test initiated for all facility staff on Abuse/Neglect.
• All employees will be educated at start of their next shift or if no scheduled shift by all staff meeting.
• The DON/designee will review incidents of sexually inappropriate behavior to ensure appropriate interventions are implemented and no trends are noted.
• The Administrator/designee will conduct random resident & staff interviews to ensure the Abuse & Neglect Policy have been followed and allegations have been investigated and reported.
• The facility administrator/designee will do random facility visits during off hours to ensure that only staff clocked in and assigned to be working are in the facility and that the charge nurse has a Master Key to all locked doors in the facility.
• The Administrator/designee will review employee files (including contracted therapist) to ensure they have completed abuse training, verification of license and background checks (DACS) is connected to the facility.
• Medical Director was informed of the incident and QAA Review & Recommendations.
• Results will be reported to the QAA committee from monitoring and follow-up.

Penalty

No penalty information released

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

Summary

The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. During an initial tour of the kitchen, it was observed that the dish machine's washing and rinse temperatures were below the manufacturer's required levels, with washing temperatures recorded at 110°F and rinse temperatures at 120°F. The Dietary Manager (DM) acknowledged the issue, stating that the dish machine temperatures fluctuated, especially during resident showers, and that the machine needed to be run multiple times to reach the appropriate temperature. Additionally, there were no sanitizer strips available to test the solution, and the DM was unable to locate any strips. A follow-up tour revealed continued non-compliance, with dish machine temperatures still below the required levels, and the sanitizer level was recorded at 100 PPM. The Low Temperature Dish Machine Log showed inconsistencies, with the last recorded temperature on the 14th, despite the follow-up occurring on the 16th. The Dietary Aide (DA) confirmed the low temperatures and admitted to documenting temperatures inaccurately. The Vendor Consultant, who visits the facility monthly, confirmed the need for the dish machine to reach temperatures above 120°F for both wash and rinse cycles and suggested changes to the logging process to include temperatures for breakfast, lunch, and dinner.

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 food that was palatable, attractive, and at a safe and appetizing temperature for its residents. During interviews, several residents expressed dissatisfaction with the food quality. One resident found the food unappealing and unappetizing, while another resident, who was sensitive to spices, reported that the food had been too spicy. Another resident mentioned the lack of substitutes, and yet another resident expressed a need for better food and was restricted to a limited amount of juice per day. Observations of the facility's tray line revealed issues with food preparation and presentation. A test tray contained bland and slimy turkey and ham with marinara sauce, pureed broccoli with chunks, and a dessert with raw cake on top. Further observations on a different day showed that the food served was not at an appetizing temperature, with pork, stuffing, broccoli, and coffee all served below ideal temperatures. The pork was tough and bland, the stuffing was mushy, and the cake was dry. Interviews with the Dietary Manager and a Vendor Consultant revealed that the alternative meal was not served to residents, and the turkey and ham had been prepared days earlier. The Vendor Consultant noted that the cook ran out of gravy and added water to the stuffing after it had been sitting on the steam table. These actions and inactions contributed to the deficiency in providing quality meals to the residents.

Penalty

No penalty information released

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

Summary

The facility failed to provide suitable and nourishing alternative meals and snacks for residents who wanted to eat at non-traditional times or outside of scheduled meal service times. Observations revealed that for 5 out of 27 sampled residents, only saltine crackers were consistently offered as snacks. Containers at both the north and south nurses stations were observed to contain primarily saltine crackers, with some instances of crackers being open to air. Although there were occasional offerings of fruits and other snacks, these were not consistently available, and the restocking of snacks appeared to be irregular. Interviews with residents indicated dissatisfaction with the snack offerings. One resident mentioned that snacks were usually filled once a week and that the availability of better snacks seemed to coincide with visits from important individuals. Another resident expressed a desire for snacks to be offered at night to avoid going to bed hungry. Staff interviews revealed that the responsibility for restocking snacks was assigned to the evening shift, but there was no consistent routine for ensuring a variety of snacks were available. This inconsistency in snack availability and variety led to the deficiency noted by the surveyors.

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 a clean, comfortable, and homelike environment, as evidenced by persistent strong odors throughout various areas, including hallways and the dining room. Observations made over several days revealed a strong urine odor, as well as bowel movement and body odors, in multiple locations within the facility. Specific instances included a brown substance on a wheelchair seat and back, contributing to the unsanitary conditions. Interviews with staff, including a registered nurse, certified nursing assistants, and a housekeeper, confirmed the presence of these odors, with some staff acknowledging that certain residents contributed to the odors due to incontinence issues and refusal to be changed. Staff interviews revealed that the odors were a known issue, with some staff attempting to mitigate the smell using air fresheners. However, the odors persisted, particularly in areas where residents with incontinence issues were located. The housekeeper noted that certain rooms consistently had odors, often due to wet briefs being disposed of in bathroom trash cans. Despite these efforts, the facility's failure to adequately address and manage these odors resulted in a deficiency in maintaining a safe, clean, and homelike environment for residents.

Penalty

No penalty information released

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

Summary

The facility failed to develop and implement written policies and procedures that effectively prohibited and prevented abuse, neglect, and exploitation of residents. This deficiency was identified when a Physical Therapy Assistant (PTA) was found not to be connected to the facility through the Direct Access Clearance System (DACS), which is a requirement for ensuring that staff members are properly screened and linked to the facility. The PTA's employee file contained an offer letter for another facility, and there was no documentation indicating employment with the facility being surveyed. The information available was from a contract rehabilitation company, suggesting a lack of proper documentation and oversight. During an interview, the Administrator confirmed that a background screening was completed for the PTA, and no issues were found. However, the Background Processing Manager (BPM) at the State Survey Agency revealed that while the PTA was eligible for work, they had not been connected to the facility in the DACS. This oversight indicates a failure in the facility's process to ensure that all staff members are appropriately linked to the facility, which is a critical step in preventing abuse and ensuring resident safety. The facility's policy on preventing abuse, neglect, and exploitation, dated 11/2017 and revised in 9/2022, outlines comprehensive guidelines for screening, training, prevention, identification, investigation, protection, and reporting. Despite these guidelines, the failure to connect the PTA to the facility in the DACS represents a significant lapse in the implementation of these policies. This deficiency highlights the need for the facility to ensure that all staff, including contracted and temporary staff, are properly screened and documented in accordance with established procedures.

Penalty

No penalty information released

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

Summary

The facility failed to develop and implement a comprehensive person-centered care plan for a resident, which resulted in multiple falls, a skin tear, and hip pain. The resident, who was admitted with several diagnoses including surgical amputation and chronic pain syndrome, was identified as being at risk for falls. Despite this, the care plan interventions, such as changing to a bariatric bed, were not implemented effectively. The resident experienced several unwitnessed falls, and although interventions like a floor mat and medication review were discussed, they were not timely or adequately executed. The resident's care plan was revised to include a bariatric bed, but this intervention was not implemented, as confirmed by staff interviews and the resident's own account. The resident continued to fall, sustaining injuries, and expressed frustration over not receiving the requested larger bed. Staff members, including CNAs and LPNs, were unaware of the care plan interventions, indicating a lack of communication and follow-through on the care plan updates. Interviews with the DON and other staff revealed discrepancies in the implementation of the care plan. The DON believed the resident had received a bariatric bed, but it was later discovered during the survey that this was not the case. The lack of proper communication and execution of the care plan interventions contributed to the resident's repeated falls and injuries, highlighting a deficiency in the facility's care planning and implementation 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 that the resident environment was free from accident hazards and did not provide adequate supervision and assistance devices to prevent accidents for one resident. This resident, who had a history of falls and was at risk due to gait and balance problems, experienced multiple falls. Despite the resident's request for a larger bed to prevent falls, the facility did not provide a bariatric bed until after several incidents occurred. The resident, who had a history of surgical amputation, diabetes, and other health issues, was admitted to the facility and had a care plan indicating a risk for falls. The care plan was revised to include a bed change to a bariatric bed, but this intervention was not implemented in a timely manner. The resident experienced several unwitnessed falls, resulting in minor injuries and complaints of hip pain, yet the facility did not provide the necessary assistance device promptly. Interviews with staff revealed a lack of awareness and implementation of interventions to prevent falls. The DON initially stated that a bariatric bed was provided, but later confirmed that the resident did not have one. The facility's failure to provide the appropriate bed and timely interventions contributed to the resident's repeated falls and injuries.