Mercy Manor Transition Center

Penalty

Inspection fine: $53,847

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 care and services consistent with professional standards of practice, as outlined in the Wisconsin Nurse Practice Act. A resident experienced a significant change in condition, including weakness, abnormal lung sounds, a fever, cough, and shortness of breath. Despite these symptoms, the facility did not complete a comprehensive nursing assessment by a registered nurse, nor did they consult with a physician as the resident's condition continued to deteriorate. The resident, who was admitted with diagnoses including end-stage renal disease, congestive heart failure, and a left ankle fracture, showed signs of respiratory distress and cognitive decline. The last documented RN assessment occurred in the morning, and it was not until 12.5 hours later that a physician was consulted, which included interventions. Throughout the day, the resident's condition worsened, and the facility's failure to act promptly and appropriately resulted in the resident's death later that night. Interviews with staff revealed that there was a lack of communication and follow-up regarding the resident's deteriorating condition. The LPN on duty did not speak to a physician or have an RN assess the resident before their passing. Additionally, the facility's policy for notifying physicians and conducting assessments was not followed, contributing to the immediate jeopardy situation.

Removal Plan

• The Administrator, Chief Nursing Officer of the Hospital, and Facility Medical Director outlined the steps to contact a physician 24 hours a day, 7 days a week. A physician will be available to assess patients 24 hours a day. This process has been communicated to all Hospitalists, Hospital Nurse Practitioners, Hospital RN House Supervisors, Administrator, Administrator Assistant, Director of Nursing, Assistant Director of Nursing, and the President of Hospital Operations.
• All Nursing staff were contacted and educated to ensure an RN assessment is completed when a resident presents with a change of condition, deterioration in their condition, and/or an immediate MD/NP consultation is needed in order to alter treatment if necessary.
• The Hospital Chief Nursing Officer reeducated every RN Hospital House Supervisors to implement the following: Frequent rounding is required in the facility to check on staff and ensure patient safety. If anyone from the facility calls the Nursing Services Office and has questions, are worried about patient safety, or seems that they are unsure what to do they are to immediately go to the facility and assess the situation and assist with calling physicians as needed. When RN House Supervisors are here, they are in charge of the hospital and everyone in it including patients and staff.
• The Hospitalist Physician assigned to the orange phone will respond to all calls and the Hospitalist Physician assigned to the black phone will respond to all calls.
• The facility Protocol for Condition Changes was revised to include the following; If a significant change in the resident's physical or mental condition occurs, a head-to-toe assessment of the resident's condition will be conducted by the RN on duty or by the MD/NP on call. The Director of Nursing has educated all Nursing Staff to the revision.
• A SNF Change of Condition Notification Protocol was developed to outline the new process of notifying the Physician of any change in a patient's condition.
• The RN Hospital Shift Supervisors will provide frequent rounding at the facility on all shifts and check in with RN/LPN on shift.
• RN Hospital Shift Supervisors will provide assistance with any patient at the facility and will come to the unit if the facility Nursing needs immediate assistance.
• If an LPN is on duty when the DON and/or ADON are not on duty, the RN Hospital Shift Supervisor will be contacted to conduct and document an RN assessment of the patient if there has been a change of condition or if the patient needs immediate assistance.
• If the facility nurse is unable to reach a physician using the protocol below; the nurse will contact the RN Hospital Shift Supervisor.
• If the nurse is unable to reach a physician using the call tree outlined in this protocol, the nurse is to contact the RN Hospital Shift Supervisor back who will then contact the Hospital Chief Nursing Officer for support.
• RRTs and Code Blues called within the facility will follow the RRT or Code Blue protocols located in the Emergency Management Binder.
• A SNF Change of Condition Reporting Protocol was revised to include the following: Our facility shall promptly notify the resident, his or her attending physician, and representative of changes in the resident's condition and/or status.
• The Director of Nursing will audit all charts for any Change of Condition to ensure an RN, or MD/NP Assessment was completed.
• The Quality Assurance Performance Improvement Committee will review these audits to ensure compliance.
• If an occurrence with a change of condition is identified during audits, the Director of Nursing will meet with the Nurses to identify the Root Cause of the occurrence and put appropriate measures in place for that specific occurrence to ensure compliance.
• The Quality Assurance Performance Improvement Committee will meet to discuss the event and corrective measures to ensure compliance.
• The Facility Assessment has been updated to include RN Hospital Supervisors as a facility resource. The Facility Assessment has also been updated to reflect the training topic of Identification of patient/resident changes in condition, including how to identify medical issues appropriately, how to determine if symptoms represent problems in need of intervention, how to identify when medical interventions are causing rather than helping relieve suffering and improve quality of life.

Penalty

Inspection fine: $53,847

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 timely reporting of an alleged sexual abuse incident involving a resident, identified as R2, to the State Survey Agency and local law enforcement. R2, who has a history of TIA, HTN, DM2, CVA, persistent atrial fibrillation, and chronic kidney disease, reported an allegation of sexual abuse by a CNA. The incident was reported to the Nursing Home Administrator (NHA) by a Registered Nurse (RN) at 5:45 AM, but the initial report to the State Agency was not completed until 4:30 PM, exceeding the required two-hour reporting window. Additionally, the facility did not notify local law enforcement as required by their abuse policy. The facility's internal investigation, which included interviews with staff and residents, concluded that the incident could not be substantiated as abuse. However, the facility's failure to report the allegation to the appropriate authorities in a timely manner was a clear violation of their abuse policy. The NHA and Assistant Administrator acknowledged during interviews with the surveyor that they did not follow the facility's policy regarding timely reporting to the state agency and local law enforcement.

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 a safe and sanitary environment for food preparation, storage, and distribution, potentially affecting all 8 residents. Observations included a box of spoiled lemons in the refrigerator, undated food items in the dry storage area, freezer, and smaller freezer, and a staff member's personal water bottle in the food prep area. Additionally, chunks of rubber were missing from spatulas, and garbage cans were found with open lids or without lids entirely. The temperature of the water in the sanitizing sink was also found to be out of the manufacturer's recommended range. Interviews with the Kitchen Office Coordinator and the System Executive Chef confirmed these deficiencies. The facility's policies on food labeling and leftovers were not followed, as evidenced by undated and expired food items such as baking chips, Oreo Cookie pieces, Graham Crackers, and frozen waffles. The staff member's personal water bottle was improperly placed on the food prep table, and garbage cans were not properly covered. The sanitizing sink's water temperature was not within the manufacturer's guidelines, and damaged rubber spatulas were still in use.

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 (R8) received the necessary services to maintain personal hygiene, specifically scheduled showers. R8, who is cognitively intact and requires substantial assistance for showers, voiced concerns about not receiving showers as scheduled. The facility's policy mandates offering bathing and other hygiene care, but documentation and interviews revealed inconsistencies in providing these services to R8. The weekly bath schedule indicated that R8 should receive baths on Tuesday mornings, but records showed missed showers and incomplete documentation of partial baths. Interviews with R8 and various staff members, including LPNs, CNAs, and the DON, confirmed that R8 did not refuse showers and that therapy sometimes assisted with showers. However, there were gaps in the documentation, and staff were unclear about whether R8 was being offered or receiving showers as scheduled. R8 expressed that staff often did not have time to assist with showers before therapy sessions, and he believed the facility was short-staffed, affecting the quality of care. The DON acknowledged the need for better documentation and education for CNAs to ensure refusals and reasons for missed showers are properly charted. Despite the facility's policy and R8's preferences, the failure to consistently provide scheduled showers and accurately document care led to the deficiency in maintaining R8's personal hygiene.