Worthington Healthcare Center

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 safe and accident-free environment for a resident who was on 1:1 observation due to suicidal ideations and a recent suicide attempt. On the day of the observation, the resident was found alone in his room, despite being on 1:1 supervision. When questioned, the resident was unaware of the staff member's whereabouts, and a Licensed Practical Nurse confirmed that the resident was supposed to be under constant observation. The staff member assigned to the resident, a Nurse Aide, was observed away from the resident's room and later stated that they had left to get the resident some ice. This absence left the resident unsupervised, which was against the facility's policy that required continuous observation for residents on 1:1 intervention. The facility's policy clearly stated that staff should be in observation of the resident at all times until the intervention is no longer required. The resident had a documented history of depression and schizophrenia, with severe cognitive impairment, and had previously attempted suicide by using a grabber to pull a pillow over his face. The resident had been sent to an acute care facility following the suicide attempt and returned to the facility with orders to remain on 1:1 supervision for safety reasons. Despite these precautions, the lapse in supervision was observed, indicating a failure to adhere to the established safety protocols.

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 comprehensive care plans for four residents, as identified during a record review and staff interview. Resident #92's care plan did not include necessary interventions for an unstageable wound on the right heel, as per the physician's orders and the Treatment Administration Record (TAR) for March 2024. Similarly, Resident #84's care plan lacked interventions for multiple wounds, including an unstageable wound on the sacrum, and did not incorporate physician-ordered wound care and repositioning strategies. Resident #39's care plan was not implemented according to the TAR, missing essential interventions such as preventative treatments and daily wound assessments. Additionally, Resident #95's care plan failed to include daily wound assessments for a surgical wound and a turning schedule, as ordered by the physician. In each case, the Corporate Registered Nurse confirmed the absence of these interventions, indicating a systemic issue in care plan development and implementation for these 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 follow physician's orders for four residents, leading to deficiencies in care. For Resident #92, the Treatment Administration Record (TAR) was incomplete for several treatments, including daily wound treatment and assessment for a stage III sacral wound, preventative treatments, and repositioning schedules. These omissions occurred on multiple dates throughout March 2024, as confirmed by the Corporate Registered Nurse (RN) #147. Resident #84 also experienced lapses in care, with the TAR missing documentation for daily treatments and assessments of various wounds, including a bullae on the right thumb and an unstageable wound on the sacrum. Additionally, the dressing change for a PICC line and monitoring for infection were not documented as ordered. These gaps in care were noted on several dates in March 2024, and RN #147 acknowledged the incomplete records. For Resident #39, the TAR lacked documentation for daily wound care and preventative measures, such as turning and repositioning, on specific dates in March 2024. Similarly, Resident #95's TAR was incomplete for February 2024, missing entries for catheter care, wound assessments, and repositioning. The Corporate RN #147 was informed of these deficiencies and confirmed the TAR should have been completed as per the physician's orders.

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 implement its policies and procedures to prevent abuse, neglect, and misappropriation of resident property by not ensuring the completion of background checks before allowing staff to work and have direct access to residents. This deficiency was identified through a review of records, legislative rules, and staff interviews. The facility did not conduct pre-hire criminal background checks for several staff members, including CNAs, a maintenance technician, and receptionists, as required by the facility's policy and the legislative rule S 69-10-1. These staff members were allowed to work without the necessary background checks, which could potentially affect all residents. The facility also failed to adhere to the provisional employment guidelines, allowing staff to work beyond the 60-day provisional period without completing the required fingerprint-based background checks. Specific instances included CNAs and other staff members who were hired and began working before their WV Cares Self-Disclosure Application and Consent Forms were completed and signed. Additionally, some staff members received their Notification of Eligible Fitness Determination well after their hire dates, indicating a lapse in the facility's compliance with the screening process. The facility's oversight in conducting timely background checks and adhering to provisional employment guidelines was acknowledged by the Administrator during an interview. The Administrator admitted that there were issues within the IDT team regarding the completion of WV Cares background checks and that staff were permitted to work more than the provisional 60 days without the necessary checks. This failure to comply with established procedures and legislative requirements led to the deficiency identified during the survey.

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 comply with state and local laws regarding employment screening and background checks for staff members. Specifically, the facility did not ensure that provisional employment screening was completed, nor did it complete background checks before allowing staff to work and have direct access to residents. This deficiency affected all residents, as the facility did not adhere to the required procedures for screening potential employees, including Certified Nursing Assistants, a Maintenance Technician, and Receptionists. The report highlights several instances where staff members were hired without the necessary background checks and fitness determinations. For example, a Certified Nursing Assistant was hired in August 2022, but the self-disclosure application and consent form were not completed until January 2024, with the fitness determination received in March 2024. Similar delays were noted for other staff members, including a Maintenance Technician and a Receptionist, who were allowed to work without the required background checks and fitness determinations. The facility's policy required pre-hire criminal background checks, including checks against the Health and Human Services Office of Inspector General's List of Excluded Individuals/Entities, criminal state and federal checks, and sex offender and elder abuse screenings. However, these procedures were not followed, leading to the employment of staff without proper clearance. The facility's failure to adhere to these policies resulted in staff working beyond the provisional 60-day period without completed background checks, as acknowledged by the facility's Administrator.

Penalty

Inspection fine: $104,14234 days payment denial

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

Summary

The facility failed to administer its resources effectively and efficiently, leading to a deficiency in ensuring the safety and well-being of its residents. The administration did not adequately address and substantiate allegations of physical abuse and involuntary seclusion involving two residents. In one incident, a resident's head was held by a nurse aide while a registered nurse performed a nasal swab for COVID testing, despite the resident's apparent distress and resistance. Multiple staff and resident statements confirmed the occurrence of this incident, yet the facility's investigation deemed it unsubstantiated. In another incident, a resident was allegedly subjected to involuntary seclusion when a registered nurse locked the resident's wheelchair and held it to prevent the resident from leaving the room. This action was reported as possible involuntary seclusion, but the facility's investigation also found this allegation unsubstantiated. Despite multiple witness statements and the resident's own account, the facility administration did not take appropriate actions to ensure the safety of the residents involved or prevent future occurrences. The failure to address these incidents placed all residents at risk for serious harm, as the alleged perpetrators remained employed at the facility. The administration's inaction and failure to substantiate the allegations despite clear evidence from multiple sources highlight a significant deficiency in the facility's management and oversight of resident care and safety.

Removal Plan

• Employee(RN) #40 will have extensive abuse and neglect training by the Regional Team Member.
• Employee (NA) #55 will have extensive abuse and neglect training by the Regional Team Member.
• Residents with BIMS scores of 12 and above were interviewed for potential physical abuse.
• Residents with BIMS scores of 11 or below had a skin assessment completed for potential physical abuse.
• Staff will be reeducated on the Abuse, Neglect, and Misappropriation Policy through in person, text blast will be physically educated with signatures. The training will be conducted by the Regional Team Member.
• There will be training for all staff on Resident Rights including the right to be free from any physical restraints imposed for purposes of discipline or convenience and not required to treat the resident medical symptoms.
• The training will be conducted by the Regional Team Member.
• Staff will be reeducated on restraint alternatives.
• There will be a team review of all reportable events to determine if physical abuse occurred, per state definitions. The team will include Social Services, Director of Nursing or Designee, and Executive Director.
• Audits will be conducted by the regional Director of Clinical Operations with correction upon discovery.
• Audit results will be reviewed by the QAPI Committee.

Penalty

Inspection fine: $104,14234 days payment denial

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

Summary

The facility failed to protect residents from physical abuse, as evidenced by two separate incidents involving physical restraint. In the first incident, a nurse aide physically restrained a resident by holding her head while a nurse swabbed her nose for a COVID test. This action was witnessed by multiple staff members and residents, who reported that the resident was screaming and appeared distressed. Despite these accounts, the facility's investigation concluded that the incident was unsubstantiated, and the involved staff members remained employed. In the second incident, a resident became agitated, and a nurse locked the resident's wheelchair and physically held it to prevent the resident from leaving the room. This action was reported as possible involuntary seclusion. The facility's investigation also deemed this allegation unsubstantiated, despite statements from staff members who witnessed the event. The facility's response included an in-service training on abuse and neglect, but the involved nurse continued to work at the facility. Both incidents placed all residents at risk for serious harm, as the alleged perpetrators were still employed, and no immediate actions were taken to prevent further abuse. The facility was notified of the immediate jeopardy situation, and a plan of correction was submitted and accepted by the state agency. However, the initial failure to address the incidents and protect the residents from abuse highlights significant deficiencies in the facility's handling of such situations.

Removal Plan

• Employee(RN) #40 will have extensive abuse and neglect training by the Regional Team Member.
• Employee (NA) #55 will have extensive abuse and neglect training by the Regional Team Member.
• Residents with BIMS scores of 12 and above were interviewed for potential physical abuse.
• Residents with BIMS scores of 11 or below had a skin assessment completed for potential physical abuse.
• Staff will be reeducated on the Abuse, Neglect, and Misappropriation Policy through in person, text blast will be physically educated with signatures. The training will be conducted by the Regional Team Member.
• There will be training for all staff on Resident Rights including the right to be free from any physical restraints imposed for purposes of discipline or convenience and not required to treat the resident medical symptoms. The training will be conducted by the Regional Team Member.
• Staff will be reeducated on restraint alternatives.
• There will be a team review of all reportable events to determine if physical abuse occurred, per state definitions. The team will include Social Services, Director of Nursing or Designee, and Executive Director.
• Audits will be conducted by the regional Director of Clinical Operations with correction upon discovery.
• Audit results will be reviewed by the QAPI Committee.

Penalty

Inspection fine: $104,14234 days payment denial

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

Summary

The facility failed to ensure that residents were free from physical abuse, as evidenced by two incidents involving physical restraint. In the first incident, a nurse aide held the head of a resident while a registered nurse performed a nasal swab for COVID testing. Multiple staff members and a resident witnessed the event, confirming that the resident was restrained against her will. Despite these accounts, the facility's investigation deemed the incident unsubstantiated, and the involved staff members remained employed without immediate corrective action. In the second incident, a resident became agitated, and a nurse locked the resident's wheelchair and physically held it to prevent the resident from leaving the room. This action was reported as possible involuntary seclusion. The facility's investigation again found the allegation unsubstantiated, despite statements from staff members who witnessed the event. The facility conducted an in-service training on abuse and neglect but did not take further immediate action against the involved staff. Both incidents placed the residents and others at risk for serious harm, as the facility did not take adequate measures to prevent future occurrences. The facility's failure to substantiate the allegations and take appropriate action contributed to an immediate jeopardy situation for all residents, highlighting a significant deficiency in ensuring resident safety and compliance with regulations regarding physical restraints.

Removal Plan

• Employee(RN) #40 will have extensive abuse and neglect training by the Regional Team Member.
• Employee (NA) #55 will have extensive abuse and neglect training by the Regional Team Member.
• Residents with BIMS scores of 12 and above were interviewed for potential physical abuse.
• Residents with BIMS scores of 11 or below had a skin assessment completed for potential physical abuse.
• Staff will be reeducated on the Abuse, Neglect, and Misappropriation Policy through in person, text blast will be physically educated with signatures. The training will be conducted by the Regional Team Member.
• There will be training for all staff on Resident Rights including the right to be free from any physical restraints imposed for purposes of discipline or convenience and not required to treat the resident medical symptoms. The training will be conducted by the Regional Team Member.
• Staff will be reeducated on restraint alternatives.
• There will be a team review of all reportable events to determine if physical abuse occurred, per state definitions. The team will include Social Services, Director of Nursing or Designee, and Executive Director.
• Audits will be conducted by the regional Director of Clinical Operations with correction upon discovery.
• Audit results will be reviewed by the QAPI Committee.

Penalty

Inspection fine: $104,14234 days payment denial

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

Summary

The facility failed to maintain appropriate infection control standards in two areas: cleansing dwell time and linen storage. During an observation, a housekeeper on the [NAME] wing incorrectly stated that the dwell time for the cleanser used on surfaces and floors was about five minutes, whereas the Housekeeping Director confirmed that the correct dwell time, as per the cleanser's label, was ten minutes. This discrepancy indicates a lack of proper training or communication regarding the correct procedures for infection control. Additionally, a linen cart on the East wing was observed to be uncovered, with a flap across the top. This was confirmed by two nurse aides and later acknowledged by the Director of Nursing, who confirmed that the linen cart should have been covered. These findings highlight lapses in maintaining infection control protocols within the facility.

Penalty

Inspection fine: $104,14234 days payment denial

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

Summary

The facility failed to implement its abuse prevention policy, resulting in two residents being physically restrained. Resident #43 was restrained by a nurse aide who held her head while a nurse performed a nasal swab for COVID testing. Multiple staff members, including a registered nurse and a nurse aide, were involved in the incident, and several witness statements confirmed the occurrence. Despite this, the facility's investigation concluded the incident as unsubstantiated, even though the resident was non-verbal and unable to express how the restraint made her feel. In another incident, Resident #11 was taken to her room by a nurse who locked the resident's wheelchair and physically held it, preventing her from leaving. This was reported as possible involuntary seclusion. The facility's investigation gathered statements from staff, including a nurse who claimed the action was therapeutic and for a limited period. However, the facility also deemed this incident unsubstantiated, despite the resident's agitation and the physical restraint used. The state agency determined that these failures caused physical and mental suffering to the residents involved and placed all 95 residents at risk of serious harm. The facility did not take immediate action to remove the alleged perpetrators from resident care areas, which contributed to the immediate jeopardy situation. The facility's abuse policy required immediate removal of employees involved in abuse allegations, but this was not followed, leaving the residents vulnerable to further harm.

Penalty

Inspection fine: $104,14234 days payment denial

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

Summary

The facility failed to implement care plans related to fall interventions for two residents. Resident #44 was identified as being at risk for falls and had a fall from bed. The care plan included an intervention to place a fall mat beside the bed, initiated on 02/13/24. However, observations on 02/19/24 and 02/21/24 revealed that the fall mat was not present beside the bed, which was confirmed by Clinical Manager #109. Resident #1, also at risk for falls, experienced multiple falls in different locations, including the dining room and lobby. The care plan specified the use of a recessed cup with a lid to prevent spillage of hot liquids, but an observation on 02/21/24 found the resident using a regular coffee cup instead. This was confirmed by Occupational Therapy Assistant #139, who described the recessed cup and confirmed the regular cup was not compliant with the care plan.

Penalty

Inspection fine: $104,14234 days payment denial

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

Summary

The facility failed to maintain a complete and accurate medical record for a resident, identified as Resident #97, during the survey process. A record review conducted on February 20, 2024, revealed a discrepancy in the discharge summary dated October 23, 2023. The discharge summary inaccurately stated that the resident was unable to participate in therapy due to a fracture. However, upon reviewing the physical therapy notes, it was found that the resident had actively participated in therapy sessions while seated in a wheelchair and was able to propel the wheelchair with standby assistance for 75 feet. This inconsistency was confirmed by Clinical Manager #109, who acknowledged the incorrect statement in the discharge summary based on the therapy notes.