Every finding on record at Miona Geriatric & Dementia Center

Based on review of clinical records and staff interviews, it was determined that the facility failed to follow the care plan to ensure that a two person assist was provided for one resident (R) (R#1) during a transfer after the resident fell out of the bed. The sample size was six residents. Findings include: Review of the most recent Minimum Data Set (MDS) Quarterly assessment dated [DATE] revealed that R#1 was totally dependent on staff for bed mobility and required two person assistance, was totally dependent on staff for bathing and required one person assist for bathing, and this quarterly assessment also documented that R#1 was totally dependent on staff for transfers and required two person assistance for transfers. Review of the care plan dated 4/6/17, last updated 1/2/18, revealed that R#1 has thin fragile skin. She bruises easily and requires assistance with Activities of Daily Living (ADL's) with an approach that required two people for transfer. During a phone interview with Certified Nursing Assistant (CNA) AA on 2/21/18 at 2:00 p.m., revealed that on 2/9/18 she was giving the resident a bed bath, turned around to get the resident's clothes out of the closet and the resident fell out of the bed onto the floor. She then picked the resident up off the floor by herself and put her back in the bed. She further stated that she knew the resident was a two person transfer according to the sign that was posted over the resident's bed. Interview on 2/21/18 at 12:55 p.m. with Licensed Practical Nurse (LPN) BB revealed that R#1 required a two person assist transfer. Interview on 2/21/18 at 1:45 p.m. with the Registered Nurse (RN) MDS Coordinator revealed that R#1 was coded to have one person assist for bathing. Further interview revealed that R#1 was care planned as requiring two person assist for transfers. Post survey telephone interview with the Director of Nursing (DON) on 3/6/18 at 10:52 a.m. revealed that if a resident has a care plan for a two person transfer then two people should transfer that resident. Further interview revealed that the DON confirmed that R#1 resident required two people when transferring. Cross refer F689

Based on review of clinical records, the Incident/Accident Policy, and staff interviews, it was determined that the facility failed to provide adequate supervision during a bed bath to prevent an avoidable fall. Actual harm was identified when Resident (R) #1 fell from her bed during a bed bath on 2/9/18, and suffered a left femur fracture and a closed nondisplaced fracture of left frontal skull. The sample size was six residents. Findings include: Record review revealed that R#1 was admitted to the facility and had the following Diagnoses: [REDACTED]. The resident was assessed on the 1/2/18 Quarterly Minimum Data Set (MDS) as having severely impaired cognition, required a two person assist for bed mobility and two person assist for transfers and required one person assist for dressing, hygiene and bathing. During a phone interview with Certified Nursing Assistant (CNA) AA on 2/21/18 at 2:00 p.m., she revealed that on 2/9/18 she was giving the resident a bed bath, turned around to get the resident's clothes out of the closet and the resident fell out of the bed onto the floor. She then picked the resident up off the floor by herself and put her back in the bed. She stated that she did not report the fall because she was scared. She stated that she did not tell the truth until about two or three days later to the Administrator and the owner. She further stated that she knew the resident was a two person transfer according to the sign that was posted over the resident's bed. During an interview with the Director of Nursing (DON) on 2/21/18 at 3:40 p.m., revealed that on 2/9/18 one of the night nurses called him to report a bruise on the resident's left elbow which they thought was caused by staff trying to remove a jacket from the resident's arm. The next morning on 2/10/18, he conducted a full head to toe assessment on the resident and noted swelling to the left hip and thigh without bruising, a bruise to the left elbow and a bruise to the left forehead at the hairline. He stated that during their investigation, they interviewed CNA AA again (meaning they interviewed the CNA two times) who admitted the resident fell out of the bed when she turned to get clothes out of the closet. The DON indicated that the distance from the bed to the closet was approximately 10 feet. The DON further revealed that the expectation would be for staff to have all of the supplies before starting a bath. He further added, if staff must get something while bathing a resident they should first lower the bed and position the resident in the center of the bed. During an interview with the Administrator on 2/22/18 at 9:45 a.m., revealed that CNA AA did not report the resident's fall until a couple of days later. She stated she would expect the staff to immediately report a fall. She stated that CNA AA was terminated. She further stated the facility did not have a policy and procedure addressing bed baths. Observation on 2/22/18 at 10:50 a.m. revealed that the distance from the bed to the closet was approximately 10 to 15 feet. Record review revealed Nurse's Notes dated 2/10/18 at 10:30 a.m., that documented the following: Reported on 2/9/18 at 7:30 p.m. by CNA during routine care bruising noted. Initial investigation indicated previous shift had difficulty with dressing resident. There was also a bath performed for resident on prior shift. Further assessment revealed purple discoloration to left side of head in hairline and tenderness to left hip. Doctor notified of findings. New orders noted. New Physician order, for R#1, dated 2/10/18 documented the following: Send to E.R. (emergency room ) for Eval (evaluation). Record review of the Nurses Notes dated 2/10/18 at 11:00 a.m. revealed that a report was called in to the emergency room . Review of the 2/10/18 History and Physical from the hospital documented that the resident had a left femur fracture and a closed nondisplaced fracture of left frontal skull. The plan noted the physician would perform left hip open reduction internal fixation (ORIF). Post survey telephone interview with the Director of Nursing (DON) on 3/6/18 at 10:52 a.m. revealed that if a resident has a care plan for a two person transfer then two people should transfer that resident. The DON further revealed that there is card over the resident's bed that specifies how many people should be used for transfers, and that if a resident has a fall, that the CNA should not move the resident. The CNA should immediately call for a Licensed Practical Nurse (LPN) or a Registered Nurse (RN) to come and complete a head to toe assessment and perform Range of Motion (ROM) before moving a resident. Further interview revealed that the DON confirmed that R#1 required two people when transferring. Review of an undated policy titled Policy on Incident/Accident revealed any staff member observing an incident should immediately contact or have someone contact a charge nurse. The charge nurse will be in charge of determining whether or not a resident should be moved. A resident should not be moved at all until a charge nurse arrives.

Based on observations during medication administration and dining and review of the Hand Hygiene Policy, the facility failed to ensure that hand washing was done appropriately for one (1) resident (#5) and three (3) randomly observed residents. The sample included twenty-five (25) residents. Findings include: 1. Observation during dining on 05/02/11 at 1:50 p.m. revealed Certified Nursing Assistant (CNA) "EE" deliver a lunch tray to a resident on the North Hall. The CNA touched and shook the bedspread trying to get the resident to turn over to eat but when the resident refused to eat, the CNA returned the tray to the food cart and removed a tray for another resident without cleaning her hands with a hand sanitizer or washing her hands. CNA "EE" took the tray to the dinning room where the resident was sitting, waiting for his meal. 2. Observation on 05/02/11 at 2:20 p.m. of Licensed Practical Nurse (LPN) "CC"",during medication administration for resident #5 revealed that the LPN put on gloves, administered an inhaler, cleaned off the resident's mouth and went into the bathroom to wash her hands. Continued observation revealed that the LPN hesitated, then left the room and put the inhaler back into the medication cart, with her gloves still on. Interview with the nurse on 05/02/11 at 2:20 p.m. revealed she should have washed her hands before entering the medication cart. 3. Observation on 05/03/11 at 11:12 a.m. of LPN "DD" during medication administration for a random resident revealed the LPN completed a fingerstick blood sugar test, removed her gloves, discarded her gloves and lancet into the receptacle on the side of the medication cart. Continued observation revealed the LPN pick up a plastic cup and one can of Ensure for administration to a resident with a feeding tube. The nurse did not use hand sanitizer or wash her hands before gather the supplies for the next resident. Interview with LPN "DD" on 5/03/11 at 11:25 a.m. revealed the handwashing policy indicated staff could use the hand sanitizer for up to 3 residents and then wash their hands. LPN confirmed she did not use the hand sanitizer after discarding the supplies used for the blood sugar of one resident and gathering the supplies for the next resident. Interview with the Director Of Nursing on 05/05/11 at 10:00 a.m. revealed that the handwashing policy did not include that staff could use hand sanitizer for 3 residents before washing hands. Continued interview revealed that her expectations were that staff wash their hands when coming in direct contact with residents, after removing gloves and before leaving the room. 4. Observation on 05/03/11 at 9:17a.m. during medication pass revealed LPN "TT" prepare and administer medication for three (3) different residents without washing/sanitizing her hands between residents and/or opening the medication cart. The LPN did not wash her hands until after administering the third resident medication.

Based on resident medical record review, staff interview, resident interview, and facility investigative summary review, the facility failed to ensure that one (1) resident (#1), on the survey sample of five (5) residents, was served a pureed diet, in accordance with a physician's pureed diet order and facility policy. Resident #1, who had a [DIAGNOSES REDACTED]. This failure to provide food prepared in a pureed consistency resulted in the likelihood of serious harm to this resident. It was therefore determined that an immediate and serious threat to resident health and safety existed on September 15, 2010, and was removed on September 23, 2010, at which time the facility took action to remove the immediate jeopardy. Findings include: Record review for Resident #1 revealed a Minimum Data Set assessment of 07/16/2010 which documented that the resident had a swallowing problem. The resident's Care Plan documented an admission date of [DATE], and documented that the resident had [DIAGNOSES REDACTED]. A Care Plan entry of 01/20/2010 indicated as a Problem/Need that the resident had difficulty swallowing, and also documented the resident's [DIAGNOSES REDACTED]. Approaches for this problem included to provide and serve the resident's diet as ordered. A September 2010 Medication Orders sheet referenced a physician's orders [REDACTED]. A Nurse's Note of 09/15/2010 at 7:50 p.m. documented that a licensed nurse administered the resident's medications with water without difficulty. A 09/15/2010, 8:10 p.m. Nurse's Notes entry documented that the nurse glanced at the resident and noted the resident to be cyanotic around the mouth and in respiratory distress. This Note documented that the nurse called for assistance from two (2) other nurses and a certified nursing assistant (CNA). A 09/15/2010, 8:15 p.m. Nurse's Notes entry again noted that the resident was in respiratory distress, and also documented that the resident was non-verbal and trying to breathe. This Note further documented that staff lowered the resident to the floor, looked in the resident's mouth, and noted several food [MEDICATION NAME] having the odor of peanut butter in the mouth. The nurse performed a sweep of the resident's mouth and removed the food [MEDICATION NAME] without difficulty, but the resident was documented as being unresponsive and without pulse and respirations at that time. Abdominal thrusts were performed and a large food [MEDICATION NAME] was removed, however the resident remained unresponsive without a palpable pulse and no respirations, and cardiopulmonary resuscitation (CPR) was begun. A 09/15/2010, 8:28 p.m. Nurse's Note documented that the physician was notified and an order was received to continue CPR until emergency personal arrived, and that the process continued as ordered. A 09/15/2010, 8:40 p.m. Nurse's Note documented that Emergency Medical Services staff had arrived, that the resident was transferred to a stretcher, that CPR was continued by the EMTs, and that the resident was transported to the hospital. A subsequent Nurse's Notes entry, labeled as an addendum, documented that the resident was deceased , per the coroner, and that the time of death was 09:05 p.m. Review of the facility's investigation summary dated 09/20/2010 from the facility's investigation which began on 09/15/2010 revealed, in the Initial Investigation section, that upon questioning, the nurse who had provided emergency care to the resident, as outlined in the Nurse's Notes above, stated that simultaneous oral cavity extraction and abdominal thrusts had been performed, and that approximately three portions of a peanut butter sandwich had been removed from the resident's mouth. This investigation summary documented that prior to questioning CNA staff about this incident, the facility interviewed Resident "A", who had been seated approximately 70 feet from Resident #1 at the time of the incident. During this interview, Resident "A" is documented as stating that a CNA had given Resident #1 a sandwich. During a subsequent interview with facility staff, Resident "A" stated that it had been CNA "BB" who had given Resident #1 a sandwich. This facility investigative summary documented that CNA "BB" was then interviewed by facility staff. She stated during this interview that on the referenced date, she had obtained a sandwich from the nourishment room and given it to another resident, but she denied giving a sandwich to Resident #1. She further stated she was aware that Resident #1 received pureed meals because she was responsible for feeding the resident pureed meals at supper. However, a later facility investigative summary dated 09/21/2010 documented that on 09/20/2010, CNA "BB" had approached the Administrator, the Director of Nurses, and a facility corporate representative and informed them that she did give Resident #1 a sandwich on the night of 09/15/2010. During this interview, she again acknowledged that she was aware of what a pureed diet was, and that she had fed Resident #1 a pureed meal for supper. The 09/20/2010 facility investigative summary referenced above documented that the coroner had ruled the death of Resident #1 an accidental death. An additional entry in this summary documented that the facility agreed, based on the interpretation of the facts at that time, that the death of this resident was correctly ruled as accidental and the sandwich was most likely the cause of the obstruction. In the Conclusion section of this summary, the facility indicated that it appeared a sandwich was the primary contributing factor to Resident #1's airway obstruction, in addition noting that the resident also had a [DIAGNOSES REDACTED]. During an interview with the Assistant Dietary Manager ""FF" conducted on 09/23/2010 at 3:00 p.m., this staff member stated that sandwiches were not included in any pureed diet. Based on the above, Resident #1 had a [DIAGNOSES REDACTED]. [REDACTED].#1, and the resident was subsequently found in respiratory distress, then became unresponsive with no respirations and no palpable pulse, with the remains of a peanut butter sandwich in the mouth. The resident was later pronounced dead, having had a blocked airway, per the coroner. It was determined that the immediate jeopardy was removed as of 09/23/2010, by which time the facility had completed the following actions: 1. On 09/16/2010, the facility had reviewed all snack procedures and diets, and had modified practices to include the following: a. Sandwiches on the snack cart are to be in an enclosed sealed container during transport from dietary to the licensed nurse. b. The sandwiches in the container will be labeled by the dietary department with the resident's name, date, and date of expiration. This will be performed for the specific resident who desires such sandwiches and has diet orders that do not prohibit such foods. c. The dietary department will review the sandwiches and all snacks against the physicians' orders of which they have an original copy in the dietary department. d. A carbon copy of the original diet order will be maintained at the nurse's desk for retrieval and review. The Licensed Nurse receiving the physician's orders [REDACTED]. (Current facility policy) The PAR committee members consists of : Administrator, DON, MDS/Care plan Coordinator, Social Service Director, QA/Infection Control Nurse, Treatment Nurse, Dietary, Activities, Housekeeping/Laundry/Maint., Medical Records/Lab, Restorative, RN Supervisor/Staff Education, Office Manager, CNA, and Windcorp representative. e. The snack cart list of residents and their diets will be reviewed or monitored weekly at PAR meetings and during QA meetings. This is to be done as new orders are received by the dietary supervisor and a member of the licensed nursing staff. f. The nourishment room is to be locked at all times with a key located at the nurse's station. The door will be checked every shift per licensed nurse and documented on the compliance sheet. g. Staff were in-serviced as to these modified and implemented rules, and new staff will be inserviced prior to working in the facility in an ongoing process. 2. On 09/16/2010, staff hiring and orientation policies were modified to include specific documentation related to residents with compromised food consumption or potential compromised food consumption, and staff inservice was conducted, as follows: a. This will be performed by documentation being maintained in the new hire's employment file including the date of training. b. New hires will be provided a skills tests prior to feeding any resident which will demonstrate to the licensed nursing staff their ability to distinguish proper food items related to physician diet orders. c. Prior to a staff member having any resident contact or performing any duties in the facility, he or she must and will be In-Serviced by the Director of Nursing and/or her designee. The designee must be a licensed member of the medical staff. 3. On 09/22/2010, the facility identified residents who have exhibited food sharing behavior, or are suspected to share food with others. This will require the resident to eat under direct supervision of a staff member. No snacks or food from dietary or other locations will be allowed in the possession of these residents without direct supervision of a staff member. This resident list will be available on the supplement cart, dietary, activities, and ADL flow sheets. Diets will be added to flow sheets with updates and changes to be monitored per licensed nurse, dietary, and medical records, on a monthly basis. 4. On 09/22/2010, all resident charts with compromised or potential compromised food consumption were reviewed to ensure that physicians' orders and resident diets were the same. This will be monitored monthly by the food service supervisor and DON or her designee (licensed member of the medical staff). 5. As part of periodic inservices, the facility will provide education to all staff related to the risk of potential hazards of other residents sharing food with residents with compromised food consumption (ex. Chewing, swallowing, etc..). This will be performed on a semi-annual basis. Upon any signs and symptoms of newly developing swallowing or chewing problems by facility protocol to notify a licensed nurse of any change in the resident status. 6. On 09/16/2010, the members of the QA Committee had been notified of the incident referenced in this deficiency, and of ongoing and subsequent investigation by telephone or in person. An additional QA meeting will be held on 9/23/10 at 7:00 a.m. These interventions will be reviewed at our next scheduled QA meeting to be held on October 13, 2010. Based on these corrective plans which had been developed and implemented by the facility, the immediacy of the deficient practice had been removed on September 23, 2010. However, the effectiveness of these corrective plans could not be fully assessed to ensure ongoing application and completion. The facility had implemented the interventions referenced above and conducted staff inservice training on the modified policies and practices, but the facility will conduct inservice for new staff in an ongoing process. Also, as part of semi-annual inservices, the facility will educate all staff related to the potential hazard of other residents sharing food with residents with compromised food consumption. Monitoring will be required to assure that this training is ongoing and has resolved the identified problems for new and existing staff. Additionally, the snack cart list of residents and their diets is to be reviewed weekly at PAR meetings and during QA meetings, and a QA meeting was held on 09/23/2010, the last day of this complaint survey. Interventions were scheduled to be reviewed at the next scheduled QA meeting to be held on October 13, 2010. Therefore, the noncompliance continues, with the scope and severity level of the deficiency decreased to the "D" level.