Every finding on record at St Luke's Regional Medical Center SNF

Based on record review, staff and resident interview, the facility failed to ensure a binding arbitration agreement consisted of key factors necessary for compliance for 8 of 8 residents in the facility (Resident #1, #2. #3, #4, #107, #108, #109, and #111). Findings include: According to the Minimum Data Set (MDS) assessment dated [DATE] Resident #2 scored 15 on the Brief Interview for Mental Status (BIMS) indicating no cognitive impairment. The resident's record contained a signed Admission Agreement which included an Arbitration Agreement on page 11 and the resident's signature on page 17. On 1/17/24 at 3:31 p.m. Resident # 2 stated she signed so much she doesn't remember what she signed. She did not know what an arbitration agreement was. The facility Binding Arbitration agreement included: By signing this Agreement, you agree with the Facility that any dispute between you and the Facility, including any dispute over services rendered prior to the date this Agreement was signed and any dispute arising out of your care, including the scope of this arbitration clause and the arbitrability of any claim or dispute, against whomever made (including, to the full extent permitted by applicable law third parties who are not signatories to this Agreement) shall be resolved by binding arbitration with one arbitrator by the American Arbitration Association in accordance with the applicable procedures for the type of dispute which will be either the commercial or consumer procedures of the American Arbitration Association. Notwithstanding the preceding sentence, this binding arbitration provision shall not apply to any actions taken by the Facility to collect on charges owed by you or to any actions taken by the Facility relating to your transfer or discharge as discussed above. The facility failed to ensure the arbitration agreement provided for the selection of a neutral arbitrator agreed upon by both parties and the selection of a venue that was convenient to to both parties. On 1/18/24 at 8:32 a.m. the Business Office Manager explained she did the admission paperwork with residents when they came in. She summarized things and told the new resident that a binding arbitration agreement meant an arbitrator would settle disputes between the resident and the facility. When the resident signed the admission agreement it included the arbitration agreement. On 1/17/24 at 2 p.m. the Administrator explained the admission packet contained their arbitration agreement. He stated all of the residents signed an admission agreement that included the arbitration agreement.

Based on record review, staff and resident interview, the facility failed to ensure a binding arbitration agreement consisted of key factors necessary for compliance for 8 of 8 residents in the facility (Resident #1, #2. #3, #4, #107, #108, #109, and #111). Findings include: According to the Minimum Data Set (MDS) assessment dated [DATE] Resident #2 scored 15 on the Brief Interview for Mental Status (BIMS) indicating no cognitive impairment. The resident's record contained a signed Admission Agreement which included an Arbitration Agreement on page 11 and the resident's signature on page 17. On 1/17/24 at 3:31 p.m. Resident # 2 stated she signed so much she doesn't remember what she signed. She did not know what an arbitration agreement was. The facility Binding Arbitration agreement included: By signing this Agreement, you agree with the Facility that any dispute between you and the Facility, including any dispute over services rendered prior to the date this Agreement was signed and any dispute arising out of your care, including the scope of this arbitration clause and the arbitrability of any claim or dispute, against whomever made (including, to the full extent permitted by applicable law third parties who are not signatories to this Agreement) shall be resolved by binding arbitration with one arbitrator by the American Arbitration Association in accordance with the applicable procedures for the type of dispute which will be either the commercial or consumer procedures of the American Arbitration Association. Notwithstanding the preceding sentence, this binding arbitration provision shall not apply to any actions taken by the Facility to collect on charges owed by you or to any actions taken by the Facility relating to your transfer or discharge as discussed above. Any award of the arbitrator may be entered as a judgment in any court having jurisdiction. This Agreement shall be governed by and interpreted under the Federal Arbitration Act, 9 U.S.C. SS 1-16. This provision for arbitration may be revoked by written notice delivered to the Facility's Administrative Office within ten days of your signature on this Agreement. All claims arising prior to the effective date of the revocation shall continue to be governed by this provision. You understand that the result of executing this Agreement is that claims, including malpractice claims that you may have against the Facility and its employees and agents, cannot be brought as a lawsuit in a court before a judge or jury and you agree that all such claims will be resolved as described in this section. Nothing in this Agreement prevents you from contacting regulatory or administrative agencies in relation to services provided by the Facility. The facility failed to ensure the resident or his/her representative acknowledged the he/she understood the agreement, failed to give the resident/representative the option to rescind the agreement within 30 days, explicitly state the resident/representative was not required to sign a binding arbitration agreement as a condition of admission to, or as a requirement to continue to receive care at the facility. On 1/18/24 at 8:32 a.m. the Business Office Manager explained she did the admission paperwork with residents when they came in. She summarized things and told the new resident that a binding arbitration agreement meant an arbitrator would settle disputes between the resident and the facility. When the resident signed the admission agreement it included the arbitration agreement. On 1/17/24 at 2 p.m. the Administrator explained the admission packet contained their arbitration agreement. He stated all of the residents signed an admission agreement that included the arbitration agreement.

Based on observation, policy review, and staff interview the facility failed to provide follow infection prevention practices when providing personal care, catheter care, and wound care 2 of 2 residents reviewed (Resident #3 and #111). While completing wound management and incontinence care, the facility failed to complete hand hygiene between gloves and failed to keep clean items clean. While providing care, the staff failed to use clean hands to get clean wash cloths for incontinence. Findings include: 1. Resident #3's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment. The MDS listed 1 unstageable pressure ulcer and 1 stage one pressure ulcer present upon admission. Resident #3's Orders printed 1/18/24 listed the following orders: a. Dressing change dated 12/28/23 to apply white foam to the right dorsal (top side) foot for protection and change 3 times a week. b. Wound care dated 12/20/23 cleanse left heel with 1/4 percent peroxide with 3/4 saline solution, rinse with saline, apply thin layer of santyl (ointment use to treat wounds) to wound bed only, apply Aquacel AG advantage (dressing), apply white foam, 4x4 gauze, and Kerlix. On 1/17/24 at 9:38 AM observed Staff A, Registered Nurse, conduct wound care on Resident #3's left and right heels. Staff A removed her gloves and replaced them without completing hand hygiene in between for 7 out 7 times. The Handwashing / Hand Hygiene policy dated January 2022 directed hands may be cleansed with alcohol-based hand rub or wash with soap and water before and after each patient contact and after removing / changing gloves. On 1/18/24 at 8:38 AM the Administrator explained he spoke with the medical staff that work both the morning and evening on 1/17/24 at 7 PM. The Administrator reported the medical staff realized after looking at procedures and policies, they didn't complete hand hygiene when they changed their gloves from contaminated to clean procedures. The Administrator stated they expected staff when moving from a contaminated procedure to a clean procedure, they would complete hand hygiene and then apply new gloves. The Administrator said they also would complete hand hygiene with all glove changes. 26527 On 1/17/24 at 3:49 p.m. observed Staff D, Certified Nursing Assistant (CNA), and Staff C, Certified Medication Aide (CMA), assist Resident #3 with incontinence care. They removed her pants and opened her incontinent pad. They had a basin of soapy water and a basin of clear water with wash cloths on a bedside table on a barrier. Staff C wrung out a washcloth and folded it over 2 times. She wiped across the lower abdomen, pulled that layer back, wiped down the right groin, then the left turning the cloth between wipes. She retrieved a washcloth from the clear water and wiped over the areas in the same manner. Without completing hand hygiene, Staff C changed gloves and retrieved another washcloth from the soapy water basin, and squeezed out the excess water. She wiped down the mid genital area and then each side turned the cloth after each wipe. She then changed gloves with no hand hygiene and cleansed down the catheter tubing about 6 inches with a soapy washcloth prepared as previous, turned the cloth and wiped down the tubing again. She then retrieved a washcloth from the clear water basin and wiped down the catheter tubing as before. She then used an alcohol wipe times 2 on the catheter tubing. Staff B, Registered Nurse (RN), (entered) and prepared to do the resident's coccyx treatment. The resident had been incontinent of stool. Staff B washed her hands and gloved. She cleaned the area first with disposable wipes and removed the dressing. She then cleansed the area with soapy washcloths, avoiding the pressure area, then changed gloves with no hand hygiene. She wiped the area with a washcloth from the water basin, then patted dry. She changed her gloves with no hand hygiene and prepared to do the treatment. She cleansed the pressure area, rinsed, then irrigated with Dakin's solution. 2. Resident #111 ' s Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 14, indicating no cognitive impairment. The MDS included diagnoses of acute osteomyelitis (infection of the bone) of the left foot and ankle, and gas gangrene (infection of soft tissue). The Baseline Care Plan dated 1/5/24 identified Resident #111 had skin care needs related to his left foot and received intravenous (IV) antibiotic therapy. On 1/17/24 at 10:40 a.m. Staff A, Registered Nurse (RN), and Staff B washed their hands and applied gloves. Staff A removed the soiled dressings from Resident #111 ' s foot. The dressing appeared moderately saturated with serosanguinous drainage. Staff A changed her gloves, and without completing hand hygiene, used peroxide and normal saline to clean the wounds. She then used 4 by 4 gauze sponges to dry Resident #111 ' s foot. Staff A again, changed gloves without hand hygiene. Staff A used Dakin's solution on the wounds and dried the foot with sponges. Staff A changed gloves with no hand hygiene. Staff A dressed the foot and wrapped with kling and ace. The Center for Disease Control's (CDC's), Hand Hygiene in Healthcare Settings last reviewed 11/21/23, directed to use an alcohol-based hand sanitizer as the preferred method for cleaning your hands when they are not visibly dirty because it was more effective at killing potentially deadly germs on hands than soap, and was easier to use during the course of care, especially when moving from soiled to clean activities with the same resident. Always clean your hands after removing gloves. Dirty gloves can soil hands.

Based on observation, staff interviews, and review of the cleaning schedules the facility failed to maintain proper cleaning of equipment and floors in the kitchen. The facility reported a census of 13 Residents. Findings include: Observation of the kitchen on 1/21/20 at 11:15 AM, with Staff B, revealed splatters of yellowish material on the wall and vents above the food fryers and a dark black area that appears to be burnt caulking agent noted to the wall. The walkway from the sink to the dishwasher in the dish room had black areas of an unidentifiable agent on the wall and baseboards. The floor where staff removed clean dishes from the dishwasher and placed on drying racks revealed dirt and crumbs on the floor. In the dry storage room which contained food, the floor showed black unidentifiable areas of a material and crumbs. Observation revealed dirt the corners of the room. During a subsequent visit to the kitchen on 1/23/20 at 8:48 AM, with Staff C, the wall above the food fryers continued to have splatters of a yellowish material on the wall and vents. The floor where staff removed clean dishes from the dishwasher and placed on drying racks continued to have dirt and dust in the corners. The dry food storage room continued to have multiple black areas to the floor and crumbs, dirt and dust in the corners. The facility provided documentation of the weekly cleaning schedules for #3 PM trayline for the week of 12/15/19 and #5 retail cook for the week of 12/29/19. The cleaning schedules directed staff to degrease vent hoods weekly. The facility could not provide any recent documentation for the month of (MONTH) 2020. On 1/23/20 at 9:10 AM, Staff D revealed the facility did not keep records of cleaning schedules. When the surveyor asked to see the current cleaning schedule, she revealed no cleaning schedule available. On 1/23/20 at 9:10 AM, Staff C revealed the facility scheduled hood vent cleaning for 1/27/2020 and planned to work on finding a chemical agent to strip the floors and wax next week. She also revealed the facility planned to professionally clean hood vents quarterly and provided the most recent invoice dated 10/10/19.

Based on record review and staff interviews the facility failed to ensure a qualified professional directed the activities program from 9/17/19 to present (1/23/2020). The facility reported a census of 13 Residents. Findings include: The facility provided a Skilled Unit Contact list and Leadership Phone Numbers list that lacked identification of the Activity Director. During an interview with the Director of Nursing (DON) on 1/22/2020 at 2:32 PM, she revealed the facility's previous Activity Director left employment 9/17/19. The facility tried to hire, but could not find appropriate candidates. The facility hired Staff A a CNA (certified nurse aide) on 1/20/2020 to fill the activity director position. The facility lacked documentation of activities offered and Resident attendance for the following months of 2019: August September October November December During an interview with the DON on 1/23/20 at 8:50 AM, she informed the surveyor that Staff A, Certified Nurses Assistant (CNA), would taking a course to meet the qualified professional standards on (MONTH) 29, 2020. She also revealed they do not have a policy or procedure on activities to be provided or frequency but that they do follow the federal regulations. The facility failed to ensure that a qualified professional was designated as an Activity Director.

Based on record review, and staff interview, the facility failed to document and provide activities for residents (Resident #2). The facility reported a census of 13 residents. Findings include: Resident #2's Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 11/18/19, showed long and short term memory problems and severely impaired skills for daily decision making. The resident's [DIAGNOSES REDACTED]. The Care Plan dated 1/23/2020 identified the resident would participate in group and individual activities of choice through the next review. The interventions identified Resident #2 enjoyed listening to music, anything to do with cars, motorcycles and engines, spending time outside, and watching movies. Through review of the facilities records of activities offered it identified Resident #2 attended activities on 1/14/2020 and 1/21/2020 no other activities attended since admission to facility on 8/19/19 as indicated by the MDS. During an interview on 1/22/2020 at 2:32 PM, the DON revealed the facility provides activities but has no documentation to show the types of activities offered, residents who attended, or the duration of the activities from (MONTH) 2019 to (MONTH) 12, 2020.

Based on clinical record review and interview, the facility failed to ensure ongoing assessment of residents undergoing [MEDICAL TREATMENT] for 2 of 2 residents reviewed (#115 and #65). The facility reported a census of 17 residents. Findings include: 1. A Nursing Progress Note dated 11/15/18 at 4:01 p.m. documented Resident #65 admitted to the facility. An entry at 4:53 p.m. recorded the resident admitted after an acute admission stay for a urinary tract infection. The resident had a fistula in her left arm and attended [MEDICAL TREATMENT] Monday and Friday. A Baseline Care Plan dated 11/15/18 documented the resident had an AV (arteriovenous) fistula of the right upper arm and not to measure her BP (blood pressure) in the left arm. The resident received [MEDICAL TREATMENT]. The clinical record lacked any documentation the facility assessed the resident's fistula. During an interview on 11/20/18 at 8:05 a.m. the Minimum Data Set Coordinator stated she thought the cardiovascular checks encompassed the checking of the fistula, but she didn't have anything that stated that. 2. The MDS assessment completed 11/9/18 for Resident #115 listed [DIAGNOSES REDACTED]. Review of a care plan with an initiation date of 11/14/18 documented the resident underwent [REDACTED]. The care plan documented the resident's [MEDICAL TREATMENT] fistula was located in the left arm and directed that no blood pressures should be taken in the left arm. The care plan did not identify the need to check the fistula daily for the bruit or thrill (bruit is a whooshing sound heard over the access site with a stethoscope and the thrill is a pulsation felt over the access site with the fingers) to indicate proper function of the fistula. Review of the facility's [MEDICAL TREATMENT] Care policy, with a revision date of (MONTH) 2008, directed the guidelines or considerations for each individual receiving [MEDICAL TREATMENT] treatment include monitoring for signs and symptoms of nausea, headaches, leg cramps, extreme itching. To report falls before or after [MEDICAL TREATMENT] to the [MEDICAL TREATMENT] unit, and if the access site is a fistula/graft, to assess the fistula daily for the bruit and the thrill and to check the site for bleeding, drainage, discoloration or pain. Review of the (MONTH) Medication Administration Record [REDACTED]. During an interview with the Director of Nursing (DON) on 11/19/18 at 10:10 AM, she stated the facility had not fully rolled out that policy yet. The DON stated the nurses are not currently assessing for the bruit or thrill daily but the nurses at [MEDICAL TREATMENT] do assess it. The facility could not locate any documentation related to fistula assessments in the resident's electronic health record. The DON stated they will focus on these assessments going forward from this point.

Based on personnel file review and staff interview, the facility failed to assure nurse aide registry verification of 2 of 5 staff reviewed (Staff A and Staff B). The facility reported a census of 17 residents. Findings include: 1. A personnel file revealed Staff A Certified Nursing Assistant hired on 1/8/18 (to the hospital attached to the skilled unit). Staff A had a South Dakota Certified Nurse Aide card. The facility completed an application for the Iowa Nurse Aide Registry on 1/8/18. A letter to Staff A notified her she was accepted to the position of CNA on the skilled care unit effective 9/16/18. A Timecard showed Staff A worked on the skilled care unit 9/16/18 starting at 6:59 p.m. The personnel record showed the facility checked the nurse aide registry 9/17/18 (after the staff worked) showing the staff eligible to work as a CNA. During an interview on 11/20/18 at 10:45 a.m. the Human Resources Employment Coordinator stated Staff A transferred to the skilled unit on 9/16/18. They had not checked the South Dakota or Iowa registry because it was not required on the hospital side. She said it should have been done prior to her working on the skilled unit. The facility's Abuse, Neglect and/or Misappropriation of Resident Funds or Property and Exploitation Prohibition policy, revised 11/17, directed the community should maintain documentation that it inquired from the State Nurse Aide Registry or Licensing Authority about the individual they wished to hire. Screening of potential staff should include verifying information with appropriate licensing boards and certification registries. 2. Review of employee files on 11/20/18, documented Staff B, CNA, began employment at the facility on 4/2/18. The facility completed background and criminal checks on 4/5/18. Staff B had a Nebraska CNA certification upon hire and received her Iowa CNA certification on 4/24/18. The facility did not verify Staff B's Iowa certification until 11/19/18. During an interview with the Human Resources Employment coordinator/Nurse recruiter on 11/20/18 at 10:40 AM , the recruiter stated Staff B came here to work but lived in Nebraska and had a Nebraska CNA certificate upon hire. The HR Recruiter stated she didn't realized Staff B had not gotten her Iowa certification verified until the state surveyors requested employee files on 11/19/18 . The HR Recruiter stated she should have re-verified her Iowa certification as soon as she learned that Staff B had gotten it. She stated they will have a process in place going forward to prevent this from happening again.

Based on review of committee attendance records and staff interview, the facility failed to maintain a quality assessment and assurance committee consisting of at a minimum the Director of Nursing (DON) services, the Medical Director or his/her designee and at least 3 other members of the facility's staff. The facility reported a census of 17 residents. Findings include: The Mission Driven QAPI (Quality Assurance/Performance Improvement) Committee Attendance Records showed the facility meetings held 11/3/17, 3/21/18, 7/31/18, and 10/26/18 had only 3 members present, the DON, the Assistant DON, and the Medical Director. During an interview on 11/20/18 at 8 a.m. the Director of Nursing (DON)/Administrator stated she did not know they needed additional members on the QA committee. The undated facility policy, Mission Driven Quality Assurance and Performance Improvement Plan (QAPI), indicated the committee included the Medical Director, the Administrator, DON, Social Services, Dietary Services, Activities, Staff Education, Pastoral Care, Housekeeping and Laundry Services, Maintenance, and other departments as determined.