Every finding on record at Vancrest of Delphos

Based on review of the medical record, observation, staff interviews, and facility policy review, the facility failed to ensure a resident had access to hearing devices and failed to investigate missing hearing aids. This affected one (Resident #23) of one resident reviewed for hearing aids. The facility census was 75. Findings include: Review of the medical record revealed Resident #23 admitted to the facility on [DATE] with diagnoses including hypertensive heart and chronic kidney disease with heart failure, type 2 diabetes mellitus, acute kidney failure, essential hypertension, chronic kidney stage 4, major depressive disorder, atrial fibrillation, presence of cardiac pacemaker, and anemia. Review of the most recent Minimum Data Set (MDS) revealed Resident #23 utilized hearing aids. Review of physician's orders revealed an order dated 08/22/23 to put left hearing aid in and collect hearing aid every shift. Review of the care plan initiated on 08/19/23 revealed Resident #23 had altered communication or impaired verbal communication related to hearing deficit, with intervention of ensure hearing aids are put in every morning and collected at bedtime. Review of the progress note dated 09/03/23 at 8:36 A.M. revealed Resident #23 was noted to be without her hearing aid. Staff looked through the room and was unable to find it. Laundry was notified of missing hearing aid and will be looking for it. Review of the progress note dated 09/03/23 at 11:40 A.M. revealed administration was notified of missing hearing aid. Review of the progress noted dated 09/03/23 1:40 P.M. revealed Resident #23's power of attorney was notified of the missing hearing aid. Staff would continue to search for the hearing aid and the resident continued to state she did not know where it could be. Further review of the medical record revealed no additional documentation pertaining to the missing hearing aid. Observation on 09/26/23 at 2:24 P.M. revealed Resident #23 seated in a recliner chair with hearing aids not in place. Staff interview on 09/26/23 at 2:26 P.M. with Registered Nurse (RN) #316 revealed Resident #23's hearing aids are missing. The treatment cart was checked and hearing aids were not in the cart. Staff interview on 09/26/23 at 3:44 P.M. with the Director of Nursing (DON) revealed when an item is missing, it is reported to the social worker and she passes it along to the Administrator. Lost or broken items are investigated and if it is staff's fault, the item is fixed or replaced, if it resident breaks the item or loses it, the family is notified, and it is the family's discretion on whether they want to replace or fix it. Staff interview on 09/27/23 at 2:19 P.M. with the Administrator and Social Services #342 revealed they were not aware of the missing hearing aid until 09/26/23, when Resident #23's son called the Administrator to say the hearing aids were missing. The Administrator acknowledged they did not follow up on the missing hearing aids when reported. Review of the undated Personal Property Policy revealed the facility promptly investigates any complaints of misappropriation or mistreatment of resident property. If it is found that the facility has lost or damaged a resident's personal property, the item will be replaced by the facility.

Based on medical record review, observation, staff interviews, and review of facility policy, the facility failed to notify a resident's physician of a significant change in weight. This affected one (Resident #52) of one resident reviewed for notification. The facility census was 75. Findings include: Review of the medical record revealed Resident #52 was admitted to the facility on [DATE] with a diagnosis of Congestive Heart Failure (CHF). Review of the Minimum Data Set (MDS) completed 07/25/23 revealed Resident #52 required limited to extensive assistance with activities of daily living. Review of Resident #52's weight history revealed on 09/21/23, Resident #52 weighed 139.6 pounds (lbs.) and on 09/26/23, the resident weighed 148.4 lbs. (8.8 lb. gain). Further review of the medical record revealed no documentation the physician was notified of Resident #52's 8.8 lb. weight gain. Observation on 09/25/23 at 1:31 P.M. revealed Resident #52 had edema (swelling) to both legs. Staff interview on 09/26/23 at 1:43 P.M. with Registered Nurse (RN) #316 and Licensed Practical Nurse (LPN) #352 revealed if a resident lost or gained five or more pounds, the physician would be notified. Residents were weighed based on diagnoses. Residents with congestive heart failure were weighed daily and the physician would be called if there was a five-pound weight gain. Staff interview on 09/27/23 at 8:23 A.M. with Nurse Practitioner (NP) #500 revealed the expectation was for staff to notify the physician the day it was discovered a resident with congestive heart failure had a three-pound weight gain in a day or a five-pound weight gain in a week. Staff interview on 09/27/23 at 1:28 P.M. with Director of Nursing #300 verified Resident #52's weights were correct and the physician was not notified of the weight gain. Review of the facility's undated policy titled, Weight Out of Parameter, revealed CHF residents will be weighed daily, if a resident has CHF, the nurse will monitor ad notify the provider if the residents weight increased by three pounds in one day or five pounds in one week. The nurse will document any communications made with the provider and any new orders received.

Based on medical record review, staff and resident interviews, and policy review, the facility failed to provide restorative programs per therapy recommendations. This affected one (Resident #66) of two residents reviewed for positioning and range of motion. The facility census was 75. Findings include: Review of the medical record for Resident #66 revealed an admitted [DATE] with medical diagnoses of acute cystitis, atherosclerosis heart disease (ASHD), chronic kidney disease stage III, and Parkinson's disease. Review of the Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #66 was cognitively intact and required extensive staff assistance with bed mobility, transfers, toileting, and bathing. Resident #66 received physical therapy (PT) and occupational therapy (OT) services. Review of the OT evaluation and treatment plan dated 07/19/23 revealed Resident #66's sitting balance was fair and Resident #66 required maximum assistance for functional mobility during activities of daily living (ADLs) and required 25% verbal cues for safety and proper positioning. Continued review of OT progress notes revealed a note dated 07/21/23 which stated OT was working on techniques to increase safety for ADLs in sitting, wheelchair seating, and positioning during ADLs. Review of an OT discharge summary note dated 08/04/23 stated therapy services were discontinued because Resident #66's insurance provider denied further coverage of therapy services. The OT discharge summary note stated therapy recommended restorative nursing/functional maintenance programs to facilitate Resident #66' ability to maintain current level of performance and prevent decline. The note stated OT recommended range of motion (ROM) and ambulation restorative programs. Review of the form titled, VanCrest Health Care Center Department of Rehabilitation Therapy Referral to Nursing, dated 08/04/23, revealed therapy recommended Resident #66 receive restorative ROM and positioning programs six to seven days per week. The form stated the programs were to include wheelchair, walker, and positioning in sitting. The form stated Resident #66 refused wedge cushion, lateral support, half lap tray, and tilt chair to assist with positioning. The form also stated to monitor seated position and fix as needed and to perform active ROM in sitting. Further review of the medical record for Resident #66 revealed no documentation to support Resident #66 participated in restorative ROM or positioning programs. Observation and interview on 09/26/23 at 8:26 A.M. revealed Resident #66 sitting in his wheelchair leaning to the right side with right side of his abdomen bent over the side of the right handle of the wheelchair and his right arm hanging over the handle with his hand touching the floor. Interview with Resident #66 stated he always leaned to the right side of his wheelchair, but the lean has worsened since he was no longer receiving therapy services. Observation on 09/26/23 at 2:27 P.M. of Resident #66 sitting in his wheelchair with right side of abdomen leaning into right wheelchair handle and right arm handing over the handle with his hand touching the floor. Interview on 09/26/23 at 2:27 P.M. with State tested Nursing Assistant (STNA) #371 confirmed Resident #66 was leaning over the right side of his wheelchair with the right side of his abdomen pressing into the handle and right arm hanging over the handle with his hand touching the floor. STNA #371 stated the facility had tried positioning devices to assist Resident #66 with proper positioning in his wheelchair but Resident #66 refused to use the devices. Interview on 09/27/23 at 8:54 A.M. with Occupation Therapist (OT) #328 stated Resident #66's ability to maintain upright posture had declined since the resident was on therapy services. OT #328 stated Resident #66 was discharged from therapy services on 08/04/23. OT #328 stated when restorative programs are recommended upon discharge from therapy services, the therapist would write the programs and provide them to nursing staff. Interview on 09/27/23 at 3:45 P.M. with Licensed Practical Nurse (LPN) #343 confirmed the therapy department provided recommendations for restorative programs for Resident #66 on 08/04/23. LPN #343 stated staff assisted Resident #66 with positioning in wheelchair daily but confirmed the facility did not have documentation to support staff completed the restorative programs for positioning and ROM as recommended by the therapy department. Review of Restorative Program policy stated rehabilitation goals and objectives are developed for each resident and outlined in his/her plan of care relative to therapy services and staff are to assist the resident in adjusting to his/her abilities and encouraging the resident to maintain his/her independent and self-esteem.

Based on observation, staff interview, and policy review, the facility failed to ensure residents were treated with dignity and respect while being provided assistance with eating in the dining room. This affected four (#22, #7, #19, and #36) of four residents observed receiving assistance with eating in the memory care dining room. The census was 74. Findings include: Observation on 11/15/21 at 12:05 P.M. of the afternoon meal service in the memory care dining room revealed state tested nurse aide (STNA) #260 was providing assistance with eating for Resident #22 and Resident #7 and STNA #270 was at another table, providing assistance with eating for Resident #19 and Resident #36. The observation revealed STNA #260 and STNA #270 were having a personal conversation with each other rather than interacting with the residents. The personal conversation between the two STNA's continued until the STNA's had finished assisting the residents with eating. Interview on 11/15/21 at 12:17 P.M. with STNA #270 verified STNA #270 was having a personal conversation with STNA #260 while providing Resident #19 and Resident #36 assistance eating. Interview on 11/15/21 at 12:19 P.M. with STNA #260 verified STNA #260 was having a personal conversation with STNA #270 while providing Resident #22 and Resident #7 assistance with eating. Review of a policy titled, Assistance with Meals undated, revealed facility staff will serve residents trays and will help residents who require assistance with eating. Residents who can not feed themselves will be fed with attention to safety, comfort, and dignity. The policy revealed keep interactions with other staff to a minimum while assisting a resident with meals.

Based on medical record review, observation, and staff interview, the facility failed to revise a resident's care plan. This affected one (#65) of three residents reviewed for accidents. The census was 74. Findings include: Review of the medical record for Resident #65 revealed the resident was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a quarterly minimum data set (MDS) assessment dated [DATE], revealed Resident #65 required extensive assistance of two people for transfers, walking in room, and locomotion on unit. Resident #65 was assessed as having one fall since admission or prior assessment. Review of a care plan dated 02/05/21, revealed Resident #65 was at risk for falls with the potential for injury related balance deficit, cognitive deficits, weakness, a history of falls, forgets to use safety devices, verbalizes dizziness, unable to transfer without assistance, impulsive, poor safety awareness, and dementia with behavioral disturbance. Interventions included anti-roll back device to wheelchair. Review of a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on 11/17/21 at approximately 9:00 AM. of Resident #65 revealed the resident was sitting up in the wheelchair in the dining room. Observation of the wheelchair revealed there was no anti-roll back device on the resident wheelchair. Interview on 11/17/21 at 9:18 A.M. with registered nurse (RN) #290 verified Resident #65 had a physicians order for anti-roll back devices on the residents wheel chair. RN #280 further verified the anti-roll back device on the residents wheelchair was a care planned fall interventions. Observation completed during the interview with RN #290 verified there was no anti-roll back device on Resident #65's wheel chair. Interview on 11/17/21 at 10:10 A.M. with the director of maintenance revealed an anti-roll back device would not fit on the high back wheelchair for Resident #65 because of the way the chair was put together. Interview on 11/17/21 at 10:15 A.M. with the director of nursing (DON) revealed Resident #65 was switched to a high back wheelchair for comfort and positioning. The DON further revealed the anti-roll back device order should have been discontinued and the care plan updated when the resident was provided the high back wheel chair.

Based on medication administration observation, medical record review, staff interview, and manufacturer's instructions review, the facility failed to ensure insulin was administered as ordered by the physician and as instructed by the manufacturer resulting in a significant medication error. This affected one (#10) of one resident observed for insulin administration. The census was 74. Findings include: Observation on 11/16/21 at 7:06 A.M. of licensed practical nurse (LPN) #280 preparing and administering insulin for Resident #10 revealed the [MEDICATION(S)] kwikpen in the medication cart did not contain enough insulin for the nurse to administer the entire scheduled dose. LPN #280 went to the storage room, obtained another [MEDICATION(S)] kwikpen, and returned to the medication cart. The observation revealed LPN #280 turned the dose knob on one kwikpen to seven units and turned the dose knob on the other kwikpen to 51 units. Continued observation revealed the nurse administered Resident #10 [MEDICATION(S)] seven units and [MEDICATION(S)] 51 units. The observation revealed LPN #280 did not prime either of the kwikpens prior to injecting the [MEDICATION(S)] insulin. Review of the medical record for Resident #10 revealed the resident was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview on 11/16/21 at 7:08 A.M. with LPN #280 verified the [MEDICATION(S)] insulin dose administered to Resident #10 was seven units from one kwikpen and 51 units from the other kwikpen which was not the correct dose of insulin. LPN #280 further verified the [MEDICATION(S)] kwikpens were not primed prior to insulin administration. Review of [MEDICATION(S)] kwikpen packaging instructions revealed the pen was to be primed (to remove the air from the needle and cartridge that may collect during normal use) before injection. It is important to prime your pen before each injection so that it will work correctly. To prime your pen- turn the dose knob to select two units. Hold your pen with the needle pointing up, tap the cartridge holder gently to collect air bubbles at the top. Continuing to hold the pen with needle pointing up push the dose knob in until it stops and zero is seen in the dose window, hold the knob in and count to five slowly.

Based on observation, staff interview and facility policy review, the facility failed to properly store [MEDICATION NAME] purified protein derivative and the control solution for the blood glucose monitoring system. This affected one (D Hall) of three medication storage rooms observed and five residents (#10, #22, #33, #45 and #47) who have their blood glucose monitored in the C Hall. The facility census was 70. Findings include: Observation on 05/16/19 at 12:45 P.M. of the C Hall medication cart revealed a box of control solution for blood glucose monitoring system which contained a small bottle of control solution labeled Level 1 and a second small bottle labeled Level 2. The box was dated 11/23/18. Observation of the medication storage room in the D Hall revealed an opened vial of [MEDICATION NAME] purified protein derivative undated. Review of the box of control solution revealed to discard after three month from opening date. Interview on 05/16/19 12:52 P.M. with Licensed Practical Nurse (LPN) #230 provided verification of the outdated control solution and the undated [MEDICATION NAME] purified protein derivative. Review of the facility policy titled Medication Storage in the Facility dated 10/22/07, revealed outdated medications should be removed and disposed of according to procedure.

Based on observation, record review, staff interview and policy review, the facility failed to apply hand splints as ordered for one (Resident #9) of one residents reviewed for positioning. The facility census was 70. Findings include: Review of the medical record of Resident #9 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly minimum data set assessment dated [DATE] revealed the resident was never or rarely understood and was totally dependent of staff for all activities of daily living. The assessment further revealed impairment of upper extremities, assistance with splints occurred three days of the look back period of 02/02/19 to 02/08/19. Observations on 05/13/19 and 05/14/19 until 1:30 P.M. revealed no splints had been applied to bilateral hands of Resident #9. Observation on 05/14/19 at 1:30 P.M. with Licensed Practical Nurse (LPN) #200 revealed no splints were applied to Resident #9's bilateral hands. LPN #200 located the splints in the bottom drawer of the bedside table and applied the splints. Interview on 05/14/19 at 1:30 P.M. with LPN #200 provided verification of the missing splints. When questioned as to the need of any splints for Resident #9, LPN #200 replied he was unaware of any need. When review of the treatment administration record for 05/19 revealed the order for bilateral hand splints to be applied from 7:00 A.M. to 7:00 P.M., LPN #200 replied I don't consider them splints. Interview on 05/14/19 at 1:35 P.M. with State tested Nursing Assistant #210 revealed a Resident Care form is in each room to identify the devices each resident has been ordered to be wearing or using. STNA #210 reviewed the form for Resident #9 and confirmed bilateral hand splints should be applied from 7:00 A.M. to 7:00 P.M. She then verified the braces had not been applied at 7:00 A.M. as ordered. Review of the facility policy tilted Contractures and Splinting undated, revealed the device should be applied according to the resident's care plan.

Based on medical record review, staff interview, and review of a facility policy, the facility failed to complete a thorough investigation to determine the root cause of a fall. This affected one (Resident #41) of three residents reviewed for accidents. The facility census was 70. Findings include: Review of Resident #41's medical record revealed an admitted d of 05/16/03. Medical [DIAGNOSES REDACTED]. Review of the resident's care plan originally dated 02/19/14 revealed she had difficulty with ambulation related to an unsteady gait. Interventions included use a gait belt at all times, unless contraindicated. Review of the resident's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a brief interview for mental status (BIMS) score of 13, indicating mild cognitive impairment. She required extensive assistance with one staff for bed mobility, transfers, walking, dressing, toilet use, and personal hygiene. She used a walker and/or wheelchair for locomotion. She had one fall since her prior assessment with no injuries. Review of the resident's nursing note from Licensed Practical Nurse (LPN) #240 dated 05/10/19 at 5:03 A.M. revealed the resident was ambulating to the bathroom with a State tested Nursing Assistant (STNA) when she urinated on floor and slipped and fell on to her buttocks. The resident complained of pain in the left leg. Review of the resident's fall investigation dated 05/10/19 created by LPN #240 and completed by the Director of Nursing (DON) revealed the resident was ambulated to the bathroom with STNA and urinated while walking and slipped and fell on her buttocks. Resident #41 was assessed and no injuries were noted. The resident was oriented to person and situation. All interventions in place at time was checked. Predisposing environmental factor was wet floor. Predisposing physical factors were listed as incontinence and gait imbalance. Predisposing situation factors were ambulating with assistance, recent room change, and using a walker. No witness statements were included. Under the section titled Witnesses was written no witnesses found. Continued review of the resident's medical record revealed [REDACTED].M. for further evaluation. Review of the resident's hospital documentation dated 05/10/19 revealed the resident presented for evaluation following a fall. The resident tripped over her walker while ambulating to the bathroom and fell . Results of a computed tomography (CT) of the resident's left hip revealed a sacral fracture. Review of a fall follow up events note dated 05/13/19 from the DON revealed the resident was educated to alert staff when she was urinating. Staff was to utilize a wheelchair if the resident had already been incontinent when in route to the bathroom. Interview with the DON on 05/15/19 at 2:34 P.M., revealed the STNA assisting Resident #41 on 05/10/19 was STNA #270. She stated she interviewed STNA #270 and the resident had her gait belt on when she fell . She stated she did not have her write a witness statement. Interview with LPN #280 on 05/15/19 at 2:40 P.M. revealed STNA #270 was not assisting the resident during the fall. She stated it was STNA #250. Interview with STNA #250 via telephone on 05/15/19 at 2:56 P.M., revealed he was assisting Resident #41 to the bathroom on 05/10/19 when she fell . He stated he assisted her with a gait belt. She stated her leg hurt and as she was walking to the bathroom, her leg gave out. She urinated on the floor. He stated he did not notice she urinated until after she fell . Interview with LPN #240 via telephone on 05/15/19 at 3:39 P.M. revealed she was called to check Resident #41 after she fell on [DATE]. She stated when she got to the resident's room, she was sitting on the floor in front of her bed. There was urine on the floor. She stated the resident did not have her gait belt on and she told STNA #250 to put the gait belt on the resident so they could assist her to stand. She stated she had not been interviewed about the fall. Interview with the DON on 05/15/19 at 4:21 P.M. verified she did not interview STNA #250 or LPN #240 regarding the resident's fall interventions. She verified she did not obtain a witness statement from STNA #250 regarding the fall. Further interview with STNA #250 on 05/15/19 at 5:35 P.M. revealed he took the resident's gait belt off after she fell . He stated he noticed it was a little loose. He stated no one had interviewed him or asked him to write a statement about the fall. Review of an undated facility policy titled Incident/Accident Reporting revealed an incident is an unexpected occurrence which is not consistent with the routine operation of the facility or the routine care of a particular resident. It may be an accident or an unusual occurrence which may or may not result in an injury. Procedures included post fall investigation and plan of care changes for falls should be completed soon after the fall to ensure appropriate follow through. Immediate intervention to prevent reoccurrence must be instituted for all falls. The administrator, DON, and/or nursing designee will review and investigate as appropriate.

Based on medical record review, staff and resident interview and policy review, the facility failed to ensure all residents were given the preference at meals regarding a choice for regular coffee. This affected two (#16, #24) of six residents reviewed for food. Facility census was 101. Findings include: Review on 04/11/18 of the medical record for Resident #16 revealed an admission date of [DATE] with the [DIAGNOSES REDACTED]. Review on 04/11/18 of the medical record for Resident #24 revealed an admission date of [DATE] with the [DIAGNOSES REDACTED]. The resident was assessed on the MDS dated [DATE] as being cognitively intact. Interview with Residents (#16 and #24) on 04/09/18 at 8:52 A.M. revealed they would love to have coffee which is caffeinated. Interview with the Director of Dietary #300 on 04/10/18 at 1:00 P.M. confirmed the facility serves all the residents decaffeinated coffee at meals but regular coffee is available in the lobby. Interview with Licensed Practical Nurse (LPN) #202 on 04/10/18 at 2:09 P.M. verified the residents must have an order in the chart to be restricted from caffeine. The general rule here is they have to specifically ask for regular coffee because they only offer decaffeinated. Interview with the Director of Nursing (DON) on 04/10/18 at 2:18 P.M. verified residents were not given preferences on whether to have regular coffee verse decaffeinated because this is always the way it has been. Review of the policy for Resident Food Preferences on 04/11/18 revealed the individual food preferences will be assessed upon admission and communicated to the interdisciplinary team. Modifications to diet will only be ordered with the residents or representatives knowledge and practitioner order. The policy interpretation and implementation included upon the resident's admission (or seven hours after his or her admission) the Dietitian or dietary staff member will identify a residents food preferences.

Based on observation, and staff interviews, the facility failed to ensure families or guardians of cognitively impaired residents were given the right to choose what time they were awaken in the morning. This affected nine (#33, #34, #36, #37, #38, #39, #40, #41 and #43) of 10 residents observed. The facility census was 107. Findings include: Observation on 01/09/18 between 4:00 A.M., and 4:45 A.M., revealed nine residents were up, dressed, sitting in the television area, hallways and in their rooms. State tested Nursing Assistant (STNA) #62 identified the residents as Resident #33, #34, #36, #37, #38, #39, #40, #41 and #43. STNA #62 confirmed the nine residents had received morning care and were dressed for the day. STNA #62 revealed she had a get up list of residents who were to be gotten out of bed between 3:00 A.M., and 3:30 A.M. Interview on 01/09/18 at 4:15 A.M., with STNA #60 revealed she started getting residents up between 3:30 A.M., and 4:00 A.M. STNA #60 revealed she had a get up list of residents who were to be gotten out of bed every morning between 3:00 A.M., and 3:30 A.M., in order to have time to get everyone up for breakfast. Review of Resident #33, #34, #36, #37, #38, #39, #40, #41, and #43's care plans revealed they each had a care plan for preferences. The care plans further revealed the residents had a right to choose when they arise. However, no times were listed as to what time each resident preferred to arise in the morning.

Based on review of open and closed medical records [REDACTED]. This resulted in Immediate Jeopardy when facility staff failed to provide timely emergent medical treatment for [REDACTED]. Subsequently, Resident #117 was found unresponsive, without a pulse or respirations, the resident did not respond to resuscitative measures and was pronounced dead at the facility. This affected one (#117) of five residents reviewed who had received treatment via a LifeVest and/or had expired in the facility. The facility identified three residents who had been admitted with and used a LifeVest while at the facility in the past year. The facility census was 115. On [DATE] at 4:33 P.M., the Administrator and Director of Nursing (DON) were notified the Immediate Jeopardy began on [DATE] at 12:32 A.M. when Resident #117's LifeVest began alarming and recording a life threatening cardiac arrhythmia. The resident's nurse, Licensed Practical Nurse (LPN) #200, was notified at this time of the audible alarm of the resident's LifeVest by State tested Nurse Aide (STNA) #205. Resident #117's LifeVest continued to alarm without any response from LPN #200 until 12:45 A.M. At this time, Resident #117 was subsequently found unresponsive, without a pulse or respirations. LPN #200 alerted a nurse working on another unit, LPN #210, of the emergency. At 12:47 A.M., Resident #117 was provided Cardiopulmonary Resuscitation (CPR) by LPN #210; however, the resident did not respond to CPR and was pronounced dead at the facility by EMS. The Immediate Jeopardy was removed on [DATE], when the facility suspended LPN #200 for not timely responding to Resident #117's emergent change in condition, no other residents in the facility were utilizing LifeVests, and the facility began implementing the following corrective actions: · On [DATE] at 1:45 A.M., the DON arrived at the facility and began an investigation into the events surrounding Resident #117's death. · On [DATE] at 2:20 A.M., LPN #200 was suspended pending further investigation. · On [DATE] at 2:00 P.M., LPN #200 was suspended from duty and disciplined for unsatisfactory work performance in regards to direction of resident care with an action plan and resolution established. Additionally, LPN #200 was required to complete the following training: 1) observation of the LifeVest product video; 2) completion of a CPR refresher course, and; 3) training on the components of a respiratory assessment. LPN #200 was also placed under a 90 day probationary period with 30 day evaluations to be performed by the DON. · On [DATE], the facility determined no residents requiring the use of LifeVests will be admitted to the facility until a live education for staff is provided by the product manufacturer. This education was tentatively scheduled to be completed on [DATE]. All nursing staff not present at the meeting shall be in-serviced by the DON prior to care of any residents requiring a LifeVest. All new hires will be in serviced by the DON prior to caring for a resident with a LifeVest. The facility will also provide annual education for all other nursing staff regarding the function of the LifeVests. · On [DATE] at 2:05 P.M., interview with the DON revealed there are no other residents utilizing LifeVests at this time. · On [DATE], review of the closed medical records [REDACTED]. · On [DATE], review of the medical records for Resident #18 and Resident #19, who both expired in the facility, revealed staff provided appropriate responses at the time of their death. · On [DATE], the DON began educating all STNAs on immediately responding to any alarm or noise coming from a LifeVest worn by a resident and to report this to their nurse immediately. · On [DATE], the DON began tracking all immediate, annual, and new employees trained on the function of the LifeVests. · On [DATE] at 2:00 P.M., the facility placed LPN #200 on an indefinite unpaid work suspension pending further review of the incident. LPN #200 was also provided another disciplinary action for failure to respond to a resident with immediate care needs. · On [DATE], the Administrator and DON began in-servicing all licensed nurses on timely response to the acute change of condition of a resident. All licensed nurses are to be in-serviced by the start of their next scheduled shift. Although the Immediate Jeopardy was removed, the facility remained out of compliance at a Severity Level 2 (No actual harm with potential for minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action plan to ensure ongoing compliance. After [DATE], any resident utilizing a LifeVest will have a tracking system in place, completed by the DON for staff education, orders, and care planning on the day the LifeVest is initiated. All future residents admitted with a LifeVest will have this noted on their initial care plan. Findings Include: Review of the closed medical record for Resident #117 revealed the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of admission assessment, dated [DATE], revealed the resident was alert and oriented times three spheres with no cognitive deficits. Review of the admission physician orders, dated [DATE], revealed Resident #117 was utilizing a LifeVest for the [DIAGNOSES REDACTED]. The resident also had an order for [REDACTED].>Review of the nurses' note dated [DATE] at 12:45 A.M. revealed LPN #210 documented LPN #200 called for help. LPN #210 documented he found Resident #117 unresponsive, pale in color, and with no pulse or respirations. The LifeVest shocked the resident and chest compressions were started at 12:47 A.M. CPR was continued until the EMS squad arrived. The EMS squad hooked the resident up to run an electrocardiogram (EKG) and no pulse was recorded. Review of nurses' note dated [DATE] at 12:45 A.M. revealed Registered Nurse (RN) #215 documented an STNA (#225) approached her and she went to assist in Resident #117's room. RN #215 documented the resident's color was a blueish gray and there was no response from the patient. Review of nurses' note dated [DATE] at 1:49 A.M. revealed LPN #200 documented STNA #205 informed her Resident #117's LifeVest started going off. LPN #200 documented she went to the room and observed the LifeVest shock the resident. LPN #200 went and got another nurse to start CPR. LPN #210 started CPR and kept doing CPR until the EMS squad arrived. The EMS hooked the resident up to an EKG, ceased CPR, and called time of death. The family, physician, and DON were notified. Review of the EMS run report dated [DATE] documented the EMS squad arrived to the resident at 12:56 A.M. The report noted the EKG indicated the resident was in asystole (a cardiac arrhythmia identified by the absence of any cardiac activity) and was pronounced dead on arrival. Review of the LifeVest event report dated [DATE] at 12:32 A.M. revealed Resident #117 had an asystole event [MEDICATION NAME] 119 seconds with no external defibrillation shocks delivered during this time period. At 12:44 A.M., Resident #117 had another asystole event [MEDICATION NAME] 119 seconds with no external defibrillation shock delivered during this time period. At 12:45 A.M., the resident had an asystole event [MEDICATION NAME] 153 seconds with a defibrillation shock being delivered with no success in treating the arrhythmia. At 12:47:15 A.M., the resident had another asystole event [MEDICATION NAME] 119 seconds with external defibrillation shocks being delivered during the 77th second and at the 102nd second, with no success treating the arrhythmia. At 12:54:36 A.M., the resident received a defibrillation shock for the asystole with no success treating the arrhythmia. Review of the facility's investigation revealed on [DATE] at 1:13 A.M. the DON received a telephone call from LPN #200 stating Resident #117 had expired in the facility. The DON questioned how this occurred as the resident had a Full Code resuscitation status. LPN #200 reported staff had noted the resident's LifeVest had shocked the resident several times and they had also been administering CPR. The EMS arrived and conducted an EKG, noted asystole, and pronounced the time of death. The DON arrived at the facility at 1:30 A.M. and began an investigation. The investigation revealed on [DATE] at 1:45 A.M. the DON spoke with LPN #200 who explained STNA #205 came to get her while she was providing care to another resident. The STNA reported Resident #117's LifeVest had begun beeping and making noises. LPN #200 stated she finished her task and went to Resident #117's room at which time she observed the LifeVest activate and shock the resident. LPN #200 then ran to get help from LPN #210 who started CPR while she called 911. RN #215 was in the room with LPN #210 until the EMS squad arrived. The EMS obtained an EKG, called the time of death, and ceased CPR. The facility investigation revealed on [DATE] at 1:50 A.M. the DON interviewed LPN #210 who verified accuracy of LPN #200's statement. He also stated Resident #117 was a bluish purple upon arrival to the room and the resident's bowels had evacuated. LPN #210 had also witnessed the LifeVest shock the patient twice. He stated the EMS took over resuscitation once they arrived. The investigation documented on [DATE] at 2:00A.M., the DON interviewed STNA #205. STNA #205 stated he assisted LPN #210 with CPR by getting the backboard and Ambu bag. At the time, STNA #225 was also present and stated she was at break while STNA #205 remained on the hall. Upon her return to the hallway from break, she could hear the LifeVest making noises. The facility investigation revealed on [DATE] at 2:20 A.M., the DON interviewed LPN #200 again with LPN #210 present to question her timeliness in response to the situation and why LPN #210 was the nurse taking charge of the situation. LPN #200 stated she finished up with the resident she was providing care for and when she noted what was occurring with Resident #117 she called for help. LPN #200 acknowledged she should have gone to the room immediately instead of finishing care on the other resident. The investigation revealed at that time LPN #200 was asked to count her narcotics with LPN #210 and leave her shift pending further investigation. Interview on [DATE] at 11:40 A.M. via telephone, LPN #200 stated she was Resident #117's nurse the night he expired. She stated she was taking care of another resident's gastrostomy tube when STNA #205 came and informed her that the alarm was going off on the external defibrillator of Resident #117. LPN #200 stated it was approximately five minutes before she went down to check on the resident. She stated she found him unresponsive, the alarm on the LifeVest was sounding, and his external defibrillator was shocking him. She stated she pressed the response button to shock the resident again because that was what the resident was supposed to do himself, but he was unresponsive. She also stated the monitor box said to call 911 for help. She stated after she pressed the response button, she ran to get LPN #210 and called 911. She stated LPN #210 started CPR while she was calling 911. LPN #200 stated she was not trained on how to monitor and respond to alarms for the LifeVest prior to Resident #117's event. During an interview on [DATE] at 11:45 A.M., the DON verified the nurses did not have a formal training on the LifeVest. She stated the facility has had residents with the device before and information on the use was provided for staff on a pamphlet which was part of the resident's medical record and was also located at the bedside. The DON stated LPN #200 was educated on the LifeVest after the incident occurred because they felt she should have responded more timely. The DON verified no other licensed nurses have been trained in the monitoring and response of LifeVests at this time. An additional interview on [DATE] at 12:09 P.M. with LPN #200 verified the resident's alarm was in the yellow status when she responded. LPN #200 again stated she pushed the response button for the resident to receive a shock because that was what the resident would do themselves when the alarm sounds in the yellow status. LPN #200 stated Resident #117 was unresponsive, was not breathing, and did not have a pulse. LPN # 210 started CPR while she called 911. LPN #200 stated when the EMS arrived they were unable to resuscitate the resident and pronounced the resident dead at the facility. LPN #200 stated she was not aware if the instructions for use of the LifeVest were available on the chart or at the bedside. LPN #200 stated after the occurrence with Resident #117 she was trained on the proper use of the LifeVest. LPN #200 verified after watching the training video, she realized she should have responded immediately to the alarm from Resident #117's LifeVest. Interview on [DATE] at 12:45 P.M., LPN #210 revealed at approximately 12:45 A.M. on [DATE], LPN #200 yelled for him to help her. He stated he ran to Resident #117's room, assessed him, and started CPR at approximately 12:47 A.M., while LPN #200 called 911. He also stated he sent the STNA (#205) to get the crash cart. He stated Resident #117 was unresponsive, was without respirations, and without a pulse. LPN #210 revealed he has not had any formal training on the LifeVest at the facility, but he has worked with them before. He also revealed any time a LifeVest was alarming you are to immediately respond. Interview on [DATE] at 1:13 P.M., STNA #205 stated at approximately 12:30 A.M., Resident #117's LifeVest alarm started sounding. He stated he checked on the resident and he was still responsive. STNA #205 stated he immediately went and informed LPN #200 of the alarming LifeVest. He then went back to the room to check on Resident #117, who was still responding to his name. STNA #205 stated the alarm continued to sound. He waited in the hall for LPN #200 to respond, but she did not respond until sometime between 12:40 A.M and 12:45 A.M. He stated the resident had become unresponsive and LPN #200 went to get the other LPN #210 for assistance. He stated LPN #210 started CPR after assessing the resident. At this time, STNA #205 and other aides obtained the crash cart while LPN #200 called 911. Interview on [DATE] at 4:49 P.M., RN #215 revealed she had not been trained how to respond or use the LifeVest if it was alarming. Interview on [DATE] at 6:00 P.M., STNA #225 revealed she was on break when Resident #117's LifeVest started alarming. She stated when she got to the resident's room between 12:30 A.M. and 12:40 A.M.; the resident was still responsive and looked at her. She stated she went out in the hall way and asked STNA #205 what was occurring because she was unaware why the LifeVest was alarming. STNA #205 responded he was waiting for the nurse to come. STNA #225 stated at approximately 12:45 P.M., LPN #200 arrived at the resident's room. At this time, Resident #117 was unresponsive. LPN #200 called LPN #210 for assistance and LPN #210 started CPR while LPN #200 called 911. STNA #225 indicated she had never received training on the LifeVest or what to do if it was alarming. Review of the undated manufacturers LifeVest patient manual revealed there are three types of alerts. One is a vibration alert to the patient, which activates on the back of the [MEDICATION NAME] belt warning them they are about to get a siren alert. The patient is to press the response button to stop this alert. The next alert is a siren alert, which is a high pitched two tone alert that means an abnormal rhythm has been detected and a shock is about to be delivered. The patient and only the patient is to press the response button. This determines if the patient is conscious and stops the treatment shock. The final alert is a gong sound that repeats about every second. This type of alert is accompanied by a message indicating there is a problem that needs attention. The message should be read to see what action needs to be taken. Review of the LifeVest manufacturer's emergency patient management sheet documented there are three levels of alerts. The first alert is a green alert which is silent or audible with the gong sound. The voice feature of the LifeVest monitor may activate and state treatment has been given and to call the physician. This means the device is monitoring the patient and the device may be alerting the patient to follow the directions on the screen. The second alert level is a yellow alert which is a two tone siren alert. The voice feature will state if patient is unresponsive to call for help and begin CPR. This means the device has not detected a heartbeat or the device has delivered the maximum number of shocks. The final alert level is a red alert. This is a two toned siren alert with a voice alert to press the button to delay treatment and bystanders do not interfere. This status means the device has detected a ventricular arrhythmia and the device is preparing to treat the patient. Shock is likely, therefore stop CPR. The status also indicates only the patient should press the response buttons, do not touch the patient, and allow the device to treat the patient. All three alerts noted to proceed with first responder instructions. These included proceeding with standard evaluation and treatment measures and CPR can be performed as long as the device is not broadcasting Press response button to delay treatment or Bystanders do not interfere. Review of an in-service dated February 2014 documented the LifeVest was discussed during a meeting with no details of the education. Review of the sign-in sheet lacked any documentation of LPN #200, LPN #210, STNA #205, STNA #225 or RN #215 being part of the in-service. Review of the personnel record for LPN #200 revealed she was hired on [DATE] as an STNA and was hired as an LPN on [DATE]. Review of her file lacked any training pertaining to the care and maintenance of a resident who was wearing a LifeVest. Review of the personnel record for LPN #210 revealed a hire date of [DATE]. The file lacked any training pertaining to the care and maintenance of a resident who was wearing a LifeVest. Review of the personnel record for of RN #215 revealed a hire date of [DATE]. The file lacked any training pertaining to the care and maintenance of a resident who was wearing a LifeVest. Review of the personnel record for STNA #225 revealed a hire date of [DATE]. The file lacked any training pertaining to the care and maintenance of a resident who was wearing a LifeVest. Review of the personnel record for STNA #205 revealed a hire date of [DATE]. The file lacked any training pertaining to the care and maintenance of a resident who was wearing a LifeVest. Review of the master facility agreement, dated [DATE], documented the agreement between the facility and the LifeVest manufacturer included the manufacturer shall meet with the facility within 30 days of the contract date to discuss initial education for the facility. The agreement indicates the manufacturer, not the facility, was responsible for training the residents in the use of the LifeVest. The agreement indicates the facility was responsible for responding in accordance with the materials to alerts and active treatment sequences for residents that occur in the facilities. Review of the undated facility policy titled Acute Condition Change-Clinical Protocol indicated direct care staff, including nursing assistants, will be trained in recognizing subtle but significant changes in the resident and how to communicate these changes to the nurse. This citation substantiates Complaint Number OH 764.

Based on medical record review, review of facility policy, observations, staff and resident interviews, the facility failed to provide a system for preventing and controlling infections. This was evidenced by failing to have notification at the entrance of a resident room to alert visitors to check with nurse before entering room. This affected one (Resident #37) of three residents reviewed for isolation precautions. The facility identified three residents with isolation precautions. The facility census was 114. Findings include: Review of the medical record for Resident #37 revealed the resident was admitted into the facility on [DATE]. [DIAGNOSES REDACTED]. angina pectoris, restless leg syndrome, [DIAGNOSES REDACTED], constipation, osteoarthritis, venous insufficiency (chronic peripheral), peripheral vascular disease, and anemia. Review of facility undated policy Isolation-Categories of Transmission-Based Precautions revealed transmission-based precautions shall be used when caring for residents who are documented or suspected to have communicable diseases or infections that can be transmitted to others. The policy further revealed the facility was to implement a system to alert staff to the type of precaution resident required and the facility would utilize blue bows located outside alert resident rooms. Signaled was to be used to indicate to staff/ visitors to see nurse prior to entering room on confused residents. Observation and interview on 01/31/17 at 4:29 P.M., Resident #37 was identified as being on isolation precautions. Upon entering resident's room, the resident was asked how she was doing. Resident #37 stated she wasn't doing so well and that surveyor should not come any further in to the room. She stated she was told by staff that she had an infection. The surveyor stepped outside of room and assessed for evidence alerting staff or visitors of isolation precautions and there were none noted. Licensed practical nurse (LPN) #200 who was across the hall with the medication cart appeared from another residents room and the surveyor asked if Resident #37 was in isolation. LPN #200 stated Resident #37 was placed in contact isolation beginning at three o'clock today. LPN #200 further stated Resident #37 had a complaint of achiness and redness on left side of face and cheek. She stated the doctor was notified and ordered medication for shingles. She stated the facility then implemented contact isolation and the family was also notified. LPN #200 was asked how the facility denotes residents were in isolation and she stated it was by the blue butterfly shape with blue ribbon at the residents name plate on the wall. When LPN #200 was asked how visitors were to be aware of isolation precautions she said if the resident is alert and oriented, the resident was to notify visitors themselves. No sign was observed on the door or near the room entrance to see the nurse before entering. Observation made on 02/01/17 at 10:31 A.M. revealed Resident #37 was asleep in her room. She was in her wheelchair which was located in the middle of the room and did not awaken when there was a knock on the door. No staff were visible in the hallways to alert the surveyor or visitors to not go into the room without checking with the nurse first. Interview with Assistant Director of Nursing (ADON) who was the infection control manager on 02/01/17 at 11:00 A.M., revealed the facility policy was to place the blue butterfly at the entrance of an alert and oriented residents room to alert staff of a resident in isolation precautions. When asked how visitors would be aware of needing to check with staff before entering a room in isolation precautions, she stated the alert resident would notify visitors. When asked how a visitor would be notified if the resident was asleep, in the bathroom, or forget to mention the information to visitors, she stated she had not thought about that and was unsure how that would occur. Interview with the Director of Nursing (DON) and the Administrator (AD) on 02/01/17 at 11:30 A.M. revealed the facility policy was to not post signs stating Check with nurse before entering on alert and oriented resident doors to prevent privacy violations. The DON and AD could not identify any privacy regulation that would violate as the sign was informational only. They did state the signs were used on residents who are cognitively impaired. When asked if a cognitively intact resident may be asleep, in the bathroom, or forget to tell visitors to check with the nurse; they agreed, visitors may not be informed and have the ability to protect themselves from infection before entering the room of a resident on isolation precautions.

Based on record review, review of facility self- reported incidents, policy review and staff interview, the facility failed to report an allegation of abuse to the State Agency. This affected one (Resident #49) of three residents reviewed for abuse. The facility had a total census of 121. Findings include: Review of Resident #49's medical record revealed the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the nursing notes dated 08/30/13 at 6:30 P.M. revealed Resident #49 was extremely agitated, had kicked the door closed and was sitting on the other side to keep everyone out. After a few attempts, Resident #49 allowed the nurse to come in and talk. The nurse brought Resident #49 to the nurses' station for some ice cream and the resident no longer seemed upset. Further review of the nurses notes dated 08/30/13 at 9:30 P.M. revealed another aide told the nurse that the resident had gotten upset and said,"the aide bruised him". Interview on 11/19/13 at 2:50 P.M. with the Director of Nursing (DON) revealed she was notified on 08/30/13 of the incident and an investigation was completed on 08/31/2013. The DON stated that Resident #49 was agitated and attempting to hit and bite at a State-tested Nursing Assistant (STNA). The STNA was educated on behavior interventions and staff continued to monitor for bruising. The DON verified that she did not report the incident to the State Agency because the resident had behaviors and they felt that this was a behavior for Resident #49. Interview on 11/19/13 at 5:00 P.M. with the Administrator and the DON revealed that investigations are completed immediately with any allegation of abuse and any injury is investigated. Review of an undated Policy and Procedure entitled Abuse/Neglect/Misappropriation of Resident Property revealed that," alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown sources and misappropriation of resident property must be reported immediately to the administrator and to the State Survey and Certification agency. "

Based on record review, review of facility self- reported incidents, policy review and staff interview, the facility failed to report an allegation of abuse to the State Agency. This affected one (Resident #49) of three residents reviewed for abuse. The facility had a total census of 121. Findings include: Review of Resident #49's medical record revealed the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the nursing notes dated 08/30/13 at 6:30 P.M. revealed Resident #49 was extremely agitated, had kicked the door closed and was sitting on the other side to keep everyone out. After a few attempts, Resident #49 allowed the nurse to come in and talk. The nurse brought Resident #49 to the nurses' station for some ice cream and the resident no longer seemed upset. Further review of the nurses notes dated 08/30/13 at 9:30 P.M. revealed another aide told the nurse that the resident had gotten upset and said,"the aide bruised him". Interview on 11/19/13 at 2:50 P.M. with the Director of Nursing (DON) revealed she was notified on 08/30/13 of the incident and an investigation was completed on 08/31/2013. The DON stated that Resident #49 was agitated and attempting to hit and bite at a State-tested Nursing Assistant (STNA). The STNA was educated on behavior interventions and staff continued to monitor for bruising. The DON verified that she did not report the incident to the State Agency because the resident had behaviors and they felt that this was a behavior for Resident #49. Interview on 11/19/13 at 5:00 P.M. with the Administrator and the DON revealed that investigations are completed immediately with any allegation of abuse and any injury is investigated. Review of an undated Policy and Procedure entitled Abuse/Neglect/Misappropriation of Resident Property revealed that," alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown sources and misappropriation of resident property must be reported immediately to the administrator and to the State Survey and Certification agency. "

Based on observations and staff interview, the facility failed to maintain resident dressers to ensure their safety. This affected nine residents (#31, #43, #82, #167, #148, #13, #92, #26 and #112). The total facility census was 114. Findings include: During the environmental tour conducted on 08/15/12 between 9:15 A.M. and 10:20 A.M., the following concerns were identified: - Room #3 (Resident #31's room) revealed the dresser located by the bathroom door had a sharp area of trim protruding from the left lower side of the dresser. - In Room #6 (Resident #43's room) revealed the night stand located at the left side of the head of the resident's bed had a large piece of trim loose and protruding from the front of the night stand, touching the resident's comforter of the bed. There were also rough edges exposed on the front of the night stand where the trim had been. - In Room #11 (Resident #82 and Resident #167's room) revealed the dresser located by the bathroom door had a sharp area of trim protruding from the left lower side of the dresser. - In Room #15 (Resident #148 and Resident #13's room) revealed the dresser located by Resident #13's closet had a sharp area of trim protruding from the left lower side of the dresser. - In Room #17 (Resident #92 and Resident #26's room) revealed the dresser located by the bathroom door had a sharp area of trim protruding from the left lower side of the dresser. - In Room #31 (Resident #112's room) revealed the dresser located by the bathroom had a loose piece of trim, approximately 3 inches in length, on the left lower corner of the dresser. During interview with the Administrator on 08/15/12 at 10:27 A.M., all of the above findings were verified. The Administrator stated the protruding trim on the dressers were very sharp and could easily cause a skin tear for a resident.