Every finding on record at Wooster Community Hospital SNF

Based on record review and interview the facility failed to provide an appropriate diagnosis for the use of an antipsychotic medication. This affected one resident (#67) out of five residents reviewed for unnecessary medications. The facility census was 14. Findings include: Review of Resident #67's medical record revealed the resident was admitted on [DATE] with diagnoses including encephalopathy, left hemiparesis, hemorrhagic stroke, and debility. Review of Resident #67's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited severe cognitive impairment, no behaviors were noted, and the resident was dependent for activities of daily living (ADL). Review of Resident #67's physician orders revealed an order dated 01/01/24 for quetiapine fumarate (antipsychotic medication) 25 milligrams (mg) give one tablet by mouth once a day. Review of the current resident diagnoses revealed this resident does not have an active diagnosis of psychosis in the medical chart. Interview on 01/02/23 at 3:50 P.M. with Administrator revealed that quetiapine fumarate was ordered for Resident #67 related to anxiety, and that quetiapine fumarate is not an antianxiety medication. The Administrator also verified that there was no documented evidence from the nursing staff that Resident #67 had signs or symptoms of anxiety or restlessness.

Based on observation, resident interview, staff interview, and facility policy review, the facility failed to ensure oxygen tubing and sterile water containers were dated. This affected three residents (#7, #69, and #166) of three residents reviewed for oxygen. The facility census was 14. Findings include: 1. Review of the medical record for Resident #7 revealed an admitted [DATE] with diagnosis including left hip revision, sleep apnea, and obesity. Review of the Social Work Admit (SWA) assessment dated [DATE], revealed Resident #7 had a Brief Interview for Mental Status (BIMS) score of 15 that indicated she was alert and oriented to person, place, and time. Review of the physician orders dated 01/01/24 revealed an order for oxygen therapy per protocol routinely. Observation and interview on 01/03/24 at 1:53 P.M. with Resident #7 revealed she was sitting in her room with her nasal canula, and oxygen tubing connected to a bottle of sterile water affixed to the wall. Resident #7's oxygen tubing and bottle of sterile water were undated. Resident #7 revealed she only wore her oxygen at night. 2. Review of the medical record for Resident #69 revealed an admitted [DATE] with diagnoses including dehydration, hypertensive heart disease with heart failure, pulmonary hypertension, and dysphagia. Review of the SWA assessment dated [DATE], revealed Resident #69 had a BIMS score of 15 that indicated she was alert and oriented to person, place, and time. Review of the physician orders dated 12/26/23 revealed an order for oxygen therapy per protocol routinely. Observation on 01/03/24 at 1:50 P.M. revealed Resident #69 sitting in a recliner with her nasal canula in place with the oxygen tubing connected to a bottle of sterile water affixed to the wall. Resident #69's oxygen tubing and bottle of sterile water were undated. 3. Review of the medical record for Resident #166 revealed an admitted [DATE] with diagnoses including pneumonia, hypertension, and acute respiratory failure with hypoxia. Review of the SWA assessment dated [DATE], revealed Resident #166 had a BIMS score of 13 that indicated she was alert and oriented to person, place, and time. Review of the plan of care dated 12/21/23 revealed Resident #166 was on two liters of oxygen. Review of the physician orders dated 12/24/23 revealed an order for oxygen therapy per protocol routinely. Review of the medical record, reflecting occupational therapy (OT), revealed Resident #166 was on two liters of oxygen but was increased to three liters during OT activity for safety and comfort. Resident #166 complained of being weak and winded. Observation and interview on 01/02/24 at 9:50 A.M. with Resident #166 revealed she had been in the facility for three weeks for therapy due to being out of breath. Observation revealed Resident #166 was sitting in a recliner with a nasal canula in place with the oxygen tubing connected to a bottle of sterile water affixed to the wall. Observation revealed the oxygen tubing and sterile water were undated. Resident #166 revealed she was unsure of when the oxygen tubing and sterile water was last changed. Interview with Registered Nurse (RN) #804 on 01/02/24 at 11:04 A.M. verified and confirmed Residents #7, #69, and #166 oxygen tubing and sterile water were undated. RN #804 revealed she was not sure when the tubing was changed out, but staff waited until the containers were empty. RN #804 revealed she could not indicate when the last time the oxygen tubing and sterile water were changed due to no documentation and no tracking system in place. Interview on 01/03/24 at 1:55 P.M. with State tested Nurse Assistants (STNAs) #811 and #819 revealed Residents #7, #69, and #166 all wore oxygen during their stay in the hospital. STNAs #811 and #819 revealed Resident #7 wore her oxygen only at night. STNAs #811 and #819 were unaware when the oxygen tubing and sterile water were changed. Interview on 01/03/24 at 2:10 P.M. with the Administrator verified the above findings. Interview with the Administrator revealed oxygen tubing and sterile water were changed every Sunday, but staff did not document the changes, there were no physician orders to change the sterile water or oxygen tubing, and it was not in their policy to do so. Interview with the Administrator revealed there was a form to document and track the changing of oxygen tubing on Sundays, but staff did not utilize it and she was unable to provide any history of utilization. Interview with the Administrator revealed there was no way to verify the time and date oxygen and tubing was changed. Review of the facility document titled PCA task List revealed the facility had a form to document and track new oxygen tubing on Sundays. The form was blank. Review of the facility document titled Oxygen Administration, Long-Term Care, revised 12/11/23, revealed the facility had a policy in place for implementation of oxygen. Review of the policy revealed staff would verify the physician order, complete the administering protocol, and document the procedure. Review of the facility document revealed the facility did not implement the policy.

Based on observation, record review, policy review, personnel file review, review of Isolation guidelines from the Center for Disease Control (CDC), review of a self-learning orientation packet for volunteers, and interview, the facility failed to ensure isolation precautions were adhered to by a volunteer. This involved one (Resident #9) resident of two residents reviewed for respiratory care/infections. This had the potential to affect all 20 residents. Findings include: Review of Resident #9's medical record revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Laboratory results from the hospital dated 01/30/20 revealed Resident #9 tested positive for RSV prior to her admission to the nursing facility. A safety assessment dated [DATE] indicated Resident #9 was placed on contact and droplet isolation precautions. On 02/10/20 at 9:15 A.M., personal protective equipment (PPE) was observed hanging from Resident #9's door to the hallway with signs on the door frame indicating droplet precautions and contact precautions. The signs indicated visitors were to wear gowns, gloves, and masks. The signs instructed visitors to wash hands before entering the room and to wash hands before leaving the room. At the time of the observation, Registered Nurse (RN) #40 reported Resident #9 was on isolation for RSV-A and people entering her room needed to wear gown, gloves and mask. On 02/10/20 at 11:47 A.M., State tested Nursing Assistant (STNA) #52 was observed taking a tray from the meal cart to the doorway of Resident #9's room and asking if she could hand the tray to Volunteer #210 who was already in the room. Volunteer #210 was observed standing in the room handling objects in the room (especially on the overbed table sitting in front of Resident #9), picking the food tray up off the bed and placing it on the over bed table. Volunteer #210 was not wearing PPE and left the room without washing her hands or using hand sanitizer. On 02/10/20 at 11:52 A.M., during interview,Volunteer #210 (who was wearing a smock with a name tag identifying her as a volunteer) verified she did not wear PPE while in Resident #9's room and stated she had never been told anything about PPE use. Volunteer #210 acknowledged the lack of hand hygiene being performed. Volunteer #210 stated she delivered mail throughout the facility and adjoining hospital. On 02/10/20 at 11:55 A.M., during interview, RN #40 stated volunteers should use the same isolation precautions as other staff and she was uncertain what kind of training volunteers received. On 02/10/20 at 11:58 A.M., during interview, STNA #52 verified she handed Resident #9's tray to Volunteer #210 who was in the room but stated she did not notice if Volunteer #210 was wearing PPE. On 02/10/20 at 12:00 P.M., during interview, RN #40 stated Volunteer #210 was in Resident #9's room as a friend at the time of the above observation. RN #40 stated sometimes there were visitors who refused to follow isolation precautions. Review of CDC Isolation Precautions Guidelines indicated: Provide job- or task-specific education and training on preventing transmission of infectious agents associated with healthcare during orientation to the healthcare facility; update information periodically during ongoing education programs. Target all healthcare personnel for education and training, including volunteers. Review of the policy Infection Control and Prevention: Standard and Transmission Based Precautions (revised 01/30/20) revealed for residents on contact precautions hand hygiene was to be performed upon room entry and before exit. Gowns and gloves were to be donned prior to entering a room and discarded with hand hygiene performed before leaving a room. Staff were to instruct visitors on Contact Precautions and the use of PPE to reduce the transmission of infectious organisms. Visitors should be encouraged to wear appropriate PPE. Visitors who were providing care to the resident was expected to wear appropriate PPE. For droplet precautions, hand hygiene was to be performed upon room entry and before exit. Surgical masks were to be worn on room entry and gloves were to be worn when handling items contaminated with respiratory secretions. PPE was to be removed and hand hygiene performed when leaving the resident's room. Staff were to instruct visitors on droplet precautions including cleaning hands on entering the room and when leaving the room. Visitors were to be encouraged to wear appropriate PPE. Visitors who were providing care to the resident were expected to wear appropriate PPE. The policy indicated for residents with RSV who were immunocompromised, standard and contact precautions were to be used for the duration of the illness. Masks were to be used in accordance with standard precautions. In immunocompromised residents, extent the duration of contact precautions due to prolonged shedding. On 02/11/20 at 1:03 P.M., RN #215 was interviewed regarding isolation policies. RN #215 stated volunteers receive training on infection control, including isolation. Nurses were responsible for educating family and visitors. When asked what the facility did in the case of visitors refusing to use PPE she stated education would be provided by nursing and she would also speak to the person. If the visitor continued to refuse to follow policies for isolation she was not sure what would happen. RN #215 verified if visitors refused to follow isolation precautions it could put other residents at risk. The facility had no policy/procedure and the infection control committee would probably have to meet to decide how to best handle the situation. RN #215 stated she had not noticed any patterns of infection. On 02/12/20 at 2:12 P.M., during interview,RN #215 stated volunteers received annual training on infection control and isolation. At 2:35 P.M., review of Volunteer #210's personnel file revealed she was absent for the 2019 training but received a refresher course in 2018. RN #215 stated the refresher course contained all the material provided to volunteers when they started and provided the packet of information. The packet was titled Self-Learning Orientation Packet for students, contracted staff, volunteers and patient safety observers. Pages 4 and 5 of the booklet addressed infection control. Page 5 instructed it was very important to read all precaution signs posted on the room door. It was the person's responsibility to follow the directions on the sign.

Based on record review, observation, and interview, the facility failed to practice proper infection control procedures during Resident #136's wound care. This affected one (Resident #136) of two residents observed for wound care. The facility census was 20 residents. Findings include: Resident #136 was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident #136's admission clinical shift report dated 08/23/16 revealed the resident had a wound on the bottom of his right foot. Review of Resident #136's podiatry consult dated 08/18/16 revealed the resident's wound was a chronic planter right foot ulcer. Resident #136's physician treatment orders revealed Resident #136's wound dressing should be changed everyday and cleansed with normal saline solution and apply aqucael silver and overlying gauze dressing. Observation on 08/24/16 at 9:25 A.M. of Registered Nurse (RN) #31 changing Resident #136's right foot wound dressing revealed the wound dressing supplies were in a basin that remained in a secured drawer in the residents room. RN #31 applied new gloves and placed the basin on the bedside table without cleansing the table. After RN #31 used the saline solution she placed the bottle of saline on the bedside table. RN #11 also placed a roll of tape from the basin on the bedside table. Upon completing the dressing change, RN #31 placed the bottle of saline and roll of tape back in the basin on top of unused wound supply packaging. RN #31 did not cleanse the bedside table upon completing the dressing change. Interview on 08/24/16 at 9:46 A.M. with RN #31 confirmed she did not cleanse the table before placing the basin, saline solution bottle, or tape on the bedside table. RN #31 confirmed she did not cleanse the bedside table after completed the dressing change.

Based on interview and record review, the facility failed to ensure pharmacy recommendations were acted upon as required. This affected three (Residents #143, #137, and #141) of five residents reviewed for medications. The facility census was 20 residents. Findings include: 1. Review of the record of Resident #137 revealed he was admitted to the facility on [DATE]. He was ordered Lovenox, an anti-platelet medication given by injection at a dose of 30 milligrams. The medication was used to prevent deep vein thrombosis, or blood clots. Review of a pharmacy recommendation progress note dated 08/10/16 revealed the resident was on Lovenox for prevention of deep vein thrombosis. Based on the resident's lab levels (Creatinine Clearance), the pharmacist recommended the Zoloft be increased to a dose of 40 milligrams, which was the manufacturer's dosing guideline. Review of the record did not reveal a note by the physician indicating the recommendation had been addressed. An interview with the facility administrator on 08/25/16 at 1:00 P.M. revealed the physician had verbally told her he declined the recommendation because he felt the resident was at risk for bleeding. The director of nursing verified there was no documentation of the explanation why Resident #137's pharmacy recommendations were rejected. 2. Review of the record of Resident #143 revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of her medications revealed she was ordered Zoloft and Cymbalta, both anti-depressants. Review of a pharmacy note (pharmacy review and recommendation) dated 08/22/16 revealed a recommendation to discontinue the medications due to sub therapeutic dosing and a possible drug interaction that would increase serotonin levels. Review of the record did not reveal a note by the physician indicating the recommendation had been addressed. An interview with the facility administrator on 08/25/16 at 1:00 P.M. revealed the physician had told her verbally that he declined the recommendation because he felt the Cymbalta helped with chronic pain and the Zoloft for depression. The director of nursing verified there was no documentation of the explanation why Resident #143's pharmacy recommendations were rejected. 3. Resident #141 was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident #141's current physician orders [REDACTED]. Review of Resident #141 medication regimen review by the pharmacist on 08/10/16 revealed the pharmacist recommended considering a dose reduction and/or making the resident's Xanax as needed considering the resident's age and comorbidities. The pharmacist also noted antipsychotics were no longer recommended for behavior unless documented increase risk of harm to self and others, with the recommendation to evaluate the Seroquel use and consider tapering or discontinuing the medication. Review of Resident #141's medical record revealed the pharmacy recommendations were not acted upon and there was no documentation on why the physician rejected the pharmacy recommendations made for Resident #141 on 08/10/16. Interview on 08/24/16 at 4:11 P.M. with Administrator revealed the physician reviewed the pharmacy recommendations as evidence by viewing who reviewed the pharmacy recommendations in Resident #141's record, but there was no documented evidence of the explanation why Resident #141's pharmacy recommendations were rejected.

Based on interview and record review, the facility failed to ensure a thorough investigation was completed for injuries of unknown origin. This affected two (Residents #21 and #102) of three residents reviewed for thorough investigations. The facility census was 20 residents. Findings include: 1. Review of the record of Resident #21 revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of her admission Minimum Data Set assessment dated [DATE] revealed she was moderately cognitively impaired and required the extensive assistance of two staff for transfers and toileting. Review of a nursing note for 05/01/16 revealed she was found with a 10 cm (centimeter by 6 cm bruise. The note indicated the resident thought the bruise had come from sticking to the seat on the bedside commode. There were no other notes regarding the bruise. Review of her record revealed she was ordered an X-ray on 05/06/16 for lower abdominal pain. Review of the results of the X-ray revealed a displaced vertical [MEDICAL CONDITION] of the left pubic bone, and limited views of the lower pelvis suggest that there are displaced fractures of the right pubic rami, as well. An investigation revealed the resident stated she felt a pull to her groin when using the commode. The investigation indicated the physician felt the fractures were pathologic in nature due to no evidence of fall or trauma and finding of lytic [MEDICAL CONDITION] in the proximal shaft of the left femur. Review of the investigation of the injury did not contain any statements of staff who cared for the resident prior to 05/06/16, including staff who assisted her with toileting or transfers at any time or specifically on 05/01/16 when she was found with a bruise she related happened in the toilet. An interview with the facility administrator on 08/23/16 at 4:45 P.M. verified the resident had said she felt a pull to her groin, as well as sticking to the toilet seat which could indicate an injury had been sustained in the days prior to that date. She verified the investigation did not contain statements from staff who would have cared for the resident prior to the discovery of the bruise or fracture. Review of the facility policy on Alleged Mistreatment , Abuse, Neglect, Injuries of Unknown Source and Misappropriation dated 10/15/12 and updated on 03/02/15 revealed alleged violations would be reported timely and investigated thoroughly. 2. Review of the record revealed Resident #102 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of his admission Minimum Data Set assessment dated [DATE] indicated he was cognitively intact and did not have a history of falls prior to admission. Review of his nursing notes from admission through 05/02/16 indicated he was comfortable and with decreasing shortness of breath. A note on 05/02/16 revealed at 8:00 A.M. that he was having pain not relieved by [MEDICATION NAME], a narcotic pain medication. He was ordered another narcotic pain medication ordered ([MEDICATION NAME] immediate release). A note on 05/02/16 at 12:39 P.M. revealed he continued to complain of pain to his breastbone at a 7-8 out of 10. The doctor ordered scheduled Tylenol. A note on 05/02/16 at 5:23 P.M. revealed his family was concerned about the chest/rib pain and were concerned it was a rib fracture from a previous fall. An X-ray was ordered and done on that date, which revealed fractures of the right 8th and 9th ribs. Review of the physician note dated 05/06/16 revealed he had a history of [REDACTED]. Review of a note dated 05/06/16 at 5:45 P.M. revealed the resident could not remember an incident that could have resulted in the rib fractures. He did state he knew that he had coughed really hard and that it may have occurred at that time. Review of the investigation of the injury did not contain any statements of staff who cared for the resident prior to the acute onset of pain on 05/02/16. An interview with the facility administrator on 08/23/16 at 4:45 P.M. verified the pain was first documented on 05/02/16, which could indicate an injury had been sustained in the days prior to that date. She verified the investigation did not contain statements from staff who would have cared for the resident prior to the onset of pain. She further verified the report of the investigation was not submitted until 05/06/16 and should have been submitted to the state agency within 24 hours of the discovery of the injury of unknown origin. Review of the facility policy on Alleged Mistreatment , Abuse, Neglect, Injuries of Unknown Source and Misappropriation dated 10/15/12 and updated on 03/02/15 revealed alleged violations would be reported timely and investigated thoroughly.

Based on record review and interview, the facility failed to provide Resident #6 a liability and appeal notice of skilled therapy ending on 04/08/16. This affected one (Resident #6) of four residents reviewed for liability notices. The facility census was 20 residents. Findings include: Resident #6 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #6's liability notices revealed Resident #6 was given a Notice of Medicare Non-Coverage (NOMNC) letter on 03/31/16 that indicated skilled nursing or therapy will end on 04/04/16. Resident #6 signed the notice on 03/31/16. Review of Resident #6's physical therapy documentation dated 04/05/16 revealed the resident's discharge to home was canceled due to a change in functional status on 04/04/16. Resident #6 was having increased difficulty with functional transfers and increased tremors. It was recommended by the physical therapist and physical therapy assistance that the resident reconsider discharge as there is increased risk for falls. The facility social worker was notified of the recommendation to delay Resident #6's discharge. Review of Resident #6's physical therapy discharge summary revealed the resident was to be discharged from therapy on 04/08/16. Review of Resident #6's progress note dated 04/06/16 revealed Licensed Social Worker (LSW) #30 met with Resident #6 and discussed discharge on 04/09/16. Interview with LSW #30 on 08/23/16 at 2:43 P.M. confirmed Resident #6's therapy continued after the 04/04/16 date originally set for skilled nursing or therapy services to end, and the resident should have been issued an additional NOMNC letter that skilled services were ending on 04/08/16 but the facility did not issue the notice.

Based on observation, interview and record review, the facility failed to ensure the direct care staffing total hours were posted on the daily staffing report as required. This had the potential to affect all 20 residents who reside in the facility. Findings include: During the initial tour of the facility on 08/22/16 at 9:15 A.M., the nursing staffing posting was observed in a bulletin board in the hall across from the therapy department. The staffing posting included the date, census, and numbers of state tested nursing assistants, licensed practical nurses, and registered nurses scheduled or working for each shift. The staffing posting did not include a total number of hours for these direct care staff. The facility administrator verified on 08/22/16 at 10:00 A.M. that the required information was not included on the form.

Based on record review and interview, the facility failed to ensure that behaviors were documented and non-pharmacological interventions were attempted prior to the administration of anxiety medication. This affected (Resident #133) of five residents reviewed for unnecessary medications. Findings Include: Review of the medical record revealed Resident #133 was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Nurses notes from September and October 2015 revealed this resident experience episodes of anxiety related to her noted changes in her condition. These changes included the need for a [MEDICAL CONDITION] and being diagnosed with [REDACTED]. Review of the physician orders [REDACTED]. Review of Resident #133 ' s September and October 2015 Medication Administration Records (MARs) revealed the resident received 13 doses of [MEDICATION NAME] 5 mg between 10/02/15 and 10/13/15. The MARs showed that the resident received [MEDICATION NAME] 0.5 mg on 9/27/15 and 10/01/15. Review of behavior logs and nursing documentation revealed that the staff did not document the behavior displayed or the non-pharmacological interventions tried prior to administering the [MEDICATION NAME] or the [MEDICATION NAME]. Interview with Registered Nurse #1 on 10/14/15 at 2:00 P.M. verified there was no documentation stating Resident #133's behavior when she received the anxiety medications and no documentation supporting non-pharmocological interventions were tried prior to administering the medications.