§483.40(a) The facility must have sufficient staff who provide direct services to residents with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with §483.70(e). These competencies and skills sets include, but are not limited to, knowledge of and appropriate training and supervision for:
§483.40(a)(1) Caring for residents with mental and psychosocial disorders, as well as residents with a history of trauma and/or post-traumatic stress disorder, that have been identified in the facility assessment conducted pursuant to §483.70(e), and [as linked to history of trauma and/or post-traumatic stress disorder, will be implemented beginning November 28, 2019 (Phase 3)].
§483.40(a)(2) Implementing non-pharmacological interventions.
|
Observations:
Based on observations, a review of clinical records, facility investigations, and staff interview, it was determined that the facility failed to provide sufficient staff, providing direct services to residents, who possess the necessary competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident as evidenced by five residents out of six sampled (Residents 1, 2, 3, 4 and CR1).
Findings include:
A review of Resident 1's clinical record revealed that the resident was admitted to the facility on June 30 2023, with diagnoses, which included alcohol induced dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning.
A review of the resident's Quarterly Minimum Data Set Assessment (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated December 22, 2023, revealed the Brief Interview for Mental Status (BIMS section of the MDS which assesses cognition) indicated the resident cognition was severely impaired.
A review of Resident 2's clinical record revealed that the resident was admitted to the facility on May 5, 2022, with diagnoses, which included schizoaffective disorder (a mental health disorder that is marked by a combination of schizophrenia symptoms, such as hallucinations or delusions, and mood disorder symptoms, such as depression or mania) and traumatic brain injury.
A review of the resident's Quarterly Minimum Data Set Assessment dated November 2, 2023, revealed the Brief Interview for Mental Status indicated the resident cognition was severely impaired.
A review of Resident 3's clinical record revealed that the resident was admitted to the facility on June 15, 2023, with diagnoses, which included dementia.
A review of the resident's Quarterly Minimum Data Set Assessment dated December 18, 2023, revealed the Brief Interview for Mental Status indicated the resident cognition was severely impaired.
A review of a facility investigation dated January 23, 2024, revealed Resident 2 was in the hallway in front of the dayroom near the nursing station. Staff heard yelling and reported a noisy environment. Staff witnessed Resident 2 open hand slap Resident 1 in the face. Resident 2 was attempted to punch Resident 1 in the face after the slap, but staff intervened and separated the residents. At that time Resident 2 indicated that everyone was yelling, and he was afraid Resident 1 was going to hurt the staff, so he hit her. Resident 3 witnessed the interaction between Resident one and Resident 2. Resident 3 then slapped Resident 2 in the face. Resident 3 stated at that time, "He hit my friend".
A review of a witness statement from Employee 1 NA (nurse aide) dated January 23, 2024, revealed the employee was standing in the dayroom doorway. The employee stated she heard a lot of yelling behind her. The employee indicated when she turned around, she saw Resident 2 hit Resident 1. The employee went to intervene, and she stated at that time Resident 3 then slapped Resident 2. Further Employee 1 stated that her and Employee 2 NA and gotten into a verbal altercation about showering residents prior to the incident. Employee 1 indicated that she told Employee 2 "whatever has gotten you in a bad mood, don't take it out on me."
A review of a witness statement from Employee 2 NA dated January 23, 2024, indicate she did not see the incident because she was in the shower room.
A review of a witness statement from Employee 3 LPN (license practical nurse) dated January 23, 2024, indicated prior to the escalation of behaviors and the incident residents were loud in the dayroom. Further the Employee indicated that Employee 1 told Employee 3 that Employee 2 had dismissed Employee 1 after a verbal disagreement. Employee 3 then indicated that Employee 2 appeared angry and slamming things on the counter on the unit.
A review of a witness statement from Employee 4 LPN dated January 23, 2024, revealed the employee heard Resident 1 saying why did he hit me. The employee at that time saw Resident 2 picking his glasses up off the floor. The employee asked Resident 3 what happened in which he stated, "he hit my friend and she is a woman, so I hit him." The employee indicated she then asked Resident 2 what happened in which he stated, " I was afraid she was going to hurt you guys. Everyone was yelling." Employee 4 further indicated right prior to this incident Employee 2 was upset and opened the shower room door and began yelling that Employee 1 needs to start cleaning up after herself and slammed the shower room door shut.
A follow up telephone interview was completed with Employee 4 on January 24, 2024. The telephone interview indicated Employee 4 stated on January 23, 2024, from 4:15 PM to 6:15 PM the unit was tense. Employee 2 was saying a lot of things under her breath. She was slamming things and every time she walked by staff, she would be mumbling things. Employee 4 stated the entire afternoon was very tense. Employee 4 stated prior to the incident occurring a resident was banging on the door and upset. At that same time Employee 2 had opened the shower room door and started yelling that Employee 1 needs to start cleaning up after herself and that Employee 2 was sick of towels being everywhere and slammed the shower door behind her. Employee 4 indicated at the same time there was another resident that was upset and crying and when she turned around the incident between Residents 1,2, and 3 had occurred. Employee 4 indicated after the incident she did voice to the staff that they need to get along and work together and be professional especially on the unit they were working because the residents feel the tension and it triggers their behaviors.
The facility concluded from their investigation that the energy and environment determined to be a contributing factor to Resident 2 hitting Resident 1 and in return Resident 3 hitting Resident 2.
A review of the clinical record revealed that Resident CR1 was admitted to the facility on November 15 2023, with diagnoses to include dementia (irreversible, progressive degenerative disease of the brain, resulting in loss of reality contact and functioning ability).
An admission MDS Assessment (Minimum Data Set - a federally mandated standardized assessment completed periodically to plan resident care) dated November 22, 2023, revealed the resident was severely cognitively impaired.
A review of the clinical record revealed that Resident 4 was admitted to the facility on October 17, 2023, with diagnoses to include dementia.
An admission MDS Assessment (Minimum Data Set - a federally mandated standardized assessment completed periodically to plan resident care) dated October 23, 2023, revealed the resident was severely cognitively impaired.
A review of a nursing note dated January 2, 2024, at 2:07 AM reveled Resident CR1 was ambulating in the hallways cursing at any person she came in contact with. At approximately 1:00 PM Resident CR 1 was yelling out obscenities towards Resident 4 who was yelling out for help. Staff noted Resident 4 lying on the floor and Resident CR1 yelling at her.
A review of a facility incident report dated January 2, 2024 revealed Resident CR1 was seen wandering the hallways exhibiting aggressive behaviors. Staff heard a thud and screaming. Resident 4 was found lying on the floor in pain with her right lower extremity externally rotated. Both residents were transferred out to the hospital for evaluations.
Further review of the facility investigation revealed a security camera timeline of the incident. It was indicated at 12:06 AM through 12:09 AM The resident were seen on camera passing by each other on multiple occasions. At 12:07 AM Employee 6 NA (nurse aide) walks down the hall and interacts with the residents out of camera view. At 12:09 Am Employee 6 was observed walking up the hall with both Resident CR1 and Resident 4. At 12:11 AM Resident CR1 was walking down the hall from the nursing station. At 12:16 AM Resident 4 walks into her room the comes out of her room and begins walking down the hall during the nursing station. At 12:16:40 Resident CR1 walks directly towards Resident 4 and makes contact with (hits) Resident 4.
A review of Employee 6's witness statement dated January 6, 2023, revealed prior to the incident Resident CR1 was being aggressive, pacing the halls, and wandering into rooms.
A statement from Employee 7 NA dated January 2, 2024, revealed the employee state she was not assigned Resident CR1. The employee stated prior to the incident Resident CR1 was agitated during the shift. When asked what the staff do for the resident when she is like that the employee stated they attempt to redirect her. When asked what redirect means the employee stated to give her something to eat or drink and direct her in another direction. The employee stated that resident will still swing out after those attempts are made.
A follow up statement was obtained from Employee 6. The statement was not dated. The follow-up statement revealed the employee was witnessed to have checked in with Resident CR1 and Resident 4 multiple times leading up to the incident. Employee 6 stated that prior to the incident Resident CR1 has been yelling at Resident 4 and she had approached the residents to redirect them. The employee further indicated that as soon as Resident CR1 had gotten out of bed she began yelling and every time she walked past Resident 4, she would yell at her and into other resident rooms. Employee 6 indicated she tried to redirect her, but she was just angry. Employee 6 revealed that she went around the nursing station and Employee 7 went to the bathroom when Resident CR1 was unsupervised and hit Resident 4.
The facility staff failed to implement effective individualized interventions or increase supervision to manage the aggressive behaviors of Resident CR1 who was actively seeking out and engaging with Resident 4 resulting in the physical abuse of Resident 4 causing a fractured hip.
Observations of the facility's second floor on January 25, 2024, at 12:03 PM, revealed that Resident C3 was walking with Employee 5, a nurse aide (NA) assigned to provide 1:1 supervision to Resident C3, and stopped at the nurses station. Resident C3 was observed engaging in a conversation with another employee and asked if she could come along with her. Employee 5 was heard to comment rudely "why don't you take her with you" and began to loudly vocalize that she was upset that she didn't get to take a break from her duties yet. Employee 5 proceeded to walk away from Resident C3 and went behind the nurses desk to search for the staff break schedule and was not within one arm reach of the resident.
Further observations of Resident C3 on January 25, 2024, revealed that she was walking with Employee 5 down the hallway and became agitated. Resident C3 put her arms up to strike Employee 5, and Employee 5 put her hands on the resident to stop her from striking her. Employee 5 then walked away from Resident C3 and was leaning up against the hallway wall and proceeded to look at her phone and with an earbud present in her ear and was not paying attention to Resident C3.
Interview with the Nursing Home Administrator on January 25, 2024, at approximately 3:10 PM confirmed that the facility failed to employ sufficient staff with the necessary competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being.
Refer F600 and F744
28 Pa Code 211.12 (d)(3)(4)(5) Nursing services
28 Pa. Code 201.18 (e)(1)(3) Management
28 Pa. Code 201.20 (a)(6) Staff development
| | Plan of Correction - To be completed: 02/12/2024
Step 1 A.Residents were separated immediately at the time of incident. Resident 1# was transferred to the hospital and treated for injury and restored to full weight bearing and independent ambulation on 1/17/24. Resident CR1 was transferred to the hospital due to increase in agitation for evaluation and treatment. This resident no longer resides at the facility. B.Residents A1, B2, and C3 were separated at the time of incident and received follow up visits by Social Services and Psychiatric services with no ill effects noted. All staff present at the time of incident received 1:1 education on maintaining appropriate environment for residents with dementia and minimizing "triggers" in environment to prevent escalation in behaviors. C.Staff member identified was removed from the floor and provided 1:1 education by the NHA on effectively and appropriately caring for individuals with dementia and dementia related behaviors at the time of survey. Resident C3 observed during survey received psychosocial follow up from social services, with no ill effects noted. Step 2 The Social Services director or designee completed observations of all units for appropriate environment to prevent escalation in behaviors in residents with dementia to effectively prevent resident to resident altercations. The Social Services director or designee complete observations of all residents with a dx of dementia to ensure there were no observed signs or symptoms of distress or escalation in behaviors due to external stimuli or environment, and early identification of escalation of behaviors to prevent resident to resident altercations. The Social Services Director or designee completed interviews with all interviewable residents (BIMs >11) and observations of uninterviewable residents (BIMs <11) to ensure no concerns with treatment or services by facility staff. Step 3 The NHA or designee educated all facility staff on caring for individuals with dementia and managing difficult behaviors including preventing escalation in behaviors with managing external stimuli and promoting appropriate environment, as well as early identification of escalation of behaviors and appropriate interventions to prevent resident to resident altercations. Additionally, facility staff were provided education on caregiver stress management techniques and support. Step 4 To monitor and maintain ongoing compliance, the NHA or designee completed observation audits across all three shifts, to ensure appropriate environment and prevention of external stimulus to prevent escalation of behaviors 5 days per week for 4 weeks, then monthly for 2 months. To monitor and maintain ongoing compliance, the DON or designee will audit behavior tracking for 10 residents with a dx of dementia, 5 days per week for 4 weeks, then monthly for 2 months to ensure residents exhibiting signs and symptoms of behaviors had appropriate and personalized interventions attempted. To monitor and maintain ongoing compliance, the NHA or designee will complete 3 observations of staff interactions with residents 5 days per week for 4 weeks then monthly for 2 months to ensure staff are utilizing effective methods to provide treatment and services to dementia residents, and attempting personalized interventions when necessary.
|
|