§483.40(b)(3) A resident who displays or is diagnosed with dementia, receives the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being.
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Observations:
Based on a review of clinical records and select incident reports, observations, and staff interviews, it was determined that the facility failed to ensure that staff possessed the necessary skills and competencies to implement person-centered dementia care approaches planned to decrease the potential for further escalation of dementia-related behaviors for one resident out of six residents sampled with dementia (Resident A1).
Findings include:
A review of Resident A1's clinical record revealed that the resident was admitted to the facility on August 12, 2023, with diagnoses that included encephalopathy [is a medical term used to describe a disease that affects brain structure or function and causes altered mental state and confusion], amnesia (a condition characterized by the inability of a person to recall facts or previous experiences), and cerebrovascular disease [is a term for conditions that affect blood flow to your brain that can result in stroke, brain bleed, aneurysm (a bulge in the wall of an artery that can rupture and cause bleeding inside the body and often leads to death)].
A quarterly Minimum Data Set (MDS) assessment dated May 16, 2024, indicated that the resident had severe cognitive impaired with a BIMS (brief interview for mental status - a tool to assess cognitive status) of 6.
Resident A1's plan of care, dated August 23, 2023, identified that the resident had behaviors of increased agitation, banging on doors, delusional thoughts, accusatory towards others, exit seeking, combativeness, and physically aggressive with peers. The established goal was for the resident to be free of harming self or others during periods of combativeness and would have no adverse effects related to behaviors. Planned interventions included to approach resident in a calm manner to avoid frustration and behavior escalation, attempt distraction during behavioral episodes (offering to watch sports, engaging in conversation about pets, offering music), Attempt to redirect resident when exhibiting behaviors, provide a calm safe environment when the patient's frustrations escalate. The resident's care plan also indicated that when behaviors escalate, and staff are unable to redirect the resident to remove other residents surrounding the resident.
Resident B2's clinical record revealed admission to the facility on June 30, 2023, with diagnoses of alcohol induced dementia (is a severe form of alcohol-related brain damage caused by many years of heavy drinking and can lead to dementia-like symptoms, including memory loss, erratic mood, and poor judgment), major depressive disorder, and insomnia.
An MDS assessment dated June 16, 2024, indicated that the resident had severe cognitive impaired with a BIMS score of 4.
Resident B2's plan of care, dated March 19, 2024, and revised June 27, 2024, identified that the resident had an impaired psychiatric/mood status related to dementia, depression, and behaviors due to a history of wandering into other resident's room and removes items, exit seeking behaviors and packing clothes, making false accusations towards others, and irritability. The resident's goal was to be free of signs and symptoms of distress, depression, anxiety, and sad mood and express effective coping mechanisms. Planned interventions were to monitor for signs and symptoms of mood changes or distress, provide a calm and safe environment when patient is emotional or frustrated and allow to voice feelings, every fifteen-minute checks while awake, and approach resident in a calm manner to avoid frustration and behavior escalation.
An incident report of a staff witnessed resident-to-resident physical aggression at the 3rd floor nurses station completed by Employee A1, a Registered Nurse (RN), on July 8, 2024, at 6:15 p.m., revealed that this writer \ was informed that Resident B2 made aggressive physical contact with Resident A1, who attempted the initial contact. Resident B2 stated that she was swung at Resident A1 with a folded fist while she was having a conversation with a nurse at the nursing station and swung back. Resident \ was redirected to a safe area and offered and accepted snacks and placed on 1:1 safety observation. No injuries were observed at the time of incident.
An incident report of a staff witnessed resident-to-resident physical aggression at the 3rd floor nurses station completed by Employee 3, a Licensed Practical Nurse (LPN), on July 8, 2024, at 10:31 p.m., related to the event that occurred at 6:15 p.m. that evening, revealed that Resident A1 became agitated and started to exit seek. After making futile attempts to leave the unit, the resident lashed out at Resident B2, who was standing at the nurses station, at the same time. She \ swung a folded fist at Resident B2, but did not make contact. Resident B2 swung back, touching the resident \ on the back between the shoulder blades, while she was moving away. No injuries were noted. Employee 3 asked the resident to describe the incident and Resident A1 stated that she "didn't want to talk about it." The immediate action was one-to-one (1:1) monitoring of Resident A1 with several attempts to calm her down. Resident A1 calmed down after speaking to her friend.
A review of an employee witness statement completed by Employee 2, a Licensed Practical Nurse (LPN), dated July 8, 2024, indicated that at 6:15 p.m., next to the 3rd floor nurses station an altercation occurred between Resident A1 and Resident B2. Resident A1 called Resident B2 a "fat b*tch" and tried to make physical contact with Resident B2 and the resident \ ducked and slapped Resident A1's right shoulder.
A review of a witness statement completed by Employee 4, a Nurse Aide (NA), dated July 8, 2024, indicated that at 6:15 p.m., at nurses station an altercation occurred between Resident A1 and Resident B2. Resident B2 was at the nurses station talking to a nurse. While Resident A1 was leaving another resident's room Employee 4 saw Resident A1 turn around to punch Resident B2. Resident B2 ducked down and struck Resident A1 in her back. Employee 4 stated that prior to this incident Resident A1 attempted to exit seek at the unit doors and was screaming that she wanted to leave while kicking, punching, and running at the doors. When she same over to yell at the nurse was when the incident occurred.
During an interview with the facility's Director of Nursing (DON) on July 24, 2024, at approximately 11 AM the DON confirmed that there was no evidence that the staff had implemented planned dementia care interventions required to maintain resident safety and ensure a safe and calm environment during episodes of escalating resident behaviors.
An incident report completed by the Director of Nursing (DON) on July 8, 2024, at 6:45 p.m., for verbal aggression received revealed that Resident A1 was attempting to leave the 3rd floor exit when Employee 1, a dietary aide, attempted to block her from exiting by pushing the resident away from the door and was then witnessed by other staff to be shouting at the resident causing further escalation in her current upset emotional state. Staff \ that was present immediately intervened to deescalate the incident. The noted resident description was "exit seeking" and "demanding" to get out. The immediate action taken was noted for staff to continue one-to-one (1:1) support to monitor the resident's safety and provide ongoing emotional support. No injuries observed at the time of incident. The report indicated that the resident was oriented to person, but was angry and upset that she could not go home. Predisposing physiological factors included the resident's impaired memory and predisposing situational factors included that the resident was an active exit seeker and behavioral.
A review an employee witness statement dated July 8, 2024, no time noted, completed by Employee 2, LPN, revealed that Resident A1 was walking around the unit and going to the doors trying to open them. When she heard the door open, she tried to push her way past an employee \ coming through the door. The dietary aide \ was coming in the door and was pushing the resident back away from the doorway. Resident A1 and Employee 1 had "words" and she went after the dietary aide because he challenged her, and I \ immediately stepped in and separated Resident A1 from the situation and the employee \ left.
A review of an employee witness statement completed by Employee 3, a LPN, dated July 9, 2024, no time noted, revealed that Resident A1 was in her sundowning mode and right after she ate her dinner, she wanted to exit the unit. " I \ was on the phone and as I hung up the phone, I heard commotion at the door exit. Resident A1 was in an altercation with Employee 1. They \ were both screaming get off me and Employee 2 got in between both and separated them and I \ notified the supervisor of what happened."
A review of an employee witness statement completed by Employee 4, a nurse aide (NA), dated July 9, 2024, no time noted, revealed that when the dietary aide \ came through the door, he yelled at Resident A1, " don't ever put your f"*king hands on me." A staff person told him not to talk like that and he turned around and left the unit and that was all I heard."
An employee witness statement completed by Employee 1, dietary aide, on July 9, 2024, no time noted, revealed that it was his second day back from his vacation and was "unaware that I needed to ring the doorbell on the third floor "dementia unit" prior to entering the floor. Upon entering the floor, there was a visitor behind me, and I moved to the left to get out of the way and for the door to shut. Resident A1 then grabbed my left forearm and push through me. I then pulled myself back from the situation. Nurses and staff then fame to see what was going on. I became overwhelmed and from that moment forward I don't remember my reaction. To my knowledge, I did not physically harm the resident."
During an interview with the Director of Nursing on July 24, 2024, at approximately 1:15 p.m., the DON stated that the facility implemented a new procedure for staff to ring the doorbell prior to entering the 3rd floor Dementia Care Unit to deter exit seeking residents from experiencing increased distress and behaviors and Employee 1 was terminated due to inappropriately responding to Resident A1's behaviors.
The facility failed to ensure that all staff required to enter the 3rd floor were educated on new procedures to enter the unit to deter exit seeking residents from experiencing increased distress and behaviors. The facility failed to ensure that all staff were sufficiently trained to demonstrate the competencies, skills, and understanding of residents exhibiting dementia related behaviors to implement individualized approaches to manage care by preventing, relieving, and/or accommodating a resident's distress to prevent escalation in resident behaviors and further emotional distress to residents.
Further interview with the DON on July 24, 2024, at 2:00 p.m., confirmed that the facility failed to ensure that all staff performing tasks on the dementia unit posed necessary skills to implement effective dementia care related interventions to prevent escalation in resident behaviors and emotional distress.
28 Pa Code 211.12 (c)(d)(3)(5) Nursing services
28 Pa. Code 201.20 (a)(6) Staff Development
| | Plan of Correction - To be completed: 08/10/2024
The residents A1 and B2 will continue to be provided psych services by Vital Psych services.
Residents from the 3rd floor with behaviors will be reviewed daily at the clinical morning meeting. Any resident with behaviors will be referred to Vital Psych Services for follow up. The behaviors will be reviewed to ensure correct staff use individualized approaches to manage care by preventing, relieving, and/or accommodating a resident's distress to prevent escalation in resident behaviors and further emotional distress to residents.
Staff Development / Designee will educate staff from the 3rd floor on necessary skills and competencies to implement person-centered dementia care approaches and procedures to enter the unit to deter exit seeking residents from experiencing increased distress and behaviors.
DON / Designee will complete audits of staff training on Dementia to ensure the 3rd floor staff have been properly trained weekly X 4 weeks then monthly for X3. Results of audits will be reported and reviewed by the Quality Assurance Performance Improvement Committee and changes will be made as needed.
Date of compliance August 10th 2024
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