Initial Comments:
A focused fundamental survey was conducted June 5, 6 and 7, 2023, to determine compliance with the Requirements of the 42 CFR Part 483, Subpart I, Requirements for Intermediate Care Facilities. The census during the survey was 12 and the sample consisted of four individuals.
Plan of Correction:
483.420(d)(2) STANDARD
STAFF TREATMENT OF CLIENTS
Name - Component - 00
The facility must ensure that all allegations of mistreatment, neglect or abuse, as well as injuries of unknown source, are reported immediately to the administrator or to other officials in accordance with State law through established procedures.
Observations:
Based on staff interview and investigation report review, it was determined facility staff failed to report four allegations of potential neglect in a timely manner to facility administration for four individuals residing at the facility. (Individuals #1, #2, #3, #4).Findings included:A. Individuals #1, #2, #3, #4
1. Review of a facility investigation and staff interview revealed an incident of a potential neglect had occurred on February 18, 2023, at approximately 10:45 p.m. The allegation was not reported to facility administration until February 20, 2023, at 9:00 a.m., thirty-four hours after the alleged incident had occurred. Investigation revealed that two staff working second shift on February 18, 2023, were sleeping when the third shift arrived at 10:45 p.m.
Individual #1 was found awake and stated that she had been yelling for staff and no one came to help her into bed. Individual #1's supervision level requires staff to provide 15 minute periodic checks while awake and hourly visual checks.
Individual #2 was found with her bedrail down and incontinent of feces and needed to be changed. Individual #2's supervision level requires five minute periodic checks while awake and hourly visual checks when asleep.
Individual #3 was awake and found wandering around while staff was sleeping. Individual #3's supervision level requires five minute periodic checks while awake, and hourly bed checks when asleep.
Individual #4 was awake and yelling for assistance to go into the bathroom. individual #4's supervision level requires five minute periodic checks.
Review of the investigation findings revealed the alleged neglect was confirmed.
Facility staff involved were terminated as a result of the incident.
B. The Qualified Intellectual Disability Professional (QIDP) was interviewed on June 7, 2023, at 9:00 a.m. During the interview the QIDP confirmed that the facility failed to ensure all allegations of mistreatment, neglect or abuse, were reported immediately to the administrator.
Plan of Correction:With regard to Item A-1, staff failed to report an allegation of Neglect for Individual #1, Individual #2, Individual #3, and Individual #4 which occurred on February 18, 2023, when the two staff on shift were found to be asleep. A certified investigation into each of these incidents began on February 20, 2023; all incidents were confirmed. Both of the target staff were terminated on February 23, 2023, as a result of the incident. The staff who failed to report the incident timely received progressive discipline according to agency policy and retraining by the ICF/ID Director on incident reporting.
All facility staff were retrained on Abuse, Neglect, and timely reporting of incidents on March 1, 2023. Additional retraining on Abuse and Neglect occurred at the June 13, 2023, team meeting. This retraining focused very strongly on when and how to report allegations of abuse and neglect. These interventions will benefit for Individual #1, Individual #2, Individual #3, Individual #4, and all other individuals who reside in the facility by assuring that staff understands what constitutes abuse and neglect and how to report these incidents. Effectiveness will be evidenced by no further allegations of abuse or late reporting of incidents. The QIDP will have overall responsibility for these interventions.
483.430(e)(3) STANDARD
STAFF TRAINING PROGRAM
Name - Component - 00
Staff must be able to demonstrate the skills and techniques necessary to administer interventions to manage the inappropriate behavior of clients.
Observations:
Based on staff interview, incident report, and facility investigation report review, it was determined that facility staff utilized a restrictive intervention that was not an approved behavioral intervention specified in one individual's behavioral support plan. (BSP) (Individual #5)
Findings included:
A. Individual #5
1. The record of Individual #5 was reviewed on June 5, 2023. This individual's diagnoses included: Severe Intellectual Disability, Pica, and Seizure Disorder.
2. Review of Individual #5's record also revealed Individual #5 does not presently have a BSP in place for restrictive physical/mechanical restraint interventions.
3. Review of a facility investigation report on June 5 and 6, 2023, revealed that on July 13, 2022, at 6:30 a.m. a facility staff implemented a mechanical restraint that is not an authorized intervention. The target staff placed a body pillow in the doorway of her bedroom in a manner that restricted Individual #5's ability to leave her bedroom. The facility initiated a certified investigation into the incident.
4. Further review of the incident report revealed that the facility determined that a body pillow had been used to "restrain" Individual #5 in her bedroom, rather than allow access to the hallway of her living area on July 13, 2022. The target staff had utilized a restrictive behavioral intervention that was not authorized. The target staff responsible for Individual #5 at that time received disciplinary action and additional training on abuse, rights violations, and seclusion as a result of this incident.
5. Interview with the Qualified Intellectual Disabilities Professional on June 7, 2023, at 9:00 a.m. confirmed that staff failed to demonstrate the skills and techniques necessary to administer interventions to manage inappropriate behavior of clients.
Plan of Correction:With regard to Item A, a certified investigation found that on July 13, 2022, staff had utilized a restrictive intervention that was not an approved behavioral intervention specified in Individual #5's behavioral support plan.
On July 14, 2022, the target staff was disciplined and retrained on abuse, individual's rights, and seclusion as a result of this incident.
Retraining on abuse, improper/unauthorized use of restraints and individual's rights occurred with all staff on August 9, 2022. Additional retraining on abuse, neglect, and improper/unauthorized use of restraints occurred at a facility meeting with all staff on June 13, 2023.
These interventions will benefit individual #5 and all other individuals who reside in the facility by assuring that staff understands what constitutes abuse and improper/unauthorized use of restraints. Effectiveness will be evidenced by no further allegations of abuse, or misuse of restraints. The QIDP will have overall responsibility for these interventions.
483.430(e)(4) STANDARD
STAFF TRAINING PROGRAM
Name - Component - 00
Staff must be able to demonstrate the skills and techniques necessary to implement the individual program plans for each client for whom they are responsible.
Observations:
Based on staff interview, investigation report review, and incident report review, it was determined the facility failed to ensure staff demonstrated the skills and techniques needed to implement the treatment plan for one of twelve individuals residing at the facility. (Individual #5)
Findings included:
1. Individual #5
a. Review of a facility incident report, documentation review, and facility investigation, revealed on May 20, 2023, at 8:30 a.m. Direct Support Professional (DSP) was observed giving Individual #5 juice in a sippy cup. Individual #5 is an aspiration risk and has a doctor's order for no fluids by mouth. Individual #5 receives 650 ML water via G Tube TID at 8 am, 4:00 p.m. and 8:00 pm, per doctor's orders. Speech and Language Pathologist is the only staff authorized to give Individual #5 liquids at this time.
b. Facility opened a Certified Investigation into the incident and determined that the DSP neglected to follow current doctor's orders and Individual Program Plan for Individual #5 by giving her fluids.
c. Facility staff DSP was disciplined per policy and received retraining as a result of the incident.
d. Interview with the Qualified Intellectual Disabilities Professional on June 7, 2023, at 9:00 a.m. confirmed staff failed to demonstrate the skills and techniques necessary to implement the individual program plan for the individuals for whom they are responsible.
Plan of Correction:In regards to Item 1-A, a certified investigation found that on May 20, 2023, staff gave Individual #5 fluid by mouth; however, Individual #5's physician orders state that fluids are only to be given via g-tube.
Facility staff was disciplined per agency policy on May 26, 2023, and received retraining on following prescribed diets and physician orders. Additional retraining on abuse and following physician orders occurred on June 13, 2023, with all facility staff.
These interventions will benefit individual #5 and all other individuals who reside in the facility by assuring that staff understands the importance of following all physician orders and prescribed diets. Effectiveness will be evidenced by no further allegations of failure to follow physician orders. The QIDP and Health Services Supervisor will have overall responsibility for these interventions.
483.460(k)(1) STANDARD
DRUG ADMINISTRATION
Name - Component - 00
The system for drug administration must assure that all drugs are administered in compliance with the physician's orders.
Observations:
Based on staff interview and incident report review, it was determined the facility failed to ensure three individual's medications were administered without error.
(Individual #6, #7, #8).
Findings included:
A. Individual #6
1. On July 11, 2022, on the a.m. shift, the individual's medications Calcium, Linzess, Claritin, Robinul, baclofen, Klonopin, Tranxene t-tab were omitted.
B. Individual #7
1. On November 21, 2022, on the p.m. shift nurse reported that one half of the a.m. medications were not given. The individual's medications Keppra, Flomax, Celexa, synthroid, vitamin D, Therems, and Arimidex were omitted.
C. Individual #8
1. On June 16, 2022, the individual's a.m. medication clonidine was not given.
D. Individuals #6, #7, and #8 had no ill effects from the medication errors.
E. The Qualified Intellectual Disability Professional (QIDP) was interviewed on June 7, 2023, at 9:00 a.m. During the interview, it was confirmed that staff failed to administer drugs in compliance with physician's orders.
Plan of Correction:With regard to Item A-1, on July 11, 2022, Individual #6's Calcium, Linzess, Claritin, Robinul, Baclofen, Klonopin, and Tranxene were omitted.
The nurse was retrained by the Health Service Supervisor on following medication pass procedures and checking the medication cassettes after med pass to ensure all medications have been administered.
With regard to Item B-1, on November 21, 2022, it was reported that Individual #7 did not receive half of their morning medications. Individual #7 did not receive Keppra, Flomax, Celexa, Synthroid, Vitamin D, Therems, or Arimidex.
The nurse was retrained by the Health Service Supervisor on medication pass procedures and checking the medication cassettes to ensure all medications have been administered.
With regard to Item C-1, Individual #8 did not receive Clonidine during an evening medication pass as the pill was found the next morning in the slot.
The nurse committing the error states that they had checked all cartridges twice at the end of med pass and there was no pill noted to be left in the slot. The Health Service supervisor completed retraining with the nurse on checking all medication cassettes after passing medication to ensure there are no missed pills in the cartridge.
Additional retraining was conducted on April 26, 2023, with all health service staff. This training was provided by the ICF Health Service Supervisor.
These interventions will benefit Individual #6, Individual #7, Individual #8 and all individuals in the facility by assuring that all medications are administered according to the physician's orders. Effectiveness of the interventions will be evidenced by no further incidents of individuals not receiving medications as prescribed. The ICF/ID Health Service Supervisor will have overall responsibility for the monitoring and effectiveness of these interventions.
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