§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, select facility policy and facility incident reports, observations, and staff interviews, it was determined that the facility failed to provide the necessary treatment and services to maintain the highest practicable level of mental, physical and psychosocial well being of three residents with a diagnosis of dementia out of 21 sampled residents (Residents 74, 80, and 77 ).
Findings include:
A review of a facility policy entitled "Behavioral Management" that was last reviewed on January 16, 2024, indicated that residents exhibiting behaviors that could endanger themselves, other residents, or staff may benefit from a behavioral care plan to ensure that they receive appropriate services and interventions to meet their needs. A behavioral health care plan could include a schedule of daily life events that address the individuality of the resident and should reflect the resident's personal preferences, and usual routines, to the extent possible. The care plan should include the recreational schedule, non-pharmacological interventions, and environmental adjustments needed to help the resident his/her highest practicable well-being. Additionally, the care plan should be reviewed quarterly for continued need of behavioral management and appropriate interventions.
A clinical record review revealed that Resident 74 was admitted to the facility on July 26, 2021, with diagnoses that included Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks). A review of a quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated January 16, 2024, revealed that Resident 74 is severely cognitively impaired.
Resident 74's care plan dated April 11, 2023, revealed that the resident displayed socially inappropriate behaviors of hitting, punching, and swinging at staff with planned interventions to encourage the resident to interact with others and participate in activities of interest and encouraging the resident to express any feelings, fears, needs, or concerns as able. The resident's care plan, dated October 18, 2022, revealed that the resident had the potential to be verbally and physically aggressive toward staff related to dementia with planned interventions to anticipate the resident's needs, provide physical and verbal cues, and provide the resident with as many choices as possible about care and activities.
A progress note dated December 6, 2023, at 5:03 AM indicated that Resident 74 had increased behaviors throughout the night. The resident was observed rummaging in other rooms, wandering with impact on others and himself, hitting and resisting staff attempts at care or redirection. At 10:00 PM on this date Resident 74 was aggressive with care throughout the evening and was observed displaying kicking and hitting behaviors.
A progress note dated January 14, 2024, at 8:03 PM indicated that Resident 74 was very angry and agitated during this shift. The resident was wandering around the unit as normal, grabbing other residents' wheelchairs, trays, garbage cans, chairs, and touching other residents. The resident was observed making threatening statements to staff. Close supervision was provided; however, the resident was not receptive to all directions.
A record review revealed a Documentation Survey Report dated February 2024, indicating that Resident 74 was observed hitting others on February 1, 2024, and February 4 of 2024; grabbing others on February 1 and 18 of 2024; and wandering on February 3, 4, and 24 of 2024.
Nursing progress notes dated February 15, 2024, at 9:06 PM revealed that a nurse aide reported Resident 74 had smacked another resident in the face. The note indicated that the residents were immediately separated, and Resident 74 had no complaints of pain or distress. However, the entry indicated that Resident 74 continued to display increased poor impulse control with behaviors such as wandering into resident rooms and pushing residents in wheelchairs. The note explained that distraction activities were provided and effective for brief periods of time.
There was no indication that the facility had implemented an individualized plan of care, including providing purposeful and meaningful activities based on Resident 74's past history, customary routines, and preferences identified, such as gardening, time outdoors, jeopardy, hallmark movies, being read too, crafting, or hymns to address the resident's known dementia related behavior to promote the resident's quality of life and highest practical level of psychosocial well-being and safety.
A clinical record review revealed that Resident 80 was admitted to the facility on September 1, 2023, with diagnoses that included dementia. A significant change in status MDS assessment dated February 1, 2023, revealed that Resident 80 is severely cognitively impaired.
A review of Resident 80's current care plan revealed that he has a problem with impaired cognitive functions, impaired thought processes, and impulse control related to his diagnosis of dementia, initiated September 3, 2023, with planned interventions to provide cueing, reorienting, and supervising as needed; engaging the resident in simple, structured activities; and providing a program of activities that accommodates the resident's abilities. Resident 80's current care plan revealed that he enjoys 50s and 60s music, word search, reading the newspaper, car magazines, time outdoors, socials, animals, kids, and assisting with bingo.
A progress note dated October 18, 2023, at 9:55 PM indicated that Resident 80 was demanding to use the mobility chair of another resident, unbuckling her safety belt, and attempting to lift her from the chair by the arm. Resident 80 was threatening staff and refusing to let go of the other resident's mobility chair for several minutes before redirection was successful. Education was provided to Resident 80 on behaviors. On October 18, 2023, at 10:13 PM Resident 80 was observed displaying increased behaviors this evening. The resident was cursing, degrading, and threatening staff and other residents.
A physician's order was noted for Resident 80 to receive Tegretol Oral Tablet (Carbamazepine- an anticonvulsant medication) 100 mg two times a day for impulse control was initiated on October 19, 2023.
A progress note dated October 29, 2023, at 11:07 PM indicated that Resident 80 was seeking out a female resident during the shift and required redirection several times. Close monitoring, emotional support, and activities were provided to residents throughout the shift. Progress notes dated October 30, 2023, at 2:55 AM indicated that Resident 80 continued to seek out female residents through the night. The resident was observed following staff in and out of female residents' rooms during care and standing in front of doors. Redirection was effective but only short periods of time.
A progress note dated November 6, 2023, at 6:46 AM indicated that Resident 80 was verbally aggressive, cursing, wandering into females' rooms, undressing in hallways, pacing, and unable to settle. The note indicated that snacks, fluids, redirection, toileting, and activities were only effective for short periods of time. On November 15, 2023, at 7:22 PM progress notes indicated that Resident 80 was easily agitated, verbally aggressive, cursing, threatening, and yelling at staff and residents. Redirection, snacks and fluids, puzzle books, and television were not effective. Resident 80 continued to threaten and yell at anyone near him. Resident 80 continued female seeking, cursing, threatening, and throwing objects. On November 24, 2023, Resident 80 was aggressive, restless, and verbally abusive towards staff and other residents. The resident yelled, "You bitch, you son's of bitches!" Snacks, fluids, toileting, a decrease in stimuli, and emotional support were offered with no change in behavior.
A progress note dated December 9, 2023, at 9:54 PM revealed that Resident 80 was verbally combative, yelling, and cursing at staff and other residents. Staff redirected and reapproached the resident with a positive outcome. Snacks were provided to the resident. A progress note dated December 18, 2023, at 2:51 AM revealed that Resident 80 was agitated, short with staff, and in a poor mood. The resident stated, "I can't stand this sh*t anymore, let it be. I don't have pain. I just hate people." A progress note dated December 22, 2023, at 5:25 PM indicated that Resident 80 was agitated at the beginning of the shift, accusing, arguing, curing, pointing, and threatening physical harm to other residents and staff. Progress notes dated December 30, 2023, at 2:54 AM indicated that Resident 80 was awake throughout the night, pacing in the halls, undressing and redressing, being argumentative, cursing at staff and other residents, and knocking on resident bedroom doors. Education, emotional support, redirection, and distraction were provided and were effective for brief periods.
A progress note dated January 10, 2024, at 10:28 PM indicated that Resident 80 was wandering into other residents' rooms and was agitated with another male resident. Progress notes dated January 18, 2024, at 10:39 PM indicated Resident 80 had increased restlessness throughout the shift and was attempting to urinate on the floor and undress. The resident required frequent redirection throughout the night. A progress note dated January 26, 2024, at 3:00 AM indicated that Resident 80 had increased restlessness, agitation, yelling, and disrupting others.
A clinical record review revealed physician orders dated January 29, 2024, discontinuing Tegretol Oral Tablet (Carbamazepine- an anticonvulsant medication) 100 mg.
A progress note dated January 30, 2024, at 3:46 AM revealed that Resident 80 was agitated and restless throughout the night, required four hours of 1:1 supervision due to poor safety awareness. The resident was observed cursing at others, yelling, and grabbing other residents' wheelchairs. The resident's behavior was unchanged with the redirection. Activity was effective for short periods of time.
A record review revealed a Documentation Survey Report dated January 2024, indicating that Resident 80 displayed agitation on January 1, 3, 10, 24, 26, 29, and 30 of 2024. The resident was cursing at others, frustration directed at others, or aggression towards others on January 1, 3, 4, 10, and 21 of 2024, and the resident displayed entering other resident rooms on January 3 and 10 of 2024.
A progress note dated February 4, 2024, at 11:40 PM indicated that Resident 80 displayed agitation, screaming, cursing at others, and spitting at an aide. The note indicated that the resident was redirected several times, talked and listened too, walked, provided a snack, and toileted. The resident's behavior was unchanged. A progress note dated February 5, 2024, at 9:22 PM indicated that Resident 80 started with increased behaviors at 6:55 PM. Resident 80 cursed at another male resident and threatened others. Redirection, distraction, and anticipation of needs had some effect. Progress note dated February 6, 2024, at 10:40 PM indicated that Resident 80 displayed restlessness, facial flushing, cursing at others, and banging on doors, walls, and banister. Distraction, activity, snacks, and fluids are provided. All effective for brief periods of time. Progress note dated February 10, 2024, at 11:02 PM indicated that Resident 80 attempted to wake up sleeping residents and was physically and verbally aggressive with staff. Ice cream, juice, a puzzle book, and anticipated needs are all effective for brief periods of time.
A record review revealed a Documentation Survey Report dated February 2024, indicating that Resident 80 displayed agitation on February 1 and 10 of 2023. The resident displayed cursing at others, frustration directed at others, or physical aggression toward others on February 4, 10, and 12 of 2024.
A clinical record review revealed that Resident 80 was in the community hospital from February 28, 2024, through March 8, 2024.
There was no indication that the facility had implemented an individualized plan of care, including facilitating purposeful and meaningful activities based on Resident 80's past history, customary routines, and identified activities preferences of music, car magazines, animals, or 50s and 60s music, to address the resident's known dementia-related behavior and promote the resident's quality of life and the highest practical level of psychosocial well-being and safety.
During an interview on March 15, 2024, at approximately 10:15 AM, the Nursing Home Administrator and Director of Nursing confirmed the facility had not consistently implemented an effective individualized and person-centered care plan to address Resident 74's or Resident 80's dementia-related behaviors.
A review of Resident 77's clinical record revealed that she was admitted to the facility on January 12, 2022, with diagnosis of unspecified dementia, cognitive communication deficit dysphagia, aphagia and anxiety. The resident had severe cognitive impairment according to the clinical record.
A quarterly Minimum Data Set assessment (Minimum Data Set - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated October 13, 2023, revealed that the resident was severely cognitively impaired.
The resident's plan of care, initiated January 18, 2022, and last revised on December 19, 2023, with altered behaviors as evidenced by socially inappropriate behaviors such as rummaging through other resident's belongings, disrobing in public, voiding/defecating in inappropriate areas, physically and verbally aggressive, calling anyone near her "Donna/Donald" and looking for husband "Mike" and pushing other residents. Resident 77's goal was to not exhibit socially inappropriate behaviors with a goal to encourage the resident to interact with others as able, enjoyed small groups such as sing-a-longs and Rosary. Resident 77's plan of care indicated that the resident was at risk for wandering and had the potential to become physically/verbally aggressive towards staff and others related to dementia.
A review of the resident's clinical record nursing progress notes dated October 2023 revealed that Resident 77 had demonstrated repeated escalations in dementia related behaviors on October 4, 2023, October 12, 2023, at 10:10 PM, and October 18, 2023.
An incident investigation dated October 18, 2023, at 9:30 p.m., revealed that Resident 77 was observed unbuttoning her shirt and was kissing Resident 80, a severely cognitively impaired male resident on the unit, in the dinette on the Gold Unit. Resident 80's hand was touching Resident 77 in the breast area. Nursing staff witnessed this from down the hall and immediately stopped the interaction. Both residents were separated and provided with increased staff supervision. Both residents attending physicians were notified, and psychiatric services consulted to re-evaluate.
On October 19, 2023, at 2:26 a.m., Resident 77 continued to display behaviors during the night shift and was awake and pacing the halls.
A "Psychiatric Progress Note" completed by facility's consultant psychiatric physician dated October 19, 2023, revealed that the resident had increased physical and verbal aggression, was more irritable and impulsive, and was easily agitated and difficult to re-direct. The psych MD assessed and diagnosed the resident with major neurocognitive disorder and increased the resident's dose of Zyprexa (an antipsychotic medication that affects chemicals in the brain and used to treat psychotic conditions such as schizophrenia and bipolar disorder) to 2.5 mg three times daily and to continue to monitor.
Further review of Resident 77's clinical record revealed progress note documentation dated from November 2023 through survey ending March 15, 2024, which revealed that the resident continued to have escalating dementia behaviors of verbal and physical aggression towards staff and peers, agitation, wandering/exit seeking behaviors, and rummaging through peer's personal belongings. The resident was disruptive to her peers by following them around and insisting other residents were her spouse.
During an observation of the Gold Unit on March 14, 2024, at approximately 10:45 a.m., Resident 77 was observed in another resident's room, room 324, laying on the other residents' bed near the door. Continued observation of the Gold Unit revealed that upon exiting the resident activity room, at approximately 11:04 a.m., nursing staff discovered that Resident 77 was not in the correct room and escorted her out. The resident entered the activity room, where a few residents were assembled with the TV on, but did not engage in the activity of watching television and instead began to wander about the unit.
The facility failed to demonstrate that it had identified, addressed and/or obtained the necessary services for the dementia care needs of residents including developing individualized interventions related to the resident's symptomology and rate of progression, reviewing and revising care plans that were ineffective, and modifying the residents' environments if needed. The Director of Nursing (DON) when interviewed on March 14, 2023, at 1:05 p.m., confirmed that the interventions developed to prevent intrusive wandering and resident to resident altercations, and related behavioral symptoms, displayed by residents with dementia have not been fully effective.
Refer F600 and F679
28 Pa. Code 211.12 (d)(3)(5) Nursing services
28 Pa. Code 201.18 (e)(1) Management
28 Pa. Code 201.29 (a) Resident rights
| | Plan of Correction - To be completed: 05/14/2024
0744 1. A care plan meeting was held for Residents 74 and 77 to address their diagnosis of dementia and to come up with a plan to maintain the highest practicable level of mental, physical and psychosocial well-being. Individualized interventions were developed for their dementia related behaviors and care planned. Behaviors will be monitored daily to assure the interventions are effective. Resident 80 is no longer under the facility's care. 2. Residents with dementia that are exhibiting behaviors will be reviewed by the IDT and/or physician/psychologist so interventions can be put in place to maintain the highest practicable level of mental, physical and psychosocial well-being. Behaviors will be monitored daily to assure the interventions are effective 3. The behavior management plan has been reviewed/revised with emphasis on dementia related behaviors to promote the highest practicable mental, physical and psychosocial well-being of residents. The behavior management plan will include investigations of behaviors including interviews of line staff. Residents' dementia related behaviors will be tracked and monitored daily at morning meeting and if needed will have new interventions put in place, including physician services if needed. The plan will be in-serviced to direct care staff. 4. The DON/designee will take a random sample of residents per week and research the EMR for behaviors. If behaviors are present the audit will verify that the correct process is followed according to the behavior management plan. This audit will be turned in to QA for review. 5. May 14, 2024
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