Initial Comments:
A focused fundamental survey was conducted on November 15, 2022 through November 18, 2022 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 37, and the sample consisted of six individuals. Two deficiencies were identified as a result of the survey.
Plan of Correction:
483.420(d)(4) STANDARD
STAFF TREATMENT OF CLIENTS
Name - Component - 00
If the alleged violation is verified, appropriate corrective action must be taken.
Observations:
Based on review of two facility investigation reports and staff interview, it was determined that the facility failed to ensure that facility corrective actions were identified and included in the investigation reports to ensure there is no recurrence. This applied two of four investigations reviewed.
Findings included:
A. Individual #1
1. A review of a facility investigation was completed on November 15, 2022. This review revealed an investigation was conducted on June 23, 2022 regarding an allegation of neglect. The facility failed to document corrective action for the above-mentioned investigation.
2. The facility was also unable to provide documentation in the investigation that the training was provided and completed by staff.
B. Individual #2
1. A review of a facility investigation was completed on November 15, 2022. This review revealed an investigation was conducted on April 4, 2022 regarding an allegation of verbal and psychological abuse. The facility failed to document corrective action for the above-mentioned investigation.
2. The facility was also unable to provide documentation in the investigation that the training was provided and completed by staff.
C. The Assistant Vice President (AVP) was interviewed on November 17, 2022 at 1:45 p.m. During the interview the AVP confirmed that two facility investigation reports failed to include corrective actions to ensure there is no recurrence.
Plan of Correction:W157 STAFF TREATMENT OF CLIENTS
Allied Services ICF/ID Program conducted two investigations, an incident of neglect in June 2022, and an incident of verbal/psychological abuse in April 2022. However the facility failed to adequately complete the investigation narrative with the "Corrective Action" and signed administrative review.
In order to address the deficient areas identified in W157, the facility will implement the following corrective action to address Individual #1's allegation of confirmed neglect and Individual #2's allegation of confirmed verbal and psychological abuse:
Individual #1: This incident involves Individual #1 receiving the incorrect meal consistency that lead to a hospitalization. Individual #1 was admitted into Allied Services ICF/ID Program (WWSR) on 6/10/22. Individual #1 is a 55 year old gentleman admitted from his natural home with a diagnosis of Moderate ID, Down Syndrome, and Dementia. He was admitted to the facility on a Mechanical Soft Diet, Bite Size Pieces and Munchkin Spoon. On 6/22/22 during a morning Stand-Up Meeting, the team, acknowledging Individual #1's difficulty chewing, recommended a "Pureed Diet" until a "Swallow Study" could be conducted. The 2nd Shift Supervisor failed to read the diet changes in the Stand-up Meeting Minutes, and Individual #1 did not receive the correct meal.
Numerous corrective actions were implemented but were not identified and omitted from the "Corrective Actions" for Individual #1's incident. Corrective Action:
-Dry Erase Board placed at Cafeteria Line to highlight daily change in resident(s) diet.
-Re-inservicing all staff on Dietary Census Cards and "Tray Cards" to ensure consistency
-Increase Dietician from Part-Time to Full-Time
-Hire of Dietary Staff with exclusive dietary functions
These "Corrective Actions" failed to be documented within the investigation narrative, and failed to have a signed administrative review.
Individual #2: This incident involved Individual #2 being a victim of verbal/psychological abuse that involved the target being terminated from employment. The investigation narrative did not identify the "Corrective Action" within the investigation narrative.
To correct the deficiency related to Individual #1 and Individual #2, the respective Certified Investigator will complete the "Corrective Action" Section of the investigation. In addition, the
agency Assistant Vice President or Program Director will provide a signed and dated administrative review.
To address all other individuals who may be adversely affected by the deficient practice, the facility will implement the following corrective actions to prevent re-occurrence:
Agency Point Persons and Certified Investigators will be re-inserviced on the correct completion of investigation narrative. Content of a complete investigation shall include:
-Background
-Incident
-Investigation & Testimony
-Conclusion & Findings
-Facility Corrective Action
-Administrative Review and Signature
In order to monitor progress in this plan of correction, the facility will use the monthly Incident Management Meetings to track progress and closure of individual investigations to ensure all components of the investigation are correctly documented.
The Assistant Vice President and/or the Program Director will be ultimately responsible for the plan of correction and to ensure there is no reoccurrence of the deficient practice noted in W157.
483.480(a)(1) STANDARD
FOOD AND NUTRITION SERVICES
Name - Component - 00
Each client must receive a nourishing, well-balanced diet including modified and specially-prescribed diets.
Observations:
Based on incident report review, investigation report review and staff interview, it was determined that the facility failed to follow the specially modified prescribed diet for one individual in the facility. (Individual #1)
Findings included:
A. Individual #1
1. Review of individual #1's medical record revealed that a pureed diet was ordered due to aspiration concerns.
2. Investigation report and incident report review revealed that on June 22, 2022, at 5:00 p.m., staff presented Individual #1 with a regular diet meal tray instead of a pureed diet meal. Individual #1 began to cough after consuming some of the meal. Staff realized that the had given the wrong meal tray to Individual #1 at that time. The staff removed the food tray, and the nurse was called to assess the situation. As a result of intermittent coughing the facility nurse determined that Individual #1 needed to be sent to the hospital for further evaluation. Individual #1 was subsequently sent to the hospital where he was admitted and treated. The investigation report determined that staff had failed to follow the specially modified prescribed diet by giving Individual #1 the wrong meal on June 22, 2022, at 5:00 p.m. Staff were counseled and retrained as a result of the incident.
B. The Assistant Vice President (AVP) was interviewed on November 17, 2022 at 1:45 p.m. During the interview the AVP confirmed that facility staff failed to follow the specially modified prescribed diet for Individual #1 and this resulted in admission and treatment at a local hospital.
Plan of Correction:W460 FOOD AND NUTRITION SERVICES
The facility failed to provide the appropriate meal to Individual #1 who had aspiration concerns that resulted in "coughing", an emergency room assessment, and hospitalization due to aspiration pneumonia and sepsis.
Individual #1 was admitted to the Allied Services ICF/ID Program at the WWSR on 6/10/22. He is a 55 year old gentleman with a diagnosis of Moderate ID, Down Syndrome and Dementia. His admission diet included Mechanical Soft Consistency, Bite Size Pieces and Munchkin Spoon. On 6/22/22, at morning Stand-Up, continued concerns over Individual #1's diet resulted in the team decision to "step-down" to a Pureed diet until a "swallow study" could be conducted. The Supervisor on the 2nd shift "missed" the order change on the Stand-Up Meeting Minutes, and Individual #1 received the incorrect meal and consistency. The result was an emergency room visit due to "coughing", then subsequent hospitalization.
Individual #1 returned to the WWSR on 7/13/22. During his hospitalization he failed several swallow studies and family provided consent for insertion of a feeding tube. The Interdisciplinary Team made the decision to have Individual #1 a 1:1 on 7/13/22 to prevent him from pulling out his tube.
To address the deficient practice that lead to Individual #1's hospitalization due to the incorrect dietary intake and to protect all others who could be adversely affected by the deficient practice, the facility implemented the following corrective action:
-Dry Erase Board placed at Cafeteria Line to highlight daily change in resident(s) diet.
(This measure "highlights" the dietary change in a more prominent manner, than the morning Stand-Up Meeting alone.)
-Re-inservicing all staff on relationship between Dietary Census Cards and "Tray Cards" to ensure accuracy and continuity between both documents.
(The Staff Training Coordinator dietary cards were completed in both English and Spanish. The Dietician will make changes in the Dietary Census Cards and communicate with kitchen/dietary staff)
-Increase Dietician from Part-Time to Full-Time
(This will allow more "meal time observations" by the dietician and increase communication with kitchen/dietary staff)
-Hire of Dietary Staff with exclusive dietary responsibilities
(In 2022, there was a reduction of dietary workers due to voluntary terms, and there were no replacements due to changes in food services delivery that resulted in Resident Assistants (Direct Support Professionals) performing increased responsibilities in food service delivery and meal time monitoring. This initiative reinstitutes the hiring of food service workers.
The facility will continue to use the morning and afternoon "Stand-up Meeting" forum that includes the QIDP, Nursing, Dietician, Assistant Supervisors, Day Program, and other disciplines to identify and communicate "hot items" that require immediate attention that can be communicated to the dietary staff and direct care staff for the benefit of the individuals' health, welfare and safety. The Assistant Vice President and/or Program Director, through either attendance or through communication with any of the disciplines, will be available for any issues that require prompt action.
In order to monitor progress in this plan of correction, the facility will use the monthly Incident Management Meetings to track progress of all the above corrective actions and modify strategies as necessary for the meal time activity.
The Assistant Vice President and/or the Program Director will be ultimately responsible for the plan of correction and to ensure there is no reoccurrence of the deficient practice noted in W460.
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