Initial Comments:
A monitoring survey was conducted on January 30 and 31, 2024, 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 233. One deficiency was identified as a result of the survey.
Plan of Correction:
483.430(e)(2) STANDARD
STAFF TRAINING PROGRAM
Name - Component - 00
For employees who work with clients, training must focus on skills and competencies directed toward clients' health needs.
Observations:
Based on facility incident report review, facility investigation report review, and staff interview, it was determined that the facility failed to ensure that staff demonstrated the necessary skills and competencies directed towards the health needs for four individuals in the sample. (Individuals #1, #2, #3 and #4)
The findings included the following:
A. Individual #1
1. An investigation report, dated January 12, 2024, was reviewed on January 30, 2024. This review revealed that on January 2, 2024, Individual #1 was transferred from her bed to a shower chair by one staff utilizing a manual transfer. According to witness statements, the staff "scooped" this individual up from her bed. This action was witnessed by the qualified intellectual disabilities professional (QIDP), who informed the staff that this was not an approved transfer method for Individual #1.
2. Further review of the investigation report revealed physician's orders, dated November 20, 2023, that indicated Individual #1 required a "mechanical lift for all transfers". In addition, the Individual Program Plan (IPP), dated December 13, 2023, indicated "Individual #1 uses a mechanical lift for all transfers". The investigation packet also included this individual's "Info Sheet", with a section titled "Transfer/Ambulation Supports". This section indicated "Two-person mechanical lift for all transfers". The facility investigation determined neglect and the staff received counseling and retraining as a result.
B. Individual #2
1. Individual #2 has a diagnosis of aspiration pneumonia. He has been hospitalized on the following dates with aspiration pneumonia: October 9-11, 2023. A physician's order, dated October 11, 2023, revealed that Individual #2 is to be totally assisted during feedings. Individual #2's dining card was updated on October 12, 2023 to reflect the dietary changes.
2. An investigation report, dated December 30, 2023, was reviewed on January 31, 2024. The investigation revealed that on November 29, 2023, a physician's assistant (PA-C) observed and reported a staff person on the second tour of duty, allowing Individual #2 to feed himself without staff assistance. The facility investigation determined neglect, and the staff received counseling and retraining as a result.
C. Individual #3
1. An investigation report dated, December 1, 2023, was reviewed on January 30, 2024. The investigation revealed that on November 23, 2023, a Licensed Practical Nurse (LPN) discovered that Individual #3 had the wrong name on the feed bag that she was hooked up to. LPN stopped the feed pump immediately. No signs or symptoms of distress noted.
2. The investigation revealed the Registered Nurse (RN) who hooked up Individual #3's feed bag did not follow the Medication Administration Policy/Procedure by not using a three-step identification process to identify the right person. Neglect was confirmed, and the nurse received counseling and retraining.
D. Individual #4
1. An investigation report, dated December 1, 2023, was reviewed on January 30, 2024. The investigation revealed that on November 23, 2023, a Licensed Practical Nurse (LPN) discovered that Individual #4 had the wrong name on the feed bag she was hooked up to. LPN stopped the feed pump immediately. No signs or symptoms of distress noted.
2. The investigation revealed Registered Nurse (RN) who hooked up Individual #4's feed bag did not follow the Medication Administration Policy/Procedure by not using a three-step identification process to identify the right person. Neglect was confirmed, and the nurse received counseling and retraining.
E. The Facility Director and Quality Assurance Risk Manager were both interviewed on January 31, 2024, at 11:00 AM and confirmed staff had failed to ensure staff demonstrated the necessary skills and competencies directed towards the health needs for four individuals.
Plan of Correction:1. For Individual #1 all Program Services staff will be trained on proper mechanical lift transfer techniques.
Chief Occupational Therapist (COT) (I)
4-26-24
2. COT ensure that in person mechanical lift training is completed for all Direct Care Staff in Program Services. Staff Development Specialist 1 (SDS1) will track the in-person training to ensure that all above mentioned staff are trained and submit the completed training rosters to the Quality Assurance Risk Management Director (QARMD).
COT (I)
SDS1 (M)
Quality Assurance Risk Management Director (QARMD) (M)
4/26/24
3. COT will develop a competency evaluation tool to be utilized to assess staff competency regarding mechanical lift transfer techniques. This tool will be utilized by Community Support Managers (CSM), Residential Services Supervisors (RSS) and Residential Services Workers (RSW) randomly at least once per shift on living areas that utilize mechanical lifts. The completed tools will be submitted to the QARMD for review to ensure that they are being completed as directed and any deficiencies noted are corrected.
COT (I)
CSM (I)
RSS (I)
RSW (I)
QARMD (M)
3-29-24 and ongoing.
4. For Individual #2 all Program Services staff will be trained on reading and following dining/feeding supports as outlined on individual's Dining Cards.
SDS1(I)
4-26-24
5. CSM will ensure training on dining/feeding supports is completed for all Direct Care Staff in Program Services. SDS1 will track the in-person training to ensure that all above mentioned staff are trained and submit the completed training rosters to QARMD.
CSM (I)
SDS1(M)
QARMD (M)
4-26-24
6. CSM will develop a Dining Observation Tool to assess that dining/feeding supports are being implemented as per each individual's Dining Card. This tool will be utilized by RSS and RSW staff randomly at mealtimes on each living area at least 3 times per week. The completed tools will be submitted to the QARMD for review to ensure that they are being completed as directed and any deficiencies noted are corrected.
CSM (I)
RSS (I)
RSW (I)
QARMD (M)
3-29-24 and ongoing.
7. For Individual #3 and Individual #4 all Nursing staff will be trained on the Medication Administration Policy/Procedure which emphasizes utilizing the three-step identification process to identify the right person.
Nurse Manager (NM) (I)
4-26-24
8. Nurse Manager (NM) will ensure that the Medication Administration Policy/Procedure Training which emphasizes utilizing the three-step identification process to identify the right person is completed by all Nursing staff. SDS1 will track the in-person training to ensure that all above mentioned staff are trained and submit the completed training rosters to Health Services Director (HSD).
NM (I)
SDS1 (M)
HSD (M)
4-26-24
9. NM will develop a competency evaluation tool to assess nursing staff competency when hooking up individual feeding bags assuring that the right individual is connected to the correct feeding bag. This Tool will be utilized by Registered Nurse Supervisors (RNS) each shift. The completed tools will be submitted to the Health Services Director (HSD) for review to ensure that they are being completed as directed and any deficiencies noted are corrected.
NM (I)
RNS (I)
HSD (M)
3-29-24 and ongoing.
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