Initial Comments:
An incident monitoring visit was completed on February 29, 2024. The purpose of this visit was to evaluate compliance with the Requirements of 42 CFR, Part 483, Subpart I Regulations for Intermediate Care Facilities for Individuals with Intellectual Disabilities. The census at the time of the visit was 40, and the sample consisted of 10 individuals.
Plan of Correction:
483.420(d)(1) STANDARD
STAFF TREATMENT OF CLIENTS
Name - Component - 00
The facility must develop and implement written policies and procedures that prohibit mistreatment, neglect or abuse of the client.
Observations:
Based on a review of incident reports, record review and interview with administrative staff, the facility failed to develop and implement procedures that prohibit n mistreatment and neglect of care in the provision of medical services for one of one sample Individuals who experienced delay of care for an injury of unknown origin. This practice is specific to Individual #1.
Findings included:
A review of incident reports was conducted on 02/29/2024 from approximately 9:00 AM to 11:30 AM. This review revealed an incident report for Individual #1 dated 07/22/2023 in which the direct care staff described the incident as follows: "while supporting [Individual #1] with a shower, I noticed a bruise on the left side of his stomach. The nurse and supervisor were notified." This bruise was reported was 7:30 PM.
In the section titled Description of injury/medical equipment: completed by the LPN, it was noted: "Notified by staff around 7:30pm. Staff stated individual observed to be in pain. On nursing observation a bruise 4" in length 1 1/2" in weight seen on Individual left lateral abdomen area. Facial grimace noted on touch to area. 2 tab acetaminophen given for minor pain."
In subsequent review of a section on the incident report titled "Administrative Comments/Summary/Conclusion" included the following information:
"07/23/2023 Incident Report Meeting was held . . . [Individual #1] was seen and treated by Unit Nurse. Staff was instructed to notify nurse for any signs of further pain or discomfort. UIR (Unexplained Injury Review) initiated." In a review of the summary of findings related to this review, the following summary of the findings, included the following:
"[Individual #1] was seen and treated by Unit Nurse follow up visit at Health Services. x-ray was done. Staff reported that [Individual #1] had a good day spent on unit relaxing on sofa."
A review of physician's progress and order records dated 07/24/2023 revealed the following:
"Bruise of left side of abdomen, below the ribs. We were called about this at the start of 2nd shift so everyone denies recent knowledge. Per 24 hour report, they noted a 4" x 1 1/2" (10.2 cm x 3.8 cm) bruise on the left side of the abdomen noted while being bathed. No know cause of bruise. He was appearing to have some tenderness in the area and was given Acetaminophen. No mention in 24 hour report yesterday. Unit nurse today was not aware of the issue until PQI (Performance and Quality Improvement) called her at end of shift. They had him come here to be seen. No apparent issues on 1st shift but I can't interview anyone now."
When questioned why Individual #1 was not seen by a physician until 2 days post the discovery of this injury, interview with the facility nurse on 02/29/2024 at 10:45 AM,
indicated that delay was due to the PCP not being available on weekends.
This interviewee was unable to explain why alternate medical care was not provided during the two days between the time of injury and being seen by PCP. In further questioning, it was noted that there was no indication that the facility had a on-call medical system in place in order to provide emergent medical services on the weekend.
Plan of Correction:The facility will develop and implement procedures that prohibit mistreatment and neglect of care in the provision of medical services for one of one sample Individuals who experienced delay of care for an injury of unknown origin. This practice is specific to Individual #1.
Corrective Action for Affected Individual: CE#1
On or before 3/22/24 all nurses will receive an Inservice on positive findings on assessment and expected follow up that will include the following:
o Documentation: Progress note, IR, acute list, 24--hour report
o Notification: Charge nurse, Primary Care Physician (PCP) and parent, as per notification grid, hotline
o Charge nurse will notify Duty Administrator (DA) and Supervisor on call for cases of possible abuse/neglect.
o Follow up: At the beginning of each shift, nursing will give and receive verbal and written reports from previous 24 hours, require follow up assessment with needed documentation, until resolved.
o Review of on-call medical service availability 24/7.
All training will be documented on a Staff Attendance (SA)/training sign-off sheet. Copies of SA sheets will be submitted to the Learning Management System and sent to Performance, Quality Improvement Coordinator (PQIC) for file and Sr. Executive Director to verify completion. Original maintained by Health Services Director.
On or before 3/15/24 a team meeting will be held for Individual #1 to discuss plan of care.
Procedure for Identifying Potentially
Affected Individuals: CE#2
On or before 4/12/24, the Performance, Quality Improvement Coordinator (PQIC) will randomly select 30 % of incident reports with identified injures, over the last 3 months (January-March), to review timelines and ensure there was no delay in care. The outcome of the audit will be documented on a spreadsheet and submitted to various department heads for review and address via retraining/corrective actions. If a delay in care is discovered, the incident reporting process will be initiated, and a neglect investigation conducted.
Corrective Actions/Systematic Changes: CE #3
When an injury is witnessed or discovered, or in the event of acute illness/injury that requires emergency medical treatment, the first responder will provide an assessment and either notify the nurse or institute 5151. If 5151 was not initiated, the nurse will provide an assessment. If the nurse determines a life-threatening event, they will initiate 5151and treat as needed. When 5151 is initiated by any staff, the security officer immediately calls 911, notifies the Duty Administrator and Charge Nurse via push to talk, and proceeds to the front entrance to lead EMS to the emergency. After assessment in non-life-threatening situations, the nurse will notify the physician directly, if indicated. If there is no response within 15 minutes, the nurse will call the charge nurse for further instructions, so care is not delayed. When contacting the physician is not indicated, the charge nurse will be contacted.
When an incident requires an investigation the Performance, Quality Improvement Coordinator (PQIC)sends out a notification requesting a certified investigator (CI) to be assigned. Once the CI has been assigned, a status update is scheduled within 7 calendar days. At the update meeting the CI will update the Executive/Associate Executive Director and team of the investigations progress to date. When applicable, recommendations for corrective actions will be documented by the Performance, Quality Improvement Coordinator (PQIC)and sent via email to responsible parties for review and implementation.
Once the investigation is completed, the CI presents the investigation's outcome to the Administrative Review Committee (ARC) (attended by various department heads to include the program executive team, Employee Relations Manager, Labor and PQI). The ARC will review the report and decide on the investigation's outcome based on the information presented. If additional information is needed, the CI will be asked to follow up and another meeting will be scheduled, the process completed again. The Performance, Quality Improvement Coordinator (PQIC)will document the outcome of the ARC mtg in section V of the investigative report.
Persons Responsible for Monitoring Corrective Actions:
Any noted discrepancies and/or corrective actions will be reported to the Senior Executive Director by the Director of Nursing and Director of Performance, Quality Approvement.
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