| 4404 |
PIONEER HEALTH OF CENTRAL GEORGIA |
115564 |
712 PATTERSON STREET |
BYROMVILLE |
GA |
31007 |
2016-12-10 |
501 |
J |
1 |
0 |
QBL111 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews and record review, the Medical Director failed to assure care was provided that met current standards of practice in areas including resident-to-resident abuse and use of [MEDICAL CONDITION] medications. The facility's failure to ensure residents were protected from further physical abuse by R#39 was determined to be likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 12/8/16 and determined to first exist on 10/23/16, when R#39 first threatened R#56 with harm using a wire clothes hanger. The facility's Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy on 12/8/16 at 2:55 p.m. An acceptable AoC was received on 12/10/16 and the surveyors validated the Immediate Jeopardy was removed on 12/10/16 as alleged. The deficient practice remained at a D (isolated potential for more than minimal harm) scope and severity while the facility developed and implemented the Plan of Correction and the facility's Quality Assurance Committee monitored the effectiveness of the systemic changes. Findings include: During the annual recertification survey and complaints investigation from 12/5/16 to 12/10/16, the facility was found out of compliance with regulatory requirements regarding prevention of resident-to-resident abuse and use of [MEDICAL CONDITION] medications. Cross-reference F222: Chemical Restraints - the facility failed to ensure resident (R) #56 and R#83 were not chemically restrained. The facility administered an array of [MEDICAL CONDITION] medications, including PRN (as needed) injections of medications and multiple medications from the same drug class, to manage residents' behaviors for staff convenience. [DIAGNOSES REDACTED]. The rationale and effectiveness of the medications was not consistently documented. Cross-reference F223: Physical Abuse - the facility failed to ensure that R#39's physically abusive behaviors were addressed and interventions were implemented to keep residents safe from further potential harm. R#39 threatened R#56 with harm from a wire clothes hanger on 10/23/16. On 12/5/16, R#39 was observed hitting R#56 with a wire clothes hanger. The facility responded with an intervention to remove all wire clothes hangers from R#39's possession. On 12/8/16, a wire clothes hanger was observed in R#39's room. The nursing staff assigned to work with R#39 were unaware of the intervention to remove wire clothes hangers from his possession. Cross-reference F226: Abuse Policies and Procedures - the facility did not ensure R#39's physically abusive behaviors were addressed and interventions were implemented to keep residents safe from further potential harm and failed to conduct a criminal background check for one of two active nurse managers reviewed. Cross-reference F280: Care Plan Revision - R#39's care plan was not revised to reflect an incident of threatening another resident; R#81's care plan was not revised to reflect the resident's positioning needs; R44's care plan was not updated with the development of a new pressure ulcer; R27's care plan was not revised to reflect the resident's current needs for help with activities of daily living; R#83, and R#22's care plans were not updated with non-pharmacological interventions to address behavioral symptoms; and R#51's care plan was not reviewed quarterly as required. Cross-reference F329: Unnecessary Medications - the facility failed to ensure the drug regimen was free of unnecessary drugs for R#88, R#40, R#83, and R#22. Cross-reference F428: Medication Regimen Review - the facility failed to ensure the drug regimen recommendations from the pharmacist were acted upon for R#88, R#22, R87, and R#40. Cross-reference F490: Administration - the facility failed to ensure it was administered in a manner that enabled it to use its resources effectively and efficiently to ensure new interventions to address resident-to-resident physical abuse by resident (R) #39 were communicated to all staff and a system was implemented to ensure the intervention was carried out to prevent further incident and to maintain substantial compliance with Federal requirements at 42 Code of Federal Regulations (CFR) Part 483, Subpart B - Requirements for Long Term Care Facilities. Cross-reference F520: Quality Assurance Activities - the facility failed to maintain an effective Quality Assurance (QA) program that systematically reviewed quality of care related to resident-to-resident abuse and use of [MEDICAL CONDITION] medications The 5/22/15 Medical Director Agreement documented: Medical Director shall perform administrative services at the facility as reasonably appropriate to the position of a medical director including but not limited to the following services: a. Provide general medical decision input and support to the administration of the community; b. Review and assist to implement resident care policies and procedures c. Coordination of medical care; d. Participate in the facility's quality assurance process, to ensure the quality of medical and medically related care, including reviewing and signing all incident reports; e. Provide on-call availability and respond to medical or regulatory or other emergencies; f. Participate in the development and presentation of education programs g. Participate, as appropriate, in matters of employee health, and promotion of the health, welfare and safety of employees; h. Help articulate the facility's mission to the community and represent the facility in the community; (and) i. Serve as patient advocate, as needed, to secure medically necessary services . Medical director agrees that the services provided under this agreement shall be provided in compliance with all applicable federal, state, and local laws, rules, and regulations, and all applicable rules and regulations of any third-party payers covering medical director's services hereunder. Exhibit A of the Medical Director Agreement went on to describe the Medical Director's duties: 1. Provide medical decision input and support to the administration of the community a. Participates in the development and review of resident care policies, as well as policies regarding services of physicians and other professionals; b. Participate in meetings with the administrator and director of nursing to discuss clinical and administrative issues, specific patient care problems and professional staff needs for education or consultants. Offer solutions to problems and identify areas where policy should be developed; c. Assists in the preparation for, review, and respond to federal, state, and local surveys and inspections; d. Advise administration of current developments regarding patient care and new treatment modalities; (and) e. Communicate on a regular basis with the administration regarding actions, recommendations and concerns . 4. Participate in the facility's quality assurance process, to ensure the quality of medical and medically related care . (and) 6. Participate in the development and presentation of education programs. On 12/10/16 at 2:38 p.m., the Administrator stated the Medical Director had not provided the facility with any education regarding behavior management, prevention of abuse, or use of [MEDICAL CONDITION] medications. Regarding the identified failures with [MEDICAL CONDITION] medication use, she stated, I've talked to (the Medical Director) several times about the lack of follow up with ([MEDICAL CONDITION] medications) without any progress. On 12/9/16 from 4:00 p.m. to 5:00 p.m., the Medical Director was interviewed. He stated he attended most monthly QA meetings, where all clinical issues were reviewed. He stated the committee attempted to identify any patterns or trends in their data and focused on those for further review. The Medical Director stated his goal was to reduce the use of [MEDICAL CONDITION] medications in the facility, as their use of these medications went up dramatically with the influx of new residents with behavioral issues or psychiatric diagnoses. The Medical Director stated his job was to show a medication was necessary and clinically appropriate or to discontinue the use of the medication. When asked if he reviewed behavior documentation, frequency of use and reasons for use of PRN (as needed) medications, or the effectiveness of the medication regimen, the Medical Director stated, The pharmacy consultant is good about looking at that, then sends me recommendations to follow up. The Medical Director stated if the pharmacist made recommendations regarding a resident's medication regimen, he would document the rationale for accepting or declining the recommendation on the pharmacy recommendation report. The Medical Director stated, In the past, [MEDICAL CONDITION] medication use was not one of his major focus areas, but within the last year the clientele at the facility had become more aggressive and had more prevalence of polypharmacy, so this was a new focus over the last year. The Medical Director stated he had not provided any education with facility staff regarding management of aggressive or problematic behaviors, [MEDICAL CONDITION] medication use, or monitoring for effectiveness of [MEDICAL CONDITION] medications. Regarding R#39, the Medical Director stated he has known the resident for a long time and knows him to be a very sweet fell ow. He stated the altercation on 12/5/16 was not his usual behavior and he had never witnessed R#39 be aggressive with others. The Medical Director stated he was unsure if the verbal abuse witnessed on 10/23/16 in the dining room was reported to him. The Medical Director stated he had never discussed the vulnerable residents in the building in order to identify those at risk and protect from aggression from other residents. He stated, That's a very good idea. The Medical Director added he was ultimately responsible for the clinical care of all the facility residents. He stated, If the resident's primary physician is not available, then I am available for all staff to contact me with any concerns. On 12/8/16 at 2:55 p.m., the Administrator and Director of Nursing (DON) were alerted to the presence of an Immediate Jeopardy situation related to R#39's continued access to wire hangers and lack of staff education related to safety interventions for R#39. The facility implemented the following actions, per their credible AoC, to remove the Immediate Jeopardy: Step 1: On 12/8/16 at approximately 3:10 p.m., the resident determined to be the aggressor was placed on one on one supervision and facility social worker began seeking inpatient stabilization services for resident. At approximately 11:45 a.m. and 3:15 p.m. on 12/8/16, the resident's room was checked to ensure that no other potentially dangerous items were present. Step 2: On 12/8/16, the Administrator will purchase adequate plastic clothes hangers and on 12/9/16 at approximately 8:00 a.m., the Housekeeping and Laundry Supervisor will begin converting all resident closets to plastic clothes hangers and all wire hangers will be placed in dumpster for removal. Step 3: At approximately 5:30 p.m. on 12/8/16, the resident was transported to (the behavioral health hospital) for direct admission for stabilization. On 12/8/16 at approximately 5:15 p.m., the Care Management Team met and reviewed residents in house to determine any other at risk residents and no other risks were identified. The Administrator and/or designee will educate all staff immediately with mandatory in-servicing regarding the removal or wire coat hangers on 12/8/16 and will be continued until 100% completion. In-service is mandatory and wall (sic) employees will participate prior to reporting to work. As of 12/10/16 at 1:30 p.m., the facility has 96% completion for removal of wire coat hanger in services the facility has one LPN, one RN, and one dietary employee remaining to be in serviced the DO and will in-service staff concerning resident abuse and managing adverse behaviors, including facility policy, test, and handout and/or video any staff member that cannot attend will be educated by telephone and will receive in-house training prior to returning to work completed by 12/10/16. As of 12/10/16 at 1:30 PM, the facility is at 93% for the abuse in servicing we have remaining to nursing assistance to LPNs one RN and one dietary staff and 2 to inservice. Step 4: A quality assurance audit tool for physical/verbal or aggression was created on 12/9/16. Incidents of physically/verbal or aggressive behavior will be audited by the DON and or her designee using the quality assurance audit for physical/verbal or aggression to ensure interventions were implemented, any findings of noncompliance will be reported to the administrator immediately effective on 12/9/16; any findings of noncompliance will be presented to the quality assurance committee monthly to determine if additional action is needed ongoing. Residents determined to be the aggressor will be placed on every 15 minute visual monitoring until the resident is stabilized or transferred to an inpatient psychiatric behavioral unit for evaluation. If unable to determine the aggressor both will be considered in aggressor as of 12/9/16 and monitoring will occur every 15 minutes until the residents are stabilized or transferred to an inpatient psychiatric behavioral unit for evaluation. If the resident is the victim of the physically/verbal or aggressive situation the residents placed on every shift pertinent chart for 72 hours as of 12/9/16 to include signs of symptoms of abuse, i.e., excessive crying, bruises, trembling, scratches, withdrawal, pain(.) If the resident is the victim of a physically/verbal or aggressive behavior the social services department will be notified and they will monitor the residence (sic) psychological wellbeing (sic) concerned in the resident as well as the resident's reaction to his or her involvement in the investigation social services will document in the resident social service notes for three days. Social services will report any psychological changes to the administrator and the director of nurses to determine if further intervention is needed. Upon return from inpatient psychiatric/behavioral unit the resident will be placed on every 15 minutes visual monitoring for 24 hours, every 30 minutes visual monitoring 48 hours and then hourly visual monitoring for four days. Effective 12/9/2016. During the seven-day period of visual monitoring if the resident exhibits physically/verbal or aggressive behavior without injury, to either party, every 15 minute, visual checks will be resumed until the resident is determined to be stabilized by the Care Management Team or transferred to an inpatient psychiatric/behavioral unit for evaluation. If the recurrence of sexually(/)physically aggressive behavior results in injury to either party, one on one supervision will be initiated immediately and will continue until the resident can be transferred to an inpatient psychiatric/behavior unit. Effective 12/9/2016(.) All residents with physical/verbal or aggressive behavior will be placed on the patient at risk program and will be reviewed weekly at the care management meeting until they are free of physically or sexually aggressive behavior for four weeks. Effective 12/9/2016. All residents with physical/verbal or aggressive behavior will continue to be evaluated by the facility contracted psychiatric group during their visits. The Administrator and director nurses (sic) will continue to be notified of any reports of physically or sexually aggressive behaviors immediately. The nursing staff will continue to complete incident reports for incidence (sic) of abusive behavior. Effective 12/9/2016(.) Care plan coordinator will be educated to implement revision of approaches and interventions to the plan of care related to both physical/verbal and aggressive behaviors by 12/9/16 care plan revisions related to physical and sexual behaviors will be audited by the director of nurses or her designee as part of the weekly care management meetings. This education was completed at 100% on 12/9/16. Any resident that were not updated will be updated immediately during the weekly care management meeting effective 12/9/16(.) The surveyors validated the implementation of the AoC as follows: Step 1: R#39 was observed with one-to-one supervision from approximately 3:15 p.m. to 5:35 p.m., when the resident was sent out to the behavioral health hospital. The order to send the resident out and the Certificate Authorizing Transport to Emergency Receiving Facility & Report of Transportation (Mental Health) were reviewed. R#39 had not returned to the facility by the close survey on 12/10/16 at 6:00 p.m. Step 2: On 12/9/16, the housekeeping staff was observed to replace all wire hangers in residents' rooms with plastic hangers. On 12/10/16, a 100% resident room audit was conducted and no wire hangers were observed. Step 3: The Care Management Team audit of residents at risk for physical aggression was reviewed. The in-service records from trainings on removal of wire coat hangers and on resident abuse and managing adverse behaviors were reviewed; 96% completion of the wire hanger removal in-service and 93% completion of the abuse and adverse behaviors in-service was verified as of 1:30 p.m. on 12/10/16. Interviews were conducted with the Social Services Director (SSD); Activity Director (AD); CNAs AY, AT, AG, AH, and AI; LPNs AE, AO, AF, and AB; Registered Nurses (RN) AB and AD; and the receptionist on 12/10/16 from 11:00 a.m. to 12:00 p.m., all of which confirmed the education was received and understood. Step 4: The quality assurance Audit Tool was reviewed, and will be completed going forward for any incident of resident-to-resident aggression. The education record of the MDS Coordinator (care plan coordinator) was reviewed on 12/10/16 and confirmed as completed. R#39 had not returned to the facility as of the survey exit on 12/10/16 at 6:00 p.m. |
2019-11-01 |