| 10646 |
HILLCREST HEALTH CARE CENTER |
515117 |
P.O. BOX 605 |
DANVILLE |
WV |
25053 |
2011-03-02 |
520 |
F |
0 |
1 |
GCMN12 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, record review, resident interview, and staff interview, the facility's quality assessment and assurance (QAA) committee failed to identify quality deficiencies of which it should have been aware, reflective of system failures in the areas of implementation of each resident's written plan of care, accident hazards, food preparation and appearance, dietary sanitation, infection control, and accurate and complete clinical records; and failed to develop and implement appropriate plans of action to correct these quality deficiencies. Each of these deficiencies was a repeat deficiency from previous surveys. This failure has the potential to affect more than an isolated number of residents. Facility census: 84. Findings include: a) Failure to implement each resident's written plan of care: 1. During the initial tour at 3:15 p.m. on 02/22/11, Resident #41 was observed with a very red face and was coughing. Two (2) staff members (Employees #30 and #7) were in the room but did not appear to notice anything happening with the resident. Another resident's family member had to summon the employees to help the resident. The resident had choked on the cheese puffs he was eating. Review of the resident's medical record, on 02/23/11, revealed he was assessed with [REDACTED]. The resident's care plan, dated 02/14/11, contained the following goal: "Resident will have no unidentified s/s (signs and symptoms) of aspiration through the next review 05/14/11." One (1) of the interventions for this goal was: "Monitor for increased incidence of choking, coughing during meals or PO (by mouth) intake, red face, watery eyes, difficulty breathing and notify MD (physician)." On 02/22/11 at 3:15 p.m., this resident was not being monitored while eating, as directed by the care plan. - 2. Review of accident and incident reports, on 02/23/11, revealed Resident #16 spilled coffee on herself on 12/05/10. She was not burned. The incident report also indicated the resident was "blind". On 02/23/11 at 9:30 a.m., this resident was observed and interviewed in her room. Upon inquiry, the resident stated she was not blind, but she could not see "very well at all". Review of the resident's medical record, on 02/23/11, revealed she had spilled coffee on herself at noon on 12/05/10 and again on 01/30/11 at breakfast. The resident's care plan, when reviewed on 02/23/11, was found to contain the following undated handwritten intervention: "Travel mug /c (symbol for 'with') lid @ (symbol for 'at') meals for coffee." On 02/24/11 at 12:45 p.m., the resident was observed in her room, just prior to the receipt of her noon meal. She was drinking coffee from a regular cup, not a travel cup with a lid. At 1:00 p.m., the director of nursing (DON - Employee #118) was asked to join the surveyor at the resident's room. The resident was asked if she had a cup of coffee before her meal, and she responded she had. Employee #118 was able to observe the regular cup on the resident's overbed table at this time. On 02/25/11, Employee #23 (a licensed practical nurse - LPN) was asked to provide this resident's "Resident Care Flow Record" which nursing assistants are supposed to follow in providing resident care. There was a handwritten (but not dated) note on the flow sheet, with an asterisk beside of it, which said, "Travel mug /c lid @ meals for coffee." The resident was not provided a travel cup with a lid for her coffee, on 02/24/11, as directed by her care plan. -- b) Accident hazards: 1. During the initial tour at 3:15 p.m. on 02/22/11, Resident #41 was observed with a very red face and was coughing. Two (2) staff members (Employees #30 and #7) were in the room but did not appear to notice anything happening with the resident. Another resident's family member had to summon the employees to help the resident. The resident had choked on the cheese puffs he was eating. Review of the resident's medical record, on 02/23/11, revealed he was assessed with [REDACTED]. The resident's care plan, dated 02/14/11, contained the following goal: "Resident will have no unidentified s/s (signs and symptoms) of aspiration through the next review 05/14/11." One (1) of the interventions for this goal was: "Monitor for increased incidence of choking, coughing during meals or PO (by mouth) intake, red face, watery eyes, difficulty breathing and notify MD (physician)." Interview with the rehabilitation manager (Employee #38), on 02/24/11 at 1:15 p.m., revealed the resident had placed more than one (1) cheese puff in his mouth. Had adequate supervision been in place while he was eating, staff could have directed him to finish one (1) cheese puff before putting another in his mouth. On 02/22/11 at 3:15 p.m., this resident was not supervised while eating, to prevent choking. - 2. Review of accident and incident reports, on 02/23/11, revealed Resident #16 spilled coffee on herself on 12/05/10. She was not burned. The incident report also indicated the resident was "blind". On 02/23/11 at 9:30 a.m., this resident was observed and interviewed in her room. Upon inquiry, the resident stated she was not blind, but she could not see "very well at all". Review of the resident's medical record, on 02/23/11, revealed she had spilled coffee on herself at noon on 12/05/10 and again on 01/30/11 at breakfast. The resident's care plan, when reviewed on 02/23/11, was found to contain the following undated handwritten intervention: "Travel mug /c lid @ meals for coffee." On 02/24/11 at 12:45 p.m., the resident was observed in her room, just prior to the receipt of her noon meal. She was drinking coffee from a regular cup, not a travel cup with a lid. At 1:00 p.m., the DON was asked to join the surveyor at the resident's room. The resident was asked if she had a cup of coffee before her meal, and she responded she had. Employee #118 was able to observe the regular cup on the resident's overbed table at this time. On 02/25/11, Employee #23 was asked to provide this resident's "Resident Care Flow Record" which nursing assistants are supposed to follow in providing resident care. There was a handwritten (but not dated) note on the flow sheet, with an asterisk beside of it, which said, "Travel mug /c lid @ meals for coffee." The resident was not provided an assistive device to prevent accidents (a travel cup with a lid for her coffee) on 02/24/11, in accordance with her care plan. -- c) Food preparation and appearance: 1. On 02/24/11 during the noon meal, observations were made of residents eating in the activity room. The pureed foods (pinto beans, sauerkraut, and polish sausage) ran together touching each other on the plates. This created an unappetizing presentation for the twenty (20) residents who required pureed foods. There was no form to the foods at all. The foods on the plates were touching each other, edge to edge, with color being the only distinguishing factor from one food to the other. This was shown to the administrator (NHA - Employee #117) and the DON at the time of the observation. The NHA confirmed the meals for residents on pureed diets were not appetizing or attractive. - 2. At noon on 03/02/11, pureed meals were observed with the dietary manager (DM - Employee #63). The pureed broccoli mix and pureed ranch style beans were thin, without form, and ran into each other on the plates. At that time, the DM confirmed the foods should have form, and not spread into each other. -- 3. On 03/02/11 at 12:55 p.m., a test tray was requested to be placed on the cart immediately following the last resident to be served at the noon meal. There was a misunderstanding, and the cart on which the test tray was placed was not the last cart to be served. In addition, it contained only three (3) trays. The meals on this cart had no wait time for service; however, the foods were tested anyway, with the DM. The hot foods were at appropriate temperatures; however, the cold food (coleslaw) was 51.4 degrees Fahrenheit (F). State law requires cold foods, at the time of service, measure no more than 50 degrees F. Due to the confusion of getting test trays, another test tray was requested. This one was immediately following the last tray served in the dining room. The tray was tested at 1:15 p.m., with the DM. The hot foods were again at appropriate temperatures; however, the coleslaw was 54.7 degrees F. Upon inquiry, the DM stated the coleslaw was prepared that morning. When asked the size and depth of the pan used to chill the coleslaw, the DM showed the surveyor a 6-inch deep 1/2 steam table pan. This pan was not shallow enough to allow for rapid chilling of cold foods. -- d) Infection control: 1. Review of Resident #38's medical record revealed a discharge summary from a local hospital, dated 02/17/11, with a discharge [DIAGNOSES REDACTED]. Review of Resident #38's facility admission orders [REDACTED]. review of the resident's medical record revealed [REDACTED]. A nurse's note, dated 02/18/11 at 3:00 a.m., revealed the resident remained on antibiotic therapy due to a positive [MEDICAL CONDITION] culture. A nurse's note, dated 02/18/11 at 12:00 p.m., revealed the resident changed rooms due to positive [MEDICAL CONDITION] with five (5) days of antibiotic therapy remaining. An interview with Employee #64, on 03/01/11, revealed Resident #38 was placed in isolation "a little before 12:00 p.m. on 02/18/11." Employee #64 also stated the resident returned to the facility on [DATE] with a discharge [DIAGNOSES REDACTED]. Review of the facility policy regarding "Isolation - Categories of Transmission - Based Precautions" revealed contact precautions should be implemented "for residents known or suspected to be infected or colonized with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment. ... Place the individual in a private room if it is not feasible to contain drainage, excretions, blood or body fluids (e.g. the individual is incontinent on the floor, or wanders and touches others)." Review of Resident #38's medical record revealed the resident was incontinent of bowel and bladder, and observation revealed she was able to ambulate in her wheelchair. For example, on 02/22/11 at 3:20 p.m. and again on 03/01/11, she was observed ambulating in her wheelchair within her room, and on 03/02/11 at 1:45 p.m., she was observed sitting in the doorway of her room in her wheelchair. - 2. On 02/23/11 at 1:50 p.m., a nursing assistant (#95) was observed passing ice on the East Hall. She was holding the pitchers, taken from residents' rooms, over the ice in the ice chest as she filled each pitcher. This practice created a potential for cross contamination. At the time of the observation, a registered nurse (Employee #105) was shown the practice and confirmed Employee #95 should not hold the pitchers over the ice while filling them. -- e) Accurate and complete clinical records: 1. Resident #48 Review of Resident #48's medical record revealed that, on 12/28/10, two (2) physician's orders had been discontinued: float heels while in bed and elevate legs while in bed. At this time, the resident had a pressure ulcer to her right heel. On 03/01/11 at 3:50 p.m., an interview with the director of nursing (DON - Employee #118) revealed these orders must have been discontinued accidently while the facility was trying to reduce the number of unneeded physician's orders. "It must have been an oversight." - 2. Resident #67 Review of Resident #67's medical record revealed dietary progress notes written by the dietician (dated 12/03/11 and 01/25/11) that were not legible. On 03/02/11 at 2:20 p.m., an interview with the administrator (Employee #117) revealed he was only able to read "bits and pieces" of the documentation. - 3. Resident #41 During the initial tour at 3:15 p.m. on 02/22/11, this resident was observed with a very red face and was coughing. The resident had choked on the cheese puffs he was eating. Review of the resident's medical record, during the afternoon of 02/23/11, revealed no documentation regarding this resident had choked on cheese puffs on 02/22/11. On 02/28/11 at 3:10 p.m., the DON stated a registered nurse (Employee #68) went to the activity room and checked the resident but did not document anything. - 4. Resident #30 Review of this resident's medical record, on 02/23/11, revealed the resident was sent to the emergency room for evaluation on 01/28/11. The resident's medical record contained no evidence the resident was provided any of the required notices upon transfer, including but not limited to readmission rights. The facility later located this information. - 5. Resident #8 Review of this resident's current medical record revealed it contained a medical power of attorney document for another resident. |
2015-01-01 |