| 4815 |
SALEM CENTER |
515071 |
255 SUNBRIDGE DRIVE |
SALEM |
WV |
26426 |
2015-11-04 |
520 |
G |
0 |
1 |
KC5S11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, resident interview, and staff interview, the facility's quality assessment and assurance (QA&A) committee failed to develop and implement plans of action, including monitoring the effect of implemented changes and making revisions to the action plans if the desired results were not obtained, to correct quality deficiencies of which it was aware, or should have been aware, in the daily operation of the facility. After unlocking the Alzheimer's unit and discontinuing services specific to the needs of residents with Alzheimer's dementia who resided on the unit, the QA&A committee failed to identify and act upon those residents' behaviors toward others, failed to ensure interventions to reduce negative behaviors, and failed to ensure appropriate activities for the residents formally residing on the Alzheimer's unit. The QA&A committee failed to identify that optimum care and services, to ensure the highest practicable well-being of each resident, was not addressed before and after the facility closed their Alzheimer's Unit. -- Resident #83 was not properly assessed for this transition. In addition, the resident's adjustment difficulties to his new environment were not identified and addressed. This resulted in psychological harm to the resident. -- There was a failure to develop care plans and/or activities to meet the activity needs and preferences for Residents #73, #99, and #50 who once had structured activities on the Alzheimer's unit. -- There was a failure to ensure the right to personal privacy, dignity, and respect for Residents #23, #120, #128, and #53 when residents who previously resided on the Alzheimer's unit began wandering into their rooms. Eight (8) thirty-five (35) sample residents (#83, #73, #99, #50, #23, #120, #128, and #53) were specifically affected; however, the practice had the potential to affect more than an isolated number of other residents. Facility census: 87 Findings include: a) Resident #83 This resident was admitted to the facility's Alzheimer's unit on 06/14/13. His [DIAGNOSES REDACTED]. On 04/20/15 the Alzheimer's unit was closed, the door to the Alzheimer's unit were unlocked, and the facility no longer provided the services of an Alzheimer's unit. Prior to the closure, the facility sent a letter to the affected families. It included, in part, This will not represent a significant change for our residents who are currently cared for on this unit. (Name of company) physicians and clinical nursing leadership have evaluated the residents and believe that a skilled nursing unit is appropriate to meet our residents needs. At 10:00 a.m. on 11/03/15, review of the medical records for Resident #83 revealed his [DIAGNOSES REDACTED]. The record was silent for evidence of an evaluation or assessment to determine if a change in the secured structured environment of an Alzheimer's unit would be detrimental to Resident #83's mental and psychosocial well being. The facility had no evidence of evaluations and/or assessments for Resident #83 to determine if his [DIAGNOSES REDACTED]. After the resident no longer received the services provided in an Alzheimer's unit, there was a delay in the facility recognizing and/or addressing a pattern of increased behaviors and resident-to-resident altercations. These behaviors began on 04/30/15. It was not until 08/26/15, that his Medical Power of Attorney (MPOA) was first contacted regarding the need for a transfer to a facility with a secured unit. Resident #83 was transferred to a facility that could meet his physical, mental, and psychosocial needs on 09/03/15, after nearly four (4) months of psychosocial related behavioral events. Review of the resident's nursing progress notes found Resident #83 had only one (1) resident-to-resident altercation from 01/01/15 through 04/29/15. The medical record showed progressive increased aggression toward staff and residents from 04/30/15 through 08/29/15. During that period of time, fourteen (14) acts of aggression were documented: 1. On 04/30/15, the resident was involved in a resident-to-resident altercation with no injuries. 2. On 05/06/15, the resident . went to hilltop and went into solarium where (resident name) was sitting at a table. This resident punched (resident name) in the chest. Both residents separated . 3. On 05/19/15, Resident #83 . was pushing (resident name) wheelchair and rubbing her shoulders and (resident name) yelled stop and he started punching her in the right arm. (Resident name) was also present and was attempting to get this resident to let go of (resident's name) wheelchair and this resident also punched (resident name) in the right arm. This resident was redirected per nurse . 4. On 05/21/15, .Resident was on Hilltop. This resident was punching at another resident's face and grabbing his arm. The other resident started hitting this resident with his Foley catheter and hitting him in the face with his hand . 5. 06/05/15, Resident #83 . attempted to enter another resident's room which upset other resident who started to swing his arms at this resident and this resident started to swing back . 6. 06/21/15, Resident on Hilltop stated that (Resident #83) hit her . 7. 06/22/15, The Administrator stated she saw resident #83 . and (resident name) in front lobby and (Resident #83) touched (resident's name) left shoulder and she started screaming don't touch me, she then took her papers and slapped him on the hands . 8. 07/08/15, Resident to resident altercation. 9. 07/18/15, Resident #83 . wandering throughout hallways in facility. (Resident name) was heard yelling from her wheelchair in hallway. Hilltop back nurse observed (Resident #83) with his hands on the back of (resident's name) neck and was pushing her head forward. This resident was observed for injuries. top of left hand red with horseshoe shaped skin tear measuring 1.0 cm x 0.2 cm . 10. On 07/24/15, Resident #83 . was seen slapping another resident as she screamed at him . 11. On 08/01/15, Resident #83, I was just pushing him when wheelchair was observed on its side and (resident name) was sitting on his left side with his legs out in front of him cursing at resident . 12. On 08/19/15 at 2:22 p.m., Resident having increased aggression. Going into female residents rooms, pulling mattresses off the beds, combative with staff, hitting, kicking and trying to bite . 13. On 08/27/15, Resident in another resident's bed. Staff assisted him back to Solana side. The resident who's bed he was in was upset. Resident began swinging at staff, grabbed another staff member's hair after the other two staff walked away . 14. 08/29/15, This resident (#83) touched (resident name) on the shoulder and (resident name) started hitting him (Resident #83) in the right arm. On 11/03/15 at 10:05 a.m., a review of the incident/accident reports revealed they corresponded with the nursing progress note documentation related to Resident #83's behaviors. During an interview, on 11/03/15 at 2:35 p.m., Physician #105 stated the residents on the Alzheimer's unit were assessed before the closing of the unit, to determine if the facility could meet their needs. He could not say if Resident #83 met the criteria for a transfer to another facility before the discontinuation of the locked Alzheimer's unit. Upon inquiry, the physician acknowledged a safety issue existed for Resident #83, as well as for other residents. When asked whether the resident should have been transferred sooner due to safety concerns, Physician #105 stated, Yes, he probably needed to be sent out sooner for safety of other residents and also his own safety. On 11/04/15 at 9:45 a.m., an interview with the Administrator revealed incident/accident reports were reviewed daily by the team and discussed monthly in the Quality Assurance meeting. She did not reply when asked if the facility identified a pattern of increased aggression in resident-to-resident altercations by Resident #83 after the Solana unit doors were unlocked. b) Residents #73, #99, and #50 The facility failed to develop care plans with measurable goals and interventions for these residents who previously resided on the Solana Alzheimer's unit, which was closed on 04/20/15 These residents no longer had a confined area to wander, and no longer were provided on-going structured activities based on their assessed needs. The residents' current care plans for activities did not contain specific interventions related to identified activity needs and preferences geared to meet the individual needs of these residents with dementia, short attention spans, and/or behaviors. 1. Resident #73 Review of the medical record, on 10/28/15 at 2:20 p.m., revealed Resident #73 was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. She was identified at risk for limited meaningful engagement related to her cognitive loss, confusion, and short attention span. The resident was unable to make her needs known, and was at risk for falls. Her behaviors included pacing to the point of exhaustion. The resident's recreational assessment, dated 05/19/15, noted the resident was rarely/never understood. Her favorite activities included music, food, and social events. The accommodations listed related to her cognitive loss included small groups, decreased environmental clutter, verbal prompts, physical prompts (hand over hand), simple noncomplex directions, and sensory focused activities. The summary stated she was confused, had a short attention span, and often wandered. The assessment noted: She needs adapted activities to her cognition, with focus on sensory stimulation. The resident's prior care plan (used before the doors were unlocked), dated 01/21/15, stated the resident loved to dress up and wear boas, beads, and hats. It indicated staff should offer her activity beads during times of restlessness. Daily observations of Resident #73, during the survey, found her actively roaming the facility halls, talking in word salads, and entering other residents' rooms. Occasionally she was found sitting at the nurses' desk eating a snack or looking at a magazine. On one (1) occasion she was sitting at the desk with a stethoscope and a blood pressure cuff. She was never found dressed up or playing with activity beads. 2. Resident #99 Review of the medical record, on 10/29/15 at 9:00 a.m., revealed Resident #99 was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. She was identified at risk for limited meaningful engagement related to cognitive loss, due to her [DIAGNOSES REDACTED]. Her behaviors included wandering, yelling at staff, and paranoia. The resident's recreation assessment, dated 07/16/15, identified her important preferences were snacks between meals, music, and going outside weekly. Her previous activity care plan (used before the doors were unlocked) was last reviewed on 01/28/15, It stated she liked to eat, read adventure and horror books, watch television, and do word searches. Throughout the survey, Resident #99 was observed walking the halls and verbally interacting with staff. She was never seen with a book or word puzzle. The resident was observed only once sitting in the television room with other residents. On 10/27/15, the resident repeatedly asked the surveyor to take her outside for a walk. There was no evidence she was offered a trip outside during the warm fall days. A review of the recreational assessment for Resident #99, with Activity Director (AD) #46 on 11/03/15 at 10:25 a.m., revealed the record was silent regarding the resident being taken outside for walks. 3. Resident #50 Review of the medical record, on 10/28/15 at 3:33 p.m., revealed Resident #50 was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. The resident's medical record indicated she needed adaptive activities, had confusion, and had a short attention span. According to the medical record, the resident was often on the go, pacing the halls in her wheel chair. Her behaviors included exit seeking, crying for extended periods, and combative actions (hits, kicks, and grabs staff). The medical record contained evidence of a resident-to-resident altercation on 10/05/15. The resident's previous activity care plan (in place prior to the doors being unlocked) with a review date of 01/28/15, stated she liked cooking, cleaning, socializing, and playing Bingo and cards. It also indicated the resident sometimes carried a baby doll. The resident's recreation assessment, dated 09/01/15, listed her favorite activities as walking or wheeling, music, food activities, church or religious activities. and talking. It indicated she would benefit from accommodations for cognitive loss, including small groups and single step activities. The assessment noted her activity participation was limited, due to her short attention span. Observations throughout the survey found the resident continuously wheeling up and down the halls. At times she was observed repeatedly bending over and picking at unseen objects on the floor. She was never observed with a baby doll. There was no evidence cooking or cleaning activities were offered to her. 4. Licensed Practical Nurse (LPN) #54 was interviewed on 10/27/15 at 9:45 a.m. and again on 10/28/15 at 8:35 a.m. She reported the residents with dementia from the Solana unit wandered throughout the facility, now that the unit was no longer locked. She said Residents #73, #99, and #50 were kept busy with activities before the discontinuation of the Alzheimer's unit. LPN #54 said now there were no activities for the residents with dementia, and they just wandered around the facility. She said some of the residents entered other residents' rooms, climbed into their beds, and took their belongings. LPN #54 said the residents were previously kept busy with a long day of activities designed to meet the needs of a resident with dementia and with a short attention span. 5. Confidential interviews with nursing assistants on 10/28/15 revealed concerns with no scheduled activities that residents with dementia could attend to meet their needs. They said, It is sad to watch them wander around and enter other peoples' rooms. 6. When interviewed on 11/03/15 at 10:25 a.m., AD #46 confirmed there was only one (1) activity calendar for the facility. She confirmed these activities did not meet the needs of residents with Alzheimer's dementia, especially with their short attention spans. She agreed the facility did not offer individualized activity interventions for Residents #73, #99 and #50 after the Alzheimer's unit was closed. AD #46 confirmed these residents wandered, and were not capable of independent stress/relaxation as documented on their recreation activity logs. She confirmed the facility did not provide a space, or environmental cues, to encourage physical exercise, decrease behaviors, and/or reduce extraneous stimulation for these residents who once were provided these services. The facility had a single rocking chair in the office, and bags of therapy beads and lotion for aromatherapy; however, these items were not readily available for the residents to access and were not routinely offered on a daily basis. AD #46 agreed the activity program needed restructured to meet the individual needs of the residents who remained on the Solana unit. 7. Review of the Alzheimer's unit daily flow sheets, obtained from the administrator on 11/04/15, revealed the residents who resided on the Alzheimer's unit had scheduled activities from 7:00 a.m. to 8:00 p.m. daily. These activities included activities of daily living, small group socials with coffee and discussing current events, exercise, artistic expression such as painting, gardening, or drawing, cognitive sharpening exercises such as Bingo, puzzles, and mazes, sensor-motor activities which included making popsicles or pudding, spiritual singing, and community story telling. Beginning 04/20/15, the residents who resided on Solana unit, preciously a locked Alzheimer's unit, were only offered the scheduled activities planned for the higher functioning residents in the facility. The planned activities to meet the needs of residents with Alzheimer's dementia were no longer available. In addition, structured activities were no longer available to them from 7:00 a.m. to 8:00 p.m. daily. The (MONTH) activity calendar listed activities from 9:45 a.m. to 4:45 p.m. It included Wifi games, horseshoes, and Bible study. There were also five (5) evening church services and two (2) evening Bingo games, one (1) evening movie, and two (2) resident choice events. 8. During the survey, observation revealed residents, who resided on the Solana unit, previously a locked Alzheimer's unit, wandered freely throughout the facility all day long. Observation revealed no planned activities to keep them busy, as they were previously provided when they resided in a setting for residents with dementia. c) Residents #23, #120, #128, and #53 The facility failed to ensure the right to personal privacy and failed to maintain an environment which promoted dignity and respect for private space for these residents. The facility provided no means to prevent wandering confused residents from entering these residents' rooms. 1. Resident #23 Observation on 10/26/15 at 2:30 p.m., revealed a female resident walked into Resident #23's room and climbed into his bed. He immediately screamed at her and she got up and walked out of the room. At 2:45 p.m., observation revealed a second resident, Resident #73, entered the room and attempted to sit on the resident's bed. After Resident #73 was assisted out of the room, Resident #23 said the residents who lived on the Solana unit, previously a locked Alzheimer's unit, repeatedly entered his room. Upon inquiry, Resident #23 said the facility had not offered him any means to deter the roaming confused residents from entering his room. 2. Resident #120 During a Stage 1 resident interview, on 10/26/15 at 2:30 p.m., two (2) female residents entered Resident #120's room between 2:30 p.m. and 2:45 p.m. The first resident climbed into the roommate's bed and exited after Resident #120 and the roommate yelled at her. The second non-communicating resident was assisted from the room by the surveyor. Resident #120 reported this was a continuous occurrence. He said the residents who resided on the Solana unit, previously a locked Alzheimer's unit, entered his room from either the bathroom door or the hallway door. He stated they often climbed into their beds, carried items out of the room, and sometimes attempted to take food off of their meal trays while they were eating in their room. Resident #120 reported he and his roommate requested a slide lock to at least keep the bathroom door closed, but the request was denied. He said he was never offered a means to deter the wandering confused residents from entering the room. 3. Resident #128 During an interview, on 10/27/15 at 8:40 a.m., Resident #128 reported the residents who resided on the Solana unit, previously a locked Alzheimer's unit, often wandered into his private room and walked around making muttering sounds. He said once a male resident entered his room and sat down in the chair for a while. Resident #128 said he also woke up one (1) night and found a resident standing over him looking at his face. He stated he reported these incidents to the nursing assistants. Upon inquiry, he said he was never offered a means to deter the wandering, confused residents from entering his private room. 4. Observation on Hilltop Wing revealed three (3) wooden swing gates were installed on residents' doorways to deter wanderers from entering the rooms. No such gates were located on Woodside hall where Residents #23, #120, and #128 resided. 5. Resident #53 Resident #53 was interviewed on 10/29/15 at 10:45 a.m. He reported several residents in the facility voiced concerns when they were informed the new ownership/management had decided to unlock the doors to the Solana unit, an Alzheimer's unit. He said the residents from the Solana unit began roaming throughout the facility, entering other residents' rooms and taking personal belongings. Resident #53 said these concerns were discussed at resident council. He said staff told them nothing could be done. Resident #53 reported a confused resident entered his room and climbed into his bed when he was not in the room. The resident said his roommate told him the resident defecated in his bed on that occasion. Resident #53 said he asked for a wooden triangular swing gate for his door, but was told he would have to wait until maintenance could make more. 6. Observations during the survey found three (3) wooden swing gates on the doors on the Hilltop wing. There were no swing gates on the Woodside hall, where Residents #23, #120, and #128 resided. 7. Maintenance Supervisor #27 was interviewed on 11/04/15 at 8:20 a.m. He was unaware of any resident's request for the triangular wooden swing gates used to deter the wandering residents from entering other residents' rooms. He said he made the wooden gates as they were needed, and did not currently have any to hang on the residents' doors. 8. Licensed practical nurse (LPN) #54 was interviewed on 10/27/15 at 9:45 a.m. She confirmed the residents with dementia wandered throughout the facility now that the Solana unit was no longer locked. She confirmed some of the residents entered other residents' rooms, climbed into their beds, and took their belongings. 9. During the survey, observation revealed residents, who resided on the Solana unit, previously a locked Alzheimer's unit, wandered freely throughout the facility all day long. They were not provided activities to keep them busy, as they were provided when they resided in a setting designed for residents with dementia. d) On 11/02/15 at 10:21 a.m., the facility administrator explained that when the Alzheimer's unit was unlocked on 04/20/15, the QA&A committee felt the biggest risk for the unit doors being unlocked was wandering residents. The administrator said they felt the other needs could be met through activities and social services. Each resident who resided on the locked Alzheimer's unit was also to receive an assessment of individual needs. On 11/04/15 at 9:45 a.m., another interview with the Administrator revealed incident/accident reports were reviewed daily by the team and discussed monthly in the QA&A meeting. She did not reply when asked if the facility identified a pattern of increased aggression in resident-to-resident altercations by Resident #83 after the Solana unit doors were unlocked. e) Evidence revealed the QA&A committee failed to ensure continued assessment, care planning, and monitoring to ensure the needs of all facility residents were met after the secured Alzheimer's unit, with structured daily activities for the residents, was closed. Neither the needs of residents with Alzheimer's dementia nor the needs of other residents who resided in the facility. were met when the Alzheimer's unit was closed. |
2019-07-01 |