cms_AZ: 79
Data source: Big Local News · About: big-local-datasette
| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 79 | DESERT HAVEN CARE CENTER | 35062 | 2645 EAST THOMAS ROAD | PHOENIX | AZ | 85016 | 2020-01-08 | 689 | E | 1 | 0 | DWKV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on staff interviews, record reviews and review of policies and procedures, the facility failed to ensure that multiple residents with aggressive behaviors (#1, 2, 4, 5) were provided adequate supervision to prevent the residents from behaving in a physically aggressive manner towards other residents. The deficient practice could result in multiple residents behaving aggressively towards other residents. Findings include: -Resident #1 was admitted on (MONTH) 13, (YEAR) and readmitted on (MONTH) 5, 2019 with [DIAGNOSES REDACTED]. A written care plan initiated on (MONTH) 25, 2019 and updated on (MONTH) 8, 2019 included that resident #1 had a history of [REDACTED]. A Behavioral Plan dated (MONTH) 9, 2019 included that on admission the resident had a history of [REDACTED]. The behavioral plan included that currently, the resident makes false accusations of peers taking her belongings, and has a history of physical altercations with peers. The behavioral plan listed multiple interventions included to monitor resident #1 for her peer's safety, listen to her concerns and to remove peers for their safety. A quarterly MDS (Minimum Data Set) assessment dated (MONTH) 21, 2019 included a BIMS (Brief Interview for Mental Status) score of 15, which indicted the resident was cognitively intact. The assessment included that resident #1 had verbal behavioral symptoms directed at others, refused care and wandered. Review of the MAR (Medication Administration Record) for (MONTH) 2019 revealed that resident #1 had the following behaviors which were documented in sections of the record for daily behavioral monitoring: -Verbally abusive behaviors were recorded on (MONTH) 1, 3, 5, 9, 10, 12 and 15, 2019. -Angry outbursts were recorded on (MONTH) 3, 5, 9, 10, and 12, 2019. -Delusions were recorded on (MONTH) 1, 4, 6, 7, 8, 11, 14, and 15, 2019. -False accusations were recorded on (MONTH) 8, 10, and 15, 2019. A Health Status Note dated (MONTH) 16, 2019 at 1:00 a.m. included that during a smoke break, a peer (resident #5) had grabbed the cigarette supply and that resident #1 had observed resident #5 grab the cigarettes. The note included that resident #1 tried to take the cigarettes from resident #5, and resident #5 then grabbed the sweater of resident #1, who slid to the floor. The note included that there were no injuries. Review of the MAR for (MONTH) 2019 revealed that resident #1 had following behaviors which were documented in daily behavioral monitoring: -Verbally abusive behaviors were recorded on (MONTH) 5, 6, 8, 12, 14, 15, 17, 19, 20, and 21, 2019. -Angry outbursts were recorded on (MONTH) 8, 12, 14, 16, 17, 20, and 21, 2019. -Delusions were recorded on (MONTH) 1-5, 8, 9, 12, 14, 15, 16, and 18-21, 2019. -False accusations were recorded on (MONTH) 8, 9, and 19-21, 2019. -Combativeness was recorded on (MONTH) 17, 2019. A Behavior Note dated (MONTH) 21, 2019 at 3:30 p.m. included that the resident had hit another resident on the right cheek and pulled the other resident's hair while they were fighting over (pet) birds, in the other resident's room. The note included that the other resident had grabbed the arm of resident #1, and the resident's were separated. This note included that there were no injuries. Review of the plan of care for resident #1 revealed that it was updated on (MONTH) 21, 2019 to include that resident #1 had a confrontation with another resident over birds, and had hit the other resident on the cheek and pulled her hair. -Resident #5 was admitted on (MONTH) 31, 2019 with [DIAGNOSES REDACTED]. An admission MDS assessment dated (MONTH) 9, 2019 included that resident #5 had a BIMS score of 7 which indicated that resident #5 had severe cognitive impairment. The assessment included that resident #5 had verbal and physical behavioral symptoms directed towards others, no functional limitations in range of motion and used a wheelchair. A psychiatric evaluation dated (MONTH) 10, 2019 included that resident #5 had displayed intermittent irritability, impulsivity, agitation, demanding behavior and verbal aggression. A plan of care for resident #5 for impaired cognitive function related to dementia, had multiple interventions listed including to cue, re-orient and supervise the resident as needed. A plan of care of care for a history and [DIAGNOSES REDACTED]. Review of the MAR for (MONTH) 2019 revealed that resident #5 had demanding and verbally abusive behaviors recorded in daily behavioral monitoring for (MONTH) 1-5, 7, 8. 11. and 13-15, 2019. An Incident Note dated (MONTH) 15, 2019 at 11:34 p.m. included that during a smoke break, resident #5 had grabbed all of the cigarettes, which caused an argument with a peer. The note included that resident #5 grabbed the peer by her sweater, which caused the peer to slide to the floor, and there were no injuries. An investigative report dated (MONTH) 20, 2019 included that (MONTH) 15, 2019 at 7:10 p.m. as residents were headed to a smoke break, and when resident #1 noticed that resident #5 had the box of (resident) cigarettes, resident #1 became angry and confronted resident #5, and resident #5 grabbed the sweater of resident #1, The report included that when resident #5 grabbed the sweater of resident #1, this caused resident #1 to fall to the ground. -Resident #2 was admitted on (MONTH) 29, 2019 with [DIAGNOSES REDACTED]. A quarterly MDS assessment dated (MONTH) 29, 2019 included that resident #2 had moderately impaired cognition and problems with short and long term memory, and behavioral symptoms not directed at others. The assessment included that the resident was short tempered, easily annoyed, and had trouble concentrating. A written plan of care for resident #2 included a plan for impaired cognitive function related to dementia, that had multiple interventions including to cue, reorient and supervise the resident as needed. A Behavior Note dated (MONTH) 4, 2019 at 10:16 a.m. included that resident #2 was worried that resident #1 was getting into her closet when she was out out of her room. A Health Status Note dated (MONTH) 8, 2019 at 5:18 p.m. included that resident #2 had complained that resident #1 had been in her room and was afraid that resident #1 would take her possessions. The note included that staff would monitor the resident for any changes and safety. A Behavioral Plan dated (MONTH) 9, 2019 included that resident #2 grabs at other residents, and that she appears to be targeting a specific peer, and takes the peers belongings. The plan included to monitor and redirect her away from a specific peer. A Behavior Note dated (MONTH) 15, 2019 at 9:02 a.m. included that resident #2 and #1 had an argument and were redirected away from each other to de-escalate the argument. A Behavior Note dated (MONTH) 21, 2019 at 4:01 p.m. included that resident #2 had grabbed another resident by the arm when the other resident tried to take her pet birds away from her. The note included that resident #2 stated that the other resident hit her on the cheek and pulled her hair, and that the other resident was trying to take her pet birds away from her when she grabbed the other resident by the arm. The note included that there were no injuries. An investigative report dated (MONTH) 24, 2019 included that on (MONTH) 21, 2019 at 3:00 p.m. resident #1 entered resident #2's room and was observing pet birds that resident #2 keeps on her dresser, and resident #1 attempted to remove the birds in their cage from the room. The report included that resident #2 grabbed resident #1's arm, and resident #1 retaliated by pulling resident #2's hair and slapping her across the face. Staff separated the resident's and there were no injuries. During an interview with an LPN (Licensed Practical Nurse/staff #72) conducted on (MONTH) 6, 2020 at 2:45 p.m. the LPN stated that the staff circulate about the unit continuously to monitor resident's behavior and for safety. The LPN stated that the unit is usually staffed with 1-2 nurses and 3 CNA's (Certified Nursing Assistants). The following interviews were conducted on (MONTH) 7, 2020 with the following staff regarding the incident that occurred on (MONTH) 21, 2019: -At 10:00 a.m. a CNA/staff #86 stated that when the incident occurred she was not present on the unit at that time because she was on a break and that she believed that two other CNA's (staff #173, and #71) and a nurse (staff #21) remained on the unit while she was on break. -At 10:09 a.m. a CNA/staff #143 stated that she did not witness what actually happened because she was in another room with another CNA (staff #71) providing care to a resident. Staff #143 stated she heard a commotion and when she went out of the room saw resident #1 placing resident #2's pet birds in the hallway, the two resident's were arguing and she helped to separate them. Staff #143 stated that another CNA was supposed to be monitoring the hallway while she and staff #71 were in another room providing care, and she did not know the location of the nurse at the time of the incident. -At 10:22 a.m. a CNA/staff #71 stated she did not observe what happened because she was assisting staff #143 to provide care in another room when the incident occurred. Staff #71 stated that there should have been a nurse and at least one of possibly tow CNA's on the unit when she was in another room providing care. -At 11:35 a.m. an LPN/staff #21 stated that when the incident occurred she was off the unit on a break and did not witness the incident. The following interviews were conducted on (MONTH) 7, 2020 with the Director of Nursing/staff #120: -At 11:50 a.m. the Director stated that there should always be a staff present in the hallway on the unit and that the staff have scheduled break times to ensure there is staff coverage on the unit. The Director stated that there may have been a miscommunication which resulted in the nurse and a CNA being off the unit at the same when the incident occurred n (MONTH) 21, 2019. -At 1:30 p.m. the Director stated that one staff is assigned to assist the resident's with smoke breaks, and that one staff is sufficient to provide safety for the residents while they smoke. The Director stated that on (MONTH) 15, 2019 when the incident occurred between resident #1 and resident #5 during the smoke break, there was one staff present, however she was unable to reach the resident's quickly enough to prevent resident #5 from grabbing resident #1. -At 3:05 p.m. the Director stated that resident #5 was very compulsive about smoking from the time she was admitted and that interventions were not effective. The Director stated that resident #5 had grabbed a box of resident cigarettes, and resident #1 tried to take it from her to protect the cigarettes and that's when resident #5 pushed down resident #1. -Resident #4 was admitted on (MONTH) 8, 2019 with [DIAGNOSES REDACTED]. An Admission MDS assessment dated (MONTH) 20, 2019 included that resident #4 had a BIMS score of 3, which indicated that the resident had severely impaired cognition, difficulty focusing attention and physical behaviors directed at others. Review of the clinical record did not reveal that a written plan of care for physical behaviors directed at other residents had been initiated. An Incident Note dated (MONTH) 7, 2019 at 10:36 a.m. included that resident #4 and resident #5 had engaged in a verbal altercation in the dining room, when resident #4 reached over and struck resident #5 on the right arm. The note included that he resident's were separated by staff, and there were no injuries. -Resident #3 was admitted on (MONTH) 6, 2014 with [DIAGNOSES REDACTED]. A Quarterly MDS assessment dated (MONTH) 9, 2019 included that the resident had speech that was unclear or slurred, and that he usually understands others. The assessment included that the resident had a BIMS score of 9, which indicated that the resident had moderately impaired cognition, and verbal behavioral symptoms directed at others. A written plan of care included that resident #3 has a [DIAGNOSES REDACTED]. The plan of care included a goal that the resident would refrain from verbally or physically abusive behavior and listed multiple interventions including to intervene by speaking calmly and professionally and in a soft tome of voice. The plan of care also included a that the resident had a communication problem related to weak voice and that he whispers, and listed multiple interventions including to allow the resident adequate time to respond. An Incident Note dated (MONTH) 17, 2019 at 10:31 a.m. included that resident #4 and resident #5 had engaged in a verbal altercation in the dining room, when resident #4 reached over and struck resident #5 on the right arm. The note included that he resident's were separated by staff, and there were no injuries. An investigative report dated (MONTH) 20, 2019 included that on (MONTH) 17, 2019 residents #4 and #3 were in the unit dining room, and began to have a verbal altercation, and that resident #5 reached over and hit resident #3 on the right arm. The report included that the residents were immediately separated and there were no injuries. During an interview conducted on (MONTH) 8, 2020 at 10:00 a.m. with the Director of Nursing/staff #120, he stated that resident #4 had never behaved aggressively towards another resident before this incident. The Director stated that sometimes resident #3 says things under his breath that are insulting to other residents, and that may have been why resident #4 struck resident #3. The Director stated that there was a CNA in the dining room at the time of the incident. A policy and procedure titled Problematic Behavior Management-Clinical Guideline included a statement that as part of the initial assessment, the staff and physician will identify individuals with a history of impaired cognition, problematic behavior, or mental illness, and that nursing staff will document the nature, duration, and associated features of any changes over time in behavior, cognition, or mood. The policy included that if the resident is being treated for [REDACTED]. | 2020-09-01 |