| 4445 |
DOUGLASVILLE NURSING AND REHABILITATION CENTER |
115273 |
4028 HWY 5 |
DOUGLASVILLE |
GA |
30135 |
2016-10-05 |
520 |
K |
1 |
0 |
ELW111 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, record review, and review of the facility's policy titled, Quality Improvement Committee, the facility failed to maintain a Quality Assurance (QA) program which reviewed, developed, and implemented plans to correct quality deficiencies for all 229 residents living in the facility as of 9/26/16. The facility's QA program failed to: identify and respond to a pattern of failures regarding the identification, protection, and timely reporting of allegations of neglect, abuse, and misappropriation of property. Failed to identify and respond to a failure to have emergency equipment, proper sized cannulas, at the bedside for residents in the ventilator (vent) unit and address staff competencies. Failed to conduct root cause analysis of known problems and implement solutions. The facility was aware of multiple and repeated individual grievances from residents, families, and the resident council regarding staffing, pest control, and dietary services. The census was 229 and the sample size was 52. An abbreviated and partial extended survey was conducted from 9/26/16 through 10/5/16 to investigate complaints, GA 372, GA 244, GA 972, GA 111, GA 424, GA 053, the survey was conducted by Healthcare Management Solutions (HCMS), LLC on behalf of the Georgia State Survey Agency (SSA). The facility was found to not be in substantial compliance with the Medicare/Medicaid regulations at 42 CFR 483 Subpart B requirements for Long Term Care Facilities. The following deficiencies resulted from the facility's non-compliance related to GA 244, GA 972, GA 11, GA 424, and GA 053. The census was 229 residents and the sample size was 52 residents. On 9/27/16 a determination was made that a situation in which the non-compliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. On 9/27/16 at 5:55 p.m. the Administrator and Director of Nursing (DON) were notified that the failure to protect residents from neglect (F224 at scope and severity of J), the failure to ensure professional standards of nursing care were followed (F281 at scope and severity of J), the failure to provide specialized respiratory services (F328 scope and severity of J), and the failure to assure the facility was administered in a manner to assure that each resident reached or maintained their highest practicable well-being (F490 at a scope and severity of K), constituted Immediate Jeopardy. F224 also constituted Substandard Quality of Care at 42 CFR 483.13, while the Immediate Jeopardy at F328 constituted Substandard Quality of Care at 42 CFR 483.25. The Immediate Jeopardy at F224, F226, F281 and F490 was identified to have existed since 9/6/16, when staff mixed [MEDICATION NAME] with Pine Sol cleaner and administered it to Resident (R) 7, with the resident sustaining burning in her throat and requiring a transfer to the hospital. The facility failed to utilize its resources and immediately report and thoroughly investigate this case of neglect of R7, as well as failed to take necessary actions to protect the resident from the potential for further neglect. On 9/28/16 at 5:30 p.m. the facility's Administrator and DON were notified that the failure to develop and implement procedures to protect residents from abuse, neglect, and misappropriation (F226 at a scope and severity of J) also constituted Immediate Jeopardy. The Immediate Jeopardies at F226 also constituted Substandard Quality of Care at 42 CFR 483.13. The Immediate Jeopardy at F328 was found to have existed since 9/26/16, when it was identified that the correct-sized emergency equipment was not available for 3 of 14 residents (R1, R9 and R10) residing on the specialty vent unit. In addition actual harm was cited at F469 S/S:G the failure to control roaches, as well as other insects such as gnats and flies, resulted in psychosocial harm for 2 of 52 sampled residents (R2 and R37), both of whom expressed fear of the roaches which had been seen in their rooms. An acceptable Allegation of Compliance (AoC) was received on 10/3/16, and Healthcare Management Solutions, (HCMS) LLC, on behalf of the State Survey Agency, validated the AoC. The Immediate Jeopardy was removed from all 5 areas on 10/4/16. The Scope and Severity was lowered to the following levels: F224:D, F226:D, F281:D, F328:D, F490:F while the facility develops and implements the Plan of Correction (PoC); and the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes: After Supervisory review by the CMS Regional Office the scope and severity of F520 was increased to a level of Immediate Jeopardy at F520:K and the scope and severity of F226 was increased to Immediate Jeopardy at F226:K. Findings include: Interview with the Director of Nursing (DON) and Administrator on 10/3/16 at 2:42 p.m. revealed that she and the Administrator had shared responsibility for the facility's Quality Assurance and Performance Improvement (QAPI) program. The Administrator stated she was working on a credible allegation to remove immediate jeopardy, and therefore, the Assistant Administrator would be present to assist the DON in answering questions about the QAPI program. Deficient areas that were identified through observations, interviews, and record review during the abbreviated survey were discussed as examples to determine how the facility's QAPI program functioned. 1. During the interview which began on 10/3/16 at 2:42 p.m., the DON and Assistant Administrator were asked if the QA committee had identified the failure to identify, immediately report, thoroughly investigate, and take immediate actions to protect residents from potential abuse, neglect, and/or misappropriation. If this area had been identified through the QA process, the DON and Assistant Administrator were asked to provide evidence the QA committee had taken the issue through their QAPI process. (Refer to F224 and F226.) Interview with the DON, during the meeting which began on 10/3/16 at 2:42 p.m., revealed the QA committee did not formally review allegations of abuse and neglect, including the identification of possible patterns and whether there was a need to take action. The DON stated there was no audit of the information contained in each individual allegation to determine possible commonalities, such as the same perpetrator, same shift, and same unit. Likewise, there was no review of allegations to identify systemic problems needing correction, such as failure to identify alleged abuse/neglect/misappropriation of property; failure to immediately report allegations; or failure to immediately suspend alleged perpetrators when an allegation was made. The DON stated grievances were reviewed and provided (MONTH) and (MONTH) (YEAR) documentation, which noted the number and concern areas from the grievances for each unit. Review of this documentation showed a lack of sufficient information to determine if grievances might, in fact, have actually constituted allegations of abuse, neglect or misappropriation of property. In addition, review of this document revealed issues with accuracy. For example: Although the report stated there was a total of 13 grievances for (MONTH) (YEAR), review of the documentation revealed there was a total of 22 grievances (8 on the 300 Unit, 2 on the Central Hall, 5 on West Unit; 6 on Magnolia Terrace, and 1 on the ventilator unit.) Although the report stated there was a total of 16 grievances for (MONTH) (YEAR), review of the documentation revealed there was a total of 22 grievances (9 on the 300 Unit, 9 on the Central Hall, 2 on Magnolia Terrace - 2 and 2 on the Ventilator Unit.) Further interview with the DON revealed the QA committee had not identified any systemic problems with its abuse/neglect prevention program, even though 8 of the 10 incidents reviewed by the survey team, were found to be deficient in at least one of the 7 required components to prevent abuse/neglect (Refer to F226). The DON stated, We had identified some staff reluctance to report. However, she was unable to provide a date when the QA committee had identified this problem. The DON related the problem of reluctance to report had not been taken through the QAPI process. She stated a root cause analysis, per facility policy, of possible reasons for the reluctance of staff to report abuse was not conducted and she verified no action plan was developed to resolve the concern. The DON stated the facility routinely provided training on reporting of abuse; however, this routine training had not been a part of the QAPI process. The DON had no evidence of evaluation of the training to determine whether the training was correcting the problem of a reluctance to report. The DON stated, That's what we're working on now (evaluation of the training), verifying this was in response to immediate jeopardy being found by the survey team. 2. During the interview which began on 10/3/16 at 2:42 p.m., the DON and Assistant Administrator were asked how the QA committee was monitoring and identifying potential care concerns in the Specialty Ventilator Unit, which was a separate, stand-along building on the facility's campus (Refer to F328). Interview with the DON revealed the Unit Director of the Specialized Ventilator Unit was a member of the QA committee, as well as an active participant in the facility's morning meetings where individual resident concerns were addressed. She reviewed the sign in sheets and confirmed that he had attended the last full quarterly QAPI meeting on 7/28/16. The DON was informed that the Unit Manager (UM)/Registered Respiratory Therapist (RRT) had informed the survey team of staffing competency concerns for the unit and was asked whether the QA committee had addressed these concerns. Continued interview with the DON revealed the DON was aware of staff training and competency concerns, for staff in the Specialized Ventilator Unit, because the UM shared these concerns during the daily stand up meetings. The DON stated, he told me directly about the problem. However, after a review of QA documentation, she stated, Those concerns didn't make it to formal QA. She reviewed the notes from the meeting and stated that the QA committee looked at audits on long-stay pain (based on Quality Measures) and the use of mittens (hand restraints) on the Specialized Ventilator Unit, as well as talked about one resident with a catheter and one resident with a skin condition. However, she continued and stated, the UM did not tell the formal QA committee that the nurses needed extra training, competencies. The DON was asked if a QAPI plan was developed, since both she and the UM were aware of issues with staff training and competency. The DON stated that in response to the UM concerns, I've got plans in my head but don't have them actually written down about what needs to be done. Further interview with the DON on 10/3/16 at 2:42 p.m., revealed the QA committee had not monitored or identified the failure to have correctly-sized emergency equipment at the bedside for residents on this unit, and was unaware of the problem, prior to identification by the survey team on 9/26/16. 3. Review of Resident council meeting notes beginning 5/5/16 documented residents' concerns about insufficient staffing. Residents' complaints included can't find staff on hall 3-11 shift. Review of resident grievances for (MONTH) (YEAR), (MONTH) (YEAR) and (MONTH) (YEAR) revealed individual complaints about lack of care from staff, delays in answering call lights, and insufficient staff to meet resident needs. Review of resident council meeting notes dated 9/1/16 revealed additional complaints about insufficient staffing/call light response time. Observations, interviews, and record review during the abbreviated survey, beginning on 9/26/16, revealed that the problem had not been solved and was ongoing (Refer to F353). During the interview which began on 10/3/16 at 2:42 p.m., the DON and Assistant Administrator were asked to provide evidence of a QAPI plan which included their analysis of possible root causes of the staffing problem, action plan to correct the problem, evidence of implementation of this plan, and analysis of the results/determination of how well the plan worked. The DON related that the QA committee developed an action plan on 5/27/16 for recruitment and retention of staff, stating that things were done for morale such as a nurse recognition activity in (MONTH) (YEAR). She stated the facility also boosted its orientation efforts, they began completing panel interviews, and fliers were sent out to the community stating the facility was hiring. Further interview with the DON revealed that the facility had not performed a root cause analysis, per facility policy, to determine the basis of the problem before implementing these activities. The DON was asked how the QA committee monitored if these efforts worked well, especially based on the ongoing complaints of lack of sufficient staffing. She related that Human Resources staff maintained retention/turn-over statistics. However, she did not have evidence of this as part of the QA documentation and would have to contact HR to see what information they could provide. Interview with the Human Resources (HR) Director on 10/3/16 at 3:36 p.m. revealed the staff-turnover rate went from 46.6% to 76.5% between (MONTH) (YEAR) and (MONTH) (YEAR). By (MONTH) (YEAR), the staff turnover rate as reported at the (MONTH) (YEAR)sub-QA meeting (monthly meetings held in which the Medical Director was not present, as opposed to the quarterly meetings where she was) had increased to 84.5% The HR Director related that the staffing problem was discussed in QA and determined to be an issue of retention. She stated, It wasn't an issue of hiring new, was retaining old. The HR, DON, and Assistant Administrator were asked to provide evidence of the action plan taken in response to this analysis, as well as evidence of implementation of how well it worked. Although they noted several actions, such as having an employee of the month on 8/15/16 and placing a banner out by the road in front of the facility, stating that they were hiring (also 8/15/16), they confirmed that there was no written action plan or evidence of monitoring to determine if the QA committee's actions had worked. 4. Review of resident council meeting documentation dated 5/5/16, demonstrated residents' concerns about pests. Residents council meeting documentation dated 6/2/16 revealed resident concerns were not resolved. Review of resident council meeting notes revealed the problem of insects continued to be noted as a resident concern in 7/7/16 and 8/4/16 resident council meetings. Observations, interviews, and record review during the abbreviated survey, which began on 9/26/16, revealed that the problem was still ongoing (Refer to F469). During the interview which began on 10/3/16 at 2:42 p.m., the DON and Assistant Administrator were asked to provide evidence of a QAPI plan which included their analysis of possible root causes of the problem, action plan to correct the problem, evidence of implementation of this plan, and analysis of the results/determination of well the plan worked. The Assistant Administrator related the facility notified the bug people whenever pests were seen, and provided multiple invoices to show that specific halls/rooms had been treated in response to individual complaints/sightings of insects. However, the Assistant Administrator acknowledged the routine monthly visits, plus additional call-backs as necessary, were what the facility had always done, and were not an action plan in response to the uncontrolled pest problem this year. She stated she was not aware if the ongoing problem of pests had been taken to the QA committee for review, if the QA had completed a root cause analysis to determine why the facility's pest control measures were not working, or if they had developed an action plan in response. Further interview with the Assistant Administrator revealed she would check and provide any additional information she could locate. No further information was provided related to QA activities in response to this problem prior to exit on 10/5/16 at 11:00 a.m. 5. Review of Resident Council meeting documentation, dated 4/12/16 revealed that under old business 15 residents indicated that their previous complaints about staff not serving trays in DR (dining room) timely had not been resolved to their satisfaction. Under new business residents expressed concerns about the 300 Hall not getting first shift ice passed, and not being offered HS (bedtime) snacks. A review of the departmental response form dated 4/15/16 revealed that a QAPI tool done. Will check progress with council and discuss QAPI mtg (meeting). Review of the 5/5/16 Resident Council meeting notes revealed that under Old Business 16 residents stated that trays were still not being served timely. Sixteen residents also indicated their other concerns were not resolved, as they were still not being offered HS snacks, or having ice passed on the first shift. During the interview which began on 10/3/16 at 2:42 p.m., the DON and Assistant Administrator were asked to provide evidence of the QAPI plans for both the old and new business concerns, including their analysis of possible root causes of the problem, action plan, evidence of implementation of this plan, the QAPI tool mentioned in the response, and analysis of the results/determination of the how well the plan worked. The DON related that she would have to look for information on the QAPI plan and tool that was alleged in the 4/15/16 departmental response. As of 3:34 p.m., the DON was still looking for evidence that a performance improvement plan had been developed as alleged in the response to the resident council. As of 4:49 p.m., the DON related that she could not find a QAPI plan related to the delays in food service. She did state that she had located an audit that identified a problem with residents not receiving bedtime snacks and ice water in a timely manner that was completed on 6/1/16, 1 1/2 months after the departmental response stated the tool was completed. The DON related that in response to the findings of the audit, the facility had done reeducation. Review of the reeducation documentation revealed that the in-services were not completed until 9/5/16 - 9/8/16, 4 months after the residents voiced concerns about snacks. At this time, the DON also provided a documented titled QA/QI HS snacks. The DON described this as a sample audit tool that would be used to monitor the facility's corrective actions. Interview with the DON revealed she had no completed audit tools to verify that staff had monitored that snacks were now being offered and ice water was present for the residents. The Assistant Administrator concluded the interview about Quality Assurance on 10/3/16 at 4:55 p.m. by acknowledging that the QA committee didn't do 'official' written action plans and they had nothing to show to indicate who was responsible for specific actions, who would monitor the identified actions, who would report back to the committee, or what information would be captured, analyzed, and reported to determine if a specific identified care concern had, in fact, been corrected. Review of the policy for Quality Improvement Committee dated (MONTH) 2013 revealed that The Quality Improvement Committee will assess and monitor the quality of services provided to the residents in the facility in order to identify potential systemic problems. The committee will implement and systemically evaluate processed to identify problems in order to proactively improve health care deliver . Create systems to provide care and achieve compliance with nursing home regulations. Strive to achieve improvements in specific benchmarks. Utilize data obtained from a variety of sources to identify quality problems, opportunities for improvement, and set priorities for actions. Performance Improvement is a pro-active and continuous study of processed with the intent to prevent or decrease the likelihood of problems by identifying areas of opportunity and testing new approaches to fix causes of persistent/systematic problems. Performance Improvement Projects will be assigned to focus on a particular problem in one area of the facility or facility wide. Perform root cause analysis, set targets, implement corrections to improve the process. Procedures for this policy included that the QA committee would: Review results of previous audits and identify action plans for any areas needing improvement . Identify quality Improvement opportunities. Assign committee members audits related to any area of concerns Provide training and education as needed to facility staff. ** F328 A[NAME] and Validation The facility implemented the following actions to remove the Immediate Jeopardy: 1. All residents on ventilators or with trachs ([MEDICAL CONDITION]) have the potential to be affected. 2. On 9/28/16 residents with trach/vents rooms were checked to ensure emergency equipment to include [MEDICAL CONDITION], one smaller size trach, pulse ox, ambu (artificial manual breathing unit) bag and mask, gloves, gauze, 5-10ml syringe, 0.9% Normal Saline vial, red waste bag, H2O based lubricant, round ended scissors, [MEDICAL CONDITION] were available to bedside by RN/RT and equipment was at residents bedside. 3. On 9/27/16 started reinservicing licensed staff by RN/RT, Director of the [MEDICAL CONDITION] Unit that: Emergency equipment at bedside to be kept in plastic bag in wall mounted cabinet in room next to bed with patient name and [MEDICAL CONDITION] and bedside emergency kits to include [MEDICAL CONDITION], one smaller size trach, pulse ox, ambu bag and mask, gloves, gauze, 5-10ml syringe, 0.9% Normal Saline vial, red waste bag, H2O based lubricant, round ended scissors, [MEDICAL CONDITION]. On 9/28/16 in-services continued to be provided by RN/RT, the Director of the [MEDICAL CONDITION] Unit. In-services will continue by RN/RT Director of [MEDICAL CONDITION] Unit, Respiratory Therapist, RN Supervisor, LPN Supervisor, LPN Staff Development Coordinator, RN Director of Nursing Services, RN Assistant Director of Nursing Services, RN Unit Manager. In-services will continue until licensed personnel that work in the vent unit have been in-serviced. 100% of in-services will be completed on 10/7/16. 80% of licensed personnel on vent unit have been in-serviced. 4. On 9/28/16 started competencies on licensed staff [MEDICAL CONDITIONS] by RN/RT.[MEDICAL CONDITION] to include preparation, course of action for cleansing inner cannula, completion of task. [MEDICAL CONDITION] suctioning included preparation, course of action of suctioning, and completion of task. Competencies will continue until 100% of licensed personnel that work the vent (ventilator) unit have been in-serviced. Competencies will continue to be provided by RN/RT Director of the [MEDICAL CONDITION] Unit or Respiratory Therapist, RN Supervisor, LPN Staff Development Coordinator, RN Director of Nursing Services, RN Unit Manager, RN Assistant Director of Nursing Services, LPN Supervisor. 100% of competencies will be completed by 10/7/16. Licensed staff will not be allowed to work until competency completed 5. [MEDICAL CONDITION] care competency includes: preparation, course of action for cleansing inner cannula, course of action for disposable inner cannula, completion of task. 6. [MEDICAL CONDITION] suctioning competency includes: preparation, course of action for suctioning, completion of task. 7. Nurses that work the vent unit will have a competency checklist completed [MEDICAL CONDITIONS]. Competencies started 9/28/16 by RN/RT. Competencies will be continued by RN/RT Director of [MEDICAL CONDITION] Unit or Respiratory Therapist, RN Supervisor, LPN Staff Development Coordinator, RN Director of Nursing Services, RN Unit Manager, RN Assistant Director of Nursing Services, LPN Supervisor. Competencies will continue until licensed nurses assigned to vent unit have been completed. 100% of competencies will be completed by 10/7/16. 8. General orientation - Transitional [MEDICAL CONDITION] Care Unit skills verification to include identification of alarms outside resident rooms, what to do when alarm sounds, will be completed for staff working vent units to include nurses, respiratory therapists, social workers, activity coordinators, dietitians, rehabilitative therapists and certified nursing assistants. Verifications started on 9/27/16 by RN Assistant Director of Nursing and RN/RT Director of [MEDICAL CONDITION] Unit. Verification continued on 9/28/16 aby RN Assistant Director of Nursing and RN/RT Director of [MEDICAL CONDITION] Unit. Verification will continue by RN/RT Director of [MEDICAL CONDITION] Unit or Respiratory Therapist, RN Supervisor, LPN Staff Development Coordinator, RN Director of Nursing Services, RN Unit Manager, RN Assistant Director of Nursing Services, LPN Supervisor. Verification will continue until staff working vent unit are completed. 100% of verifications will be completed by 10/7/16. Staff will not be allowed to work vent unit until verification completed. 80% of staff working vent unit have been completed. 9. During orientation process, newly hired nurses will have a competency checklist completed [MEDICAL CONDITION] to include preparation, course of action for cleansing inner cannula, completion of task [MEDICAL CONDITION] to include preparation, course of action for suctioning and completion of task if working on the vent unit by RN/RT Director of [MEDICAL CONDITION] Unit, Respiratory Therapist, RN Supervisor, LPN Staff Development Coordinator, RN Director of Nursing Services, RN Unit Manager, RN Assistant Director of Nursing Services, LPN Supervisor. 10. Certified nursing assistants working the vent unit will have competencies completed on oral care/bathing/showering of residents with vents and trachs to include: preparation, course of action, positioning, and completion of task by RN/RT Director of [MEDICAL CONDITION] Unit or Respiratory Therapist, RN Supervisor, LPN Staff Development Coordinator, RN Director of Nursing Services, RN Unit Manager, RN Assistant Director of Nursing Services, LPN Supervisor. Competencies will be completed by 10/7/16. Certified Nursing Assistants working the vent unit will not be allowed to take an assignment until competency is completed. If certified nursing assistant is pulled from the main building, employee will not be allowed to take an assignment until competency completed. 11. No staff will be allowed to work until competencies and in-servicing are completed. 12. During orientation process, newly hired staff working vent unit will have general orientation-transitional [MEDICAL CONDITION] care until skill verification to include verification to include identification of alarms outside resident room. What to do when alarm sounds. Will be completed by RN/RT Director of [MEDICAL CONDITION] Director or RN Assistant Director of Nursing, Respiratory Therapist, RN Supervisor, LPN Staff Development Coordinator, RN Director of Nursing Services, RN Unit Manager, RN Assistant Director of Nursing Services, LPN Supervisor (sic.) 13. RN Director of Nursing Services or RN Assistant Director of Nursing Services will audit weekly x 4 weeks then monthly x 2 months for emergency equipment at the bedside to include [MEDICAL CONDITION], one smaller size trach, pulse ox, ambu bag and mask, gloves, gauze, 5-10ml syringe, 0.9% Normal Saline vial, red waste bag, H2O based lubricant, round ended scissors, [MEDICAL CONDITION] and ensure emergency kit is placed in wall mount cabinet in resident rooms. Audit findings will be discussed on QA. If problem is noted the problem will be corrected then presented to the Director of Nursing for appropriate action (example 1:1 in-service, disciplinary action.) 14. If a licensed nurse is pulled from the main building to work on the vent unit, employee will be in-serviced on emergency equipment at bedside to be kept in plastic bag in wall counted cabinet in room next to be with patient name and [MEDICAL CONDITION] and bedside emergency kits to include [MEDICAL CONDITION], one smaller size trach, pulse ox, ambu bag and mask, gloves, gauze, 5-10ml syringe, 0.9% Normal Saline vial, red waste bag, H2O based lubricant, round ended scissors, [MEDICAL CONDITION].[MEDICAL CONDITION] to include preparation, course of action for cleansing inner cannula, course of action for disposing of inner cannula, completion of task.[MEDICAL CONDITION] to include preparation, course of action for suctioning, completion of task. (sic) Any other staff member to include nurses, respiratory therapists, social workers, activity coordinators, dietitians, rehabilitative therapists and certified nursing assistants will be in-serviced on transitional [MEDICAL CONDITION] care unit. Skill verification to include identification of alarms outside resident's room, what to do when alarm sounds. In-service/training will be conducted by RN or RT on the vent unit. The staff member will be in-serviced prior to taking an assignment on the vent unit and on new nurses in orientation. 15. QA meeting was held 9/29/16. Participants were Executive Director, Assistant Executive Director, Social; Service Director, Director of [MEDICAL CONDITION] Services, Medical Director. 16. In-services for emergency equipment at bedside to be kept in plastic bag in wall mounted cabinet in room next to bed with patient name and [MEDICAL CONDITION] and bedside emergency kits to include [MEDICAL CONDITION], one smaller size trach, pulse ox, ambu bag and mask, gloves, gauze, 5-10ml syringe, 0.9% Normal Saline vial, red waste bag, H2O based lubricant, round ended scissors, [MEDICAL CONDITION]. Will be completed quarterly on licensed staff. (sic) HCMS on behalf of the State Survey Agency validated the implementation of the facility's Credible Allegation of Jeopardy Removal (CAJR) as follows: 1. No action plan was listed in this statement for verification. 2. Documentation of the 9/28/16 room checks were verified during the abbreviated survey. Observation during a tour of the unit on 10/4/16 at 3:30 p.m. found that all resident rooms on the TPCU (Specialized Ventilator Unit) were equipped with the correct size equipment, as well as all other emergency equipment listed in the AoC. Observation of the bedside cabinets containing emergency equipment were checked for 13 residents (residing in Resident Rooms: 101D, 102W, 104D, 104W, 106D, 107W, 110W, 110D, 111W, 111D, 112, 113W, and 115D). Emergency equipment observed including 2 replacements [MEDICAL CONDITION] cannulas (one the same size as what was currently in place for the resident, and one a size smaller, an ambu bag, a pulse ox machine, gloves, gauze, [MEDICAL CONDITION] ties, scissors, vials of Normal Saline, syringe, lubricant, suction catheter and red biohazard bag, was found at each bedside. 3. In-servicing records for all licensed/certified staff working in the vent unit were reviewed, and matched against the staffing schedule, as well as direct observation of staff and interviews on 10/4/16. All licensed/certified staff working in this unit was found to have the in-service records alleged in the A[NAME]. Based on interviews with staff and the review of the facility documentation staff are not being allowed to work in this unit without first attending this training, based on interviews with staff, and a review of facility documentation. Interviews were held on 10/4/16 with the following staff: RN 272 at 3:10 p.m., RN 273 at 10:30 a.m., LPN 288 at 10:15 a.m., LPN Orientee 308 at 9:40 a.m., CNA 292 at 9:50 a.m., CNA 166 at 11:55 a.m., CNA 151 at 11:15 a.m., RT 251 at 11:25 a.m., RT 257 11:40 a.m., SW 270 at 9:20 a.m., and PT 309 at 12:20 p.m., as well as the Unit Secretary at 9:10 a.m. The in-service records revealed that each staff received in-service training regarding the general orientation to the TCPU which included but wa |
2019-10-01 |