| 694 |
THE MILLENNIUM INSTITUTE FOR ADVANCE NURSING CARE |
405028 |
CALLE COSME REPARTO SAN LUCAS SECTOR CANEJAS |
RIO PIEDRAS |
PR |
926 |
2013-08-30 |
520 |
F |
|
|
ET9L11 |
Based on observation, interview and record review, it was determined that the Quality Assurance (QA) Committee was not effective in addressing identified resident care issues and in resolving deficiencies pertaining to the Quality of Care and Quality of Life of the facility residents. Previously cited deficiencies were not corrected as alleged by the facility. Plans which the QA Committee developed to bring the facility into compliance were not implemented in a manner which assured ongoing compliance. All required personnel were not present at quarterly QA meetings. This deficient practice had the potential to affect all 30 residents in the facility. The findings include: 1. Review of Quality Assurance (QA) on 08/29/13 at 2:00pm revealed attendance records lacked documented evidence of any QA meetings during 2013. Review of the QA records for the last two quarters of 2012 lacked documented evidence of who attended the meetings on 7/19/12 and 10/16/12. Interview with Registered Nurse (RN) 25, who served as head of the QA committee, revealed that all 2013 QA records were at her home, waiting to be transcribed and she would provide them on 8/30/13. Further interview confirmed that although each department ' s name was listed on the sign-in sheet attached to the 2012 minutes, the sign-in sheet had not been completed and she did not have documentation to verify that the Director of Nursing (DON), Medical Director, and at least three other staff had been present during the meeting. Further review of QA records on 8/30/13 at 9:50am revealed that each of the 2012 QA minutes now contained a completed sign-in sheet, indicating the Medical Director had been present at the meeting. Interview with RN25 confirmed that she had the Medical Director sign these sheets on the morning of 8/30/13, over a year after the 7/19/12 meeting occurred. Review of the 2013 QA attendance records provided on 8/30/13 revealed quarterly meetings were held on 1/12/13 and 4/10/13. Review of the sign-in sheets for these two meetings lacked documented evidence that the DON had been present. Interview with RN25 on 8/30/13 at 9:50am confirmed that there had been no DON at the January, 2013 QA meeting due to turnover in staff, and the new DON had not been present at the meeting in April. 2. Review of facility records revealed that during a survey conducted in March, 2012, the facility was cited for regulatory violations in multiple areas, including: F226 - Failure to develop and implement policies and procedures to prevent abuse/neglect; F248- Failure to provide an activity program to meet individual resident needs; F281 - Failure to provide services in accordance with professional standards of practice; F309 - Failure to provide care to assure each resident meets their highest practicable well-being; F332 - Failure to assure a medication error rate less than 5%; F371 - Failure to assure Food Sanitation; F425 - Failure to provide required pharmacy services; F501 - Medical Director responsiblities; F520 - Quality Assurance Program; In response, the facility submitted a Plan of Correction (POC), alleging that each deficiency had been corrected. However, the findings of the 8/26 - 8/30/13 survey revealed that the Quality Assurance committee failed to assure that these actions were implemented, and performed in a manner which corrected the deficiency on an ongoing basis, as each of the previously cited areas was re-cited. For example, during the 2012 survey, the facility was cited at F248 for residents not receiving activities as planned. Review of the POC revealed " We gave instructions that when the Recreational Therapist can not give his therapist, they have to be given by the OT (Occupational Therapist) so the residents can take their recreational therapies. This will be in charge of OT Supervisor. " However, review of the findings of the 8/30/13 standard and extended survey revealed that the facility continued to not provide activities as planned. Initial assessments by the OT were not completed timely, and initial care plans to meet resident ' s therapeutic activity needs were not developed. (Refer to F248.) The facility was also cited during the 2012 survey at F226 for a failure to provide annual abuse training to all staff. The POC dated 4/12/12 stated " It will provide educational presentation related to the protocol of abuse and neglect. The MDS (Minimum Data Set) Coordinator in coordination with the Director of the HR (Human Resources) Department will be responsible for this. " However, review of personnel records revealed staff continued to not receive annual abuse training. Interviews with both the MDS Coordinator and HR person on 8/29/13 at 3:40pm revealed that neither had documented evidence that this corrective action had been completed. (Refer to F226.) In addition, the POC also alleged that the facility had taken actions to correct the deficient practice cited in 2012 at F309 regarding pain management. Review of the POC revealed that " It provides incidental education to RN (Registered Nurse) staff to discuss the importance of pain management immediately the resident referral. It redirects standards and procedures on pain management and documents of this event in the clinical nrecord. Monitoring will be provided to comply with this procedure using daily rounds to be held by the Nursing Director and Head Nurse. " However, review of the findings of the 8/30/13 survey revealed that residents ' complaints of pain/possible infection were not promptly acted upon. Required 2-hour pain assessments were not completed/documented. Assessments of treatment to determine if pain was relieved were also not documented. (Refer F309.) Review of the POC revealed that the use of disposbile dishware was also cited during the 2012 survey. Review of the POC revealed that " Disposible dishware is only be used if the regular dishware is not ready to be used due to any inconveniene such as malfunction of the dishwasher. In any other case where the regular dishware can be used it will be - the kitchen supervisor and dietitian are responsible for assuring the use of these. " However, observation during all five days of the survey revealed that disposible dishware, including plates, utensils, and drink containers, continued to be in use. Interview with the Nutricionista, on 8/29/13 at 1:20pm revealed she was not employed at the facility at the time of last year ' s survey, and was unaware that the facility had previously been cited for the use of disposible dishware. The Nutricionista stated that she was a member of the QA committee; however, she had not been informed since she joined the committee that she was responsible for monitoring and assuring that disposible dishware was not being used. (Refer to F252.) Interview wih RN25 on 8/29/13 at 2:00pm revealed that she was in charge of the QA committee, She related that she had no evidence that any of the monitoring described in the 2012 POC had been completed. She stated that the DON who was employed at the time of the 2012 survey never gave her any documentation to show that the promised monitoring of various areas had occurred, She stated that when the present DON was hired approximately 4 months ago, she had been instructed to read the last two Statements of Deficiencies (SOD) so she would know what the facility ' s problems were. However, although the SODs she was to read included the POCs which stated that monitoring would occur, this DON had also failed to provide any evidence of monitoring to demonstrate that the previously cited deficiencies were being corrected. Final interview with RN25 revealed that since the DON reported directly to the Administrator it was possible that he had some evidence that this monitoring had occurred, However, interview with the Administrator during the entrance conference on 8/26/13 at 11:00am revealed his statement that RN25 was in charge of the QA committee and he had no records of the committee ' s performance. |
2014-03-01 |