cms_TN: 14345
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 14345 | CRESTVIEW HEALTH AND REHABILITATION | 445409 | 2030 25TH AVE N | NASHVILLE | TN | 37208 | 2012-05-15 | 319 | J | LH9611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, review of material safety data sheets (MSDS), medical record review and interview, it was determined the facility failed to assess, notify the physician and provide appropriate treatment and services to address mental and psychosocial adjustment difficulties for 1 of 32 (Resident #66) sampled residents in Stage 1 and Stage 2. Failure of the facility to assess, implement interventions, adequately supervise and notify the physician of behaviors placed Resident #66 in immediate jeopardy. The findings included: Review of the facility's "Behavior Management Plan" policy documented, "The purpose of the Behavior Management Plan is to help improve the management of the behavioral symptoms... The following four-step plan provides the methods of problem solving needed to deal with behavioral symptoms in a quick and consistent way... 1. Immediate Action to control a threatening or dangerous behavioral symptom. 2. Behavior assessment to observe and describe the behavior. 3. Medical evaluation to look for medical or other causes of the behavioral symptom that need treatment... Psychiatric evaluation may be needed. 4. Care plan development to decide upon realistic goals for behavior change and the steps needed to reach these goals. This includes trying the care plan and then evaluating it to see how well it worked... Each separate targeted behavior is monitored to try to determine cause of the behavior, what interventions to put in place, and whether the interventions are effective... Residents displaying mental or psychosocial adjustment difficulty as evidenced by behaviors may require a mental health consultant referral, Depending on the severity of the issue, the nurse phones the physician, the director of nursing, the administrator, and the mental health consultant... Residents will be immediately transported to a designated or requested acute care facility for evaluation..." Review of the facility's "Change in Condition" policy documented, "...A resident's physician and legal representative or responsible party must be notified of a change in the resident's condition... Documentation of the Change in Condition will be made in the appropriate condition system folder in the Electronic Medical Record... Situations in which a physician and legal representative or responsible party should be notified Immediately of a change in a resident's condition include... significant and unexpected change/decline in a resident physical, mental and/or psychosocial status..." Review of the MSDS sheets for the two moisture barrier creams used in the facility revealed the following: a. MSDS for [MEDICATION NAME] Extra Protective Cream "...ACUTE HEALTH HAZARDS... INGESTION... GASTROINTESTINAL IRRITATION. INGESTION OF LARGE QUANTITIES CAN BE HAZARDOUS. SYMPTOMS OF INTOXICATION... Contact a poison control center for instructions... After first aid, get appropriate in-plant, paramedic, or community medical support... EYES... may cause eye irritation... Avoid eye contact." b. MSDS for [MEDICATION NAME] Dimethicone Protectant "...ACUTE HEALTH HAZARDS... Ingestion: Large doses may cause [MEDICAL CONDITION] upset, dangerous upon ingestion. First Aid Measures... Ingestion: not known... After first aid, get appropriate in-plant, paramedic, or community medical support.... EYES: May cause irritation with redness and pain... Flush eyes (including under lids) with copious amounts of water for at least 15 minutes." Medical record review for Resident #66 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Nurses' notes documented the following: a. [DATE] - "Resident scratches himself and has scabs all over body. Hospital staff stated this is his behavior... resident's decisions are poor; cues/supervision required... " b. [DATE] at 3:50 AM - " [MEDICATION NAME] Tablet given for anxiety restless... stating that he can't sleep without medication..." [DATE] at 4:45 - "...observed on floor... minor injury moves all extremities laceration to right elbow immediately applied, steristrips... 02 (oxygen) Saturation: 84% (percent) on 02." c. [DATE] at 7:47 AM - "..Resident has slept for only 1- (to) 2 hrs, sitting up in wheelchair, propel himself, up and down in hallway all night... confused and talkative... refused to rest in bed and put oxygen on 02 sat (saturation) checked ,[DATE]% on room air..." [DATE] at 2:32 PM - "...Resident noted to be very anxious this shift... proceeded to take a family members milkshake and was going to drink it but ended up dumping it onto the floor, nurse entered room and reminded resident that he is a diabetic and is not to have such items and also that it was inappropriate to take things from other residents... At approximately 1030 his nurse was called to resident's room by CNT (certified nursing technician)... Resident noted sitting on side of bed, snorting a white powdery substance off of a paper located on bedside table using a temperature probe cover with the once closed end open with jagged edges. Also noted on table were a bread knife and credit card. When resident noticed that staff had entered the room he immediately stopped and started apologizing. Substance and paper were taken from resident and placed in zip-lock bag. Resident asked what he was doing and stated that he had found a round, white pill on the floor, crushed it up, and started snorting it because he knew it would get into his system faster... it looked like an [MEDICATION NAME]" [DATE] at 5:21 PM - "...Resident seen getting out of wheelchair and attempting to transfer without assist... falling onto his bottom and then onto back hitting the back of his head on the floor..." d. [DATE] at 8:41 AM - "resident has been up all through out the night... up and down the hallway and came to the nurses station several times and asked nurse something constantly... he would not stay in bed... He appeared to be very anxious, agitated. He was given [MEDICATION NAME] 0.5 mg (milligrams) at 2:01 am but that was ineffective... he is uncooperative with cares and very difficult to redirect..." [DATE] at 7:48 PM - "resident is rummaging around, invading other's space, he is non-compliant with staying in his w/c (wheelchair), he gets up and wanders around his room he approaches any and every one in his path, he's making unreasonable request, asking for things that he doesn't have ordered, he refuses to listen to any reasoning, he is obnoxious to staff when he's asked to scoot back out of the personal space he's invaded, he repeats his self over and over again, state's that he can't stop talking, he is anxious and makes those around him uncomfortable per other residents that are trying to walk and get exercise he has absolutely no respect for others, he manipulates staff's time, visitors to other residents time and space, makes request of visitors that are inappropriate asking for phone numbers so he can contact them if he has an emergency, these are not his visitors, medication is not helpful in getting him to calm down." e. [DATE] at 6:56 AM - "...noted his lower leg with feet swollen and respirations slightly dyspnic (dyspneic). He was asked to (go) back in bed for leg elevation and put Oxygen nasal cannula on but he was not follow the directions... At 6:41 am, observed resident getting out of wheelchair and starting to walk without staff assistance. Before staff reached him to hold his body, he lost his balance and stepped backward then fell down on his bottom..." f. [DATE] at 5:44 AM - "...PRN (as needed) MED (medication) GIVEN; [MEDICATION NAME] FOR AGITATION CONSTANTLY GETTING UP FROM CHAIR... VERY UNSTEADY ON FEET... FREQUENTLY REMOVING OXYGEN... SAT% 84... TRYING TO EAT OR DRINK WHATEVER IS IN REACH... GENERALLY CONFUSED... TEMP (temperature) 102.8... a little later, found resident eating skin protectant paste. Noted white ointment in full of his mouth and he spread that cream on his glasses..." g. [DATE] at 3:37 AM - "[MEDICATION NAME] given for anxiety UP from bed resisting instructions for safety... refusing to keep 02 on, refusing to call for ambulatory assistance... LUNG SOUNDS: crackles heard, lower bilateral lobes... pale, cool..." h. [DATE] at 8:48 AM - "Note: At 0605 am ...LPN (Licensed Practical Nurse) brought to my attention that resident was not breathing and that he did not have a pulse. Upon assessment of resident he was noted not to have a apical pulse, no blood pressure, no visible respiration... pronounced resident expired at 0655 am..." Review of a 5 day Minimum Data Set ((MDS) dated [DATE] documented the brief interview for mental status (BIMS) score was 11, had no behaviors, no wandering and no rejection of care. The care plan dated [DATE] did not address the residents behaviors of drug seeking, snorting, eating the moisture barrier, taking items that are not his, low oxygen saturations, abnormal lung sounds or elevated temperature. During a telephone interview in the Assistant Director of Nursing's (ADON) office on [DATE] at 6:15 PM, the physician stated, "Yes I remember (stated Resident #66's name), he was not there very long, don't remember seeing him after admission note..." The physician was asked if he was made aware of all the residents behaviors of agitation, anxious, rummaging, wandering, resisting care, refusing oxygen, refusing to go to bed, being up all hours, constantly talking, eating and drinking everything. The physician stated, "...am aware of some of his behaviors, told in a couple of conversations..." When asked if he was informed about the incident of the resident eating the moisture barrier cream. The physician stated, "No, I don't know anything about him eating the barrier cream..." When he was asked if he was notified of the residents symptoms of low oxygen saturations and lung sounds." The physician stated, "...I know he had problems, wasn't there very long, don't remember being told he was not using oxygen, I do remember the powder incident and some of the behaviors." During an interview in the ADON's office on [DATE] at 7 PM, the Director of Nursing (DON) stated, "...yes, I would expect nurses to notify and document the physician was made aware of behaviors, change in condition of residents." During an interview in the ADON's office on [DATE] at 9:40 AM, the physician stated, "...this guy (Resident #66) was aware but not reliable, had diastolic heart failure, not ambulatory, had back pain, people on these drugs need pain clinic, I did not see where behavioral health saw patient, normally would need psychiatric evaluation and care, if I had known just one day of those (documented behaviors) I would have sent him out. He needed to go back to the hospital... I know I would have called psych (psychiatry) in if I had known..." There was no documentation that the physician was notified of Resident #66's repeated behaviors, anxiety and agitation. There was no documentation of a behavior assessment completed per facility protocol. There was no documentation that the physician was notified of the resident's repeatedly low oxygen saturation results or of the resident being noncompliant with using the oxygen. There was no documentation that the physician was notified of the resident eating the moisture barrier cream. There was no documentation of any medical care given after the resident was found eating the moisture barrier cream. There was no documentation that the poison control center was consulted per MSDS recommendations. There was no incident report completed for the behavior of snorting the white powdery substance or eating the barrier cream. The facility failed to adequately assess, provide interventions and supervision to ensure that the psychosocial needs were treated which resulted in immediate jeopardy when Resident #66 continued to exhibit behaviors and deterioration of condition. On ,[DATE] through (-) ,[DATE] an annual re-certification survey was completed. The facility was cited with an Immediate Jeopardy (IJ) at F319 with a scope and severity of a "J". The facility's failure to assess and provide the necessary care and services to provide the highest practicable physical, mental and psychosocial well being of the resident displaying mental difficulty, placed the Resident #66 in immediate jeopardy. An extended survey was completed on [DATE]. The Administrator (Adm), the Director of Nursing (DON), and the Regional Nurse Consultant were informed of the IJ in the Assistant Director of Nursing's (ADON) office on [DATE] at 7:35 PM and on [DATE] at 11:55 AM. An Allegation of Compliance (AOC) was received from the facility on [DATE] at approximately 5:25 PM. The AOC the facility presented to the survey team documented the following corrective measures put in place: 1. Inservicing 100 percent (%) of the licensed nursing staff and Certified Nursing Assistants (CNA) began on [DATE] on the following topics: a. Verbal questions and answers with staff. b. Physician notification and Responsible Party notification. c. Change of Condition. d. Behavior Management. The inservicing was conducted by the Adm, DON, and the Nurse Educator/ADON. All new hires will be inserviced during orientation. 2. The facility developed an "Alert Charting Log" to document resident identification, reason for alert charting, start and end date of charting for nurses to use when documenting. 3. The facility developed an "Event Log" audit form that included physician notification, root cause, Plan of Correction (POC) update, interventions, fall risk update, alert charting done and neuro checks done to be audited, results communicated to Quality Assurance (QA) committee. 4. The facility developed an "Oxygen orders and use audit form with results to be communicated to QA committee. 5. A "Nursing Notes Audit for Change of Condition" audit form was developed to audit nurse documentation, physician notification for residents with a change in condition. Results to be communicated to the QA committee. 6. The facility developed a Weekly At Risk QA/ Performance Improvement (PI) audit log that audits behaviors, events reported, new declines in activity of daily living (ADL)s, change of conditions/general decline conditions. Results to be communicated to the QA committee. 7. The facility developed at Behavior QA/PI tool to be completed by Social Services that included behaviors, resisting care, psychiatric services, alert charting, behaviors on MDS. This audit tool to be communicated to the QA committee. 8. All results of audits/inservices will be reviewed by the Administrator for any aberrant results. The results from the audits/ inservices will be reported monthly to the QA/PI committee for review to ensure compliance. The Administrator and Director of Nursing will conduct weekly review of audits with any abnormal results being investigated and resolved immediately. The QA/PI Committee will ensure compliance by trending audits and making recommendations. 9. Corporate staff will assist with onsite visits to review the facility staff (Administrator) progress on obtaining and maintaining compliance. Corporate staff will assist and review policies, procedures, educational material as needed in order to ensure the facility acquires and maintains compliance. An exit conference was conducted with the Adm, DON, Regional Director of Operations, Vice President of Clinical Services, three Regional Nurse Consultants and the ADON in the therapy room on [DATE] at approximately 7:30 PM. The facility staff were informed of the survey findings of the IJ identified on [DATE]. The surveyors determined the IJ was abated on [DATE] at 9:30 AM, based on the facility's acceptable AOC. The surveyors verified the AOC was in place by review of the facility's documentation of 100 percent completion of all staff inservices physician notifications, condition changes and recognizing the possible need of behavior management and review of findings on audit tools which were initiated on [DATE] and completed on [DATE]. The IJ was abated as of [DATE]. Non-compliance of the Immediate Jeopardy continues at a scope and severity of a "D" level for F319 for monitoring of corrective actions. The facility is required to submit a plan of correction for this tag. | 2014-01-01 |