| 14360 |
CRESTVIEW HEALTH AND REHABILITATION |
445409 |
2030 25TH AVE N |
NASHVILLE |
TN |
37208 |
2012-05-15 |
520 |
J |
|
|
LH9611 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, review of residents' rights, review of material safety data sheets (MSDS), medical record review, observation and interview, it was determined the facility's administrative staff failed to identify and address quality of care issues such as failure to ensure adequate supervision of residents; failure to ensure adequate interventions were developed to manage and prevent falls; failure to provide necessary care and services for the management and treatment of [REDACTED].#66) sampled residents reviewed in the Stage 2 review. The facility failed to implement written policies and procedures that prohibit mistreatment, neglect and abuse of residents for 2 of 10 (Random Resident (RR) #1 and Resident #25) residents interviewed in the Stage 1 review and failed to investigate the reported abuse for Resident #25. The facility failed to assess and address the care and prevention of pressure ulcers for 1 of 2 (Resident #138) sampled residents observed with pressure ulcers. The facility failed to ensure the facility's protocol for monitoring nutrition was followed for 1 of 7 (Resident #118) sampled residents for nutrition in the Stage 2 review. The failure of the Quality Assurance and Assessment (QAA) Committee to identify and address these concerns resulted in the potential cause of death for Resident #66 as evidenced by repeated falls, no treatment and services for repeated behaviors and no physician notification of his deteriorating conditions. The failure of the QAA Committee to investigate and report the alleged abuse reported to the facility by Resident #25 and the failure to ensure RR #1 and Residents #25 were free from mistreatment and neglect placed these residents in immediate jeopardy as evidenced by tearful emotional responses when interviewed. The findings included: 1. During an interview in the Assistant Director of Nursing's (ADON) office on 5/15/12 at 2:00 PM, the Administrator, who coordinated the QAA Committee, did not identify any allegations of abuse, falls, behaviors, notification of physician and responsible party of accidents or condition changes, pressure ulcers, or weight loss as problems identified by the QAA Committee. The QAA Coordinator stated problems may be identified by anyone on the QAA Committee, but could not identify any resident care areas that had been through the QAA Committee. Refer to F223, F224, F225 , F226, F314 and F325. 2. During an interview in the ADON's office on 5/15/12 at 2:10 PM, the QAA Coordinator was asked if the QAA Committee had identified and addressed any concerns with notification of the physician when changes in condition of residents occurred. The QAA Coordinator stated, "Nurses have said the doctor doesn't call back quick enough." Refer to F157. 3. During an interview in the ADON's office on 5/15/12 at 2:10 PM, the QAA Coordinator was asked if the conditions of the resident environment, such as chipped paint, scuffed walls, cracked and missing tile and torn or broken equipment had been identified by the Committee. The QAA Coordinator stated, "We have plans that are not always feasible." Refer to F253. 4. On 5/7 through (-) 15/12 an annual re-certification survey was completed. The facility was cited with an Immediate Jeopardy (IJ) at F157, F272, F280, F282, F309, F319, F323, F328, F490 and F520 all with a scope and severity of a "J". The facility's failure to provide an environment that remains as free from accident hazards as possible and 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 Resident #66 in immediate jeopardy. The facility was cited with an IJ at F223, F224, F225, F226, F490 and F520 all with a scope and severity of a "J". The facility's failure to protect residents from psychological harm and the failure to follow the facility policy of reporting and/or investigating allegations of abuse placed Resident #25 and Random Resident #1 in immediate jeopardy as evidenced by tearful, emotional responses during interviews concerning abuse. An extended survey was completed on 5/15/12. 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 5/10/12 at 7:35 PM and on 5/11/12 at 11:55 AM. An Allegation of Compliance (AOC) was received from the facility on 5/14/12 at approximately 5:25 PM. The AOC the facility presented to the survey team documented the following corrective measures put in place: 1. The Social Services Director interviewed all 96 residents using the "Resident Questionnaire Regarding Abuse" form with the following results: a. Ninety residents denied any form of abuse. b. Three residents named a Certified Nursing Technician (CNT) - the CNT was terminated after investigation. c. Two residents alleged verbal abuse by staff - one was substantiated and the CNT was terminated, one was unsubstantiated. d. One allegation of misappropriation of medication - investigated and unsubstantiated. 2. Investigations were initiated utilizing the Vanguard Event Management process. 3. The Social Services Department will complete audits/interviews weekly for one month, monthly for three months and then once a quarter and as needed. 4. The Social Service Director began one-on-one visits with each resident and/or responsible party defining abuse, how and when to report allegations of abuse and to inform of no retaliation from reporting alleged abuse on 5/12/12. 5. The Adm, DON, ADON, Nurse Educator and Minimum Data Set (MDS) nurses began assessing all residents for signs and symptoms of respiratory and cardiac distress on 5/11/12 and reported any findings of signs and symptoms to the physician. 6. The Adm, DON, ADON and MDS nurses began reviewing all care plans for accuracy, correcting any interventions as needed and reporting their findings using an audit tool beginning on 5/11/12. 7. Inservicing 100 percent (%) of the facility staff began on 5/12/12 on the following topics: a. Abuse Prevention. b. Abuse Reporting. c. Staff questionnaire on abuse. The inservicing was conducted by the Adm, DON, and the ADON. All new hires will be inserviced during orientation. 8. Inservicing 100% of the licensed nursing staff and Certified Nursing Assistants (CNA) began on 5/11/12 on the following topics: a. Fall Interventions. b. Fall and Incident reporting. c. Verbal questions and answers with staff. d. Fall interventions. e. Physician notification and Responsible Party notification. f. Change of Condition. g. Recognizing signs/symptoms of respiratory and cardiac distress. h. Behavior Management. The inservicing was conducted by the Adm, DON, and the ADON. All new hires will be inserviced during orientation. 9. Auditing/Monitoring tools will be used for follow-up and continued monitoring for the following areas: a. Behavior Quality Assurance/ Performance Improvement (QA/PI) tool. b. Weekly At Risk QA/PI Log. c. Care Plan Audit. d. Oxygen orders and use. e. Nursing Notes Audit For Change of Condition. f. Alert Charting Log. g. Event Log. 10. 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. 11. 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, ADON, Regional Director of Operations, Vice President of Clinical Services and three Regional Nurse Consultants in the therapy room on 5/15/12 at approximately 7:30 PM. The facility staff were informed of the survey findings of the IJ identified on 5/10/12. The surveyors determined the IJ was abated on 5/15/12 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 "Resident Questionnaire Regarding Abuse", all staff inservices for abuse prevention, abuse reporting, fall interventions, fall and accident reporting, physician notifications, condition changes, recognizing signs and symptoms of respiratory and cardiac distress and behavior management and review of findings on audit tools which were initiated on 5/11/12 and completed on 5/15/12. The IJ was abated as of 5/15/12. Non-compliance of the Immediate Jeopardy continues at a scope and severity of a "F" level for monitoring of corrective actions. The facility is required to submit a plan of correction for this tag. |
2014-01-01 |