| 1 |
PINE LODGE |
515001 |
405 STANAFORD ROAD |
BECKLEY |
WV |
25801 |
2018-02-09 |
600 |
D |
1 |
0 |
3JZJ11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based upon record review, abuse and neglect policy review, staff interview and local Veterans Administration Medical Center (VAMC) staff interview, the facility failed to provide necessary care and services to Resident #92 in preparation for scheduled appointments outside of the facility, of which the facility was aware of or should have been aware. The facility also failed to provide Resident #92 care and services in the care areas concerning baths and shaving. This was true for one (1) of six (6) sample residents dependent for care. This practice had the potential to affect more than a limited number of residents. Resident identifier: #92. Facility census: 107. Findings include: a) Scheduled appointments outside of the facility Resident #92 is a paraplegic (paralysis of legs and lower body) with [MEDICAL CONDITION] bladder. He is totally dependent for all care, is legally blind, and newly diagnosed with [REDACTED]. C1 indicates the first cervical vertebrae. Cervical vertebrae are bones that are a part of the neck. C1 is located at the base of the head. Compression or a pinching of the C5 nerve can produce numbness, paresthesia (pins and needles), and paralysis of the arms. Records show Resident #92's forearms, wrists, and hands were affected and symptomatic from the C5 compression. Review of medical records from VAMC physician progress notes [REDACTED]. C5 shows chronic cord compression possibly from an old trauma. Review of records on 02/05/18 at 2:55 PM revealed a significant change minimum data set (MDS) with an assessment reference date (ARD) 01/04/18. The resident had impaired vision (legally blind); had clear speech, was able to understand and make himself understood. The MDS revealed a Brief Interview for Mental Status (BIMS) with a score of fifteen (15) indicating the resident was cognitively intact. Resident #92 needed extensive assistance with eating and was dependent for all other activities of daily living (ADL) including bed mobility, transfer, dressing, toileting, and hygiene. The resident was on scheduled and as needed pain medication and had not had a fall during the seven day look back period. Resident received speech therapy, occupational therapy, and physical therapy. Observations, on 02/05/18 at 11:55 AM., revealed Resident#92 appeared clean, without any body odors, hair stubble noted on chin, and Foley catheter was draining to drainage bag on bedside. The bed rails properly fit the bed. The resident had a special needs call light (Blow call light) to accommodate resident due to paralysis and inability to use hands. Blow call light was within reach of the resident and he was observed using it with staff responding timely. Resident#92 did not want to be interviewed at the time the surveyor attempted an interview, and this surveyor told the resident the surveyor would come back the next day to talk to him. The next day when this surveyor went to interview Resident #92, the resident was no longer a resident at the facility, Resident #92 was transferred to live at another facility and was unavailable for interview On 02/06/18 at 11:25 AM, review of reportable events revealed a report concerning Resident #92, dated 12/26/17, where the Veterans Administration Medical Center (VAMC) notified the facility of an incident occurring that morning that was reported to all appropriate agencies. The incident reported to the facility, alleged upon EMS (emergency management service) ambulance arriving to take the resident to scheduled appointments, the resident was not cleaned up, had no breakfast, catheter needed emptied, and call light was not in reach. The report revealed, Per VA the resident stated his head hitting side rail on bed and he was yelling. Someone came and shut the door but did not provide care. The results of the facility's reportable investigation revealed the allegations were unsubstantiated due to lack of information provided by EMS. The facility requested an extension for five day follow up from 12/31/17 to 01/05/18, due to awaiting statements from EMS. Review of the facility's five day follow up report findings, revealed EMS arrived at approximately 7:00 AM on 12/26/17, and the NA (Nurse Aid) had not cleaned the resident up yet. The NA did clean the resident and emptied his catheter, after being told by a nurse to clean him up for his appointment after the EMS ambulance crew arrived to pick up the resident. Breakfast had not been served yet. The social worker (SW#68) noted that EMS had been contacted multiple times, requesting statements concerning the description of the incidence (the facility reported they did not receive EMS statements). Social worker SW#68's written investigation statement in response to these allegations, dated 12/27/17, stated the ambulance arrived closed to 7:00 AM for a 9:00 AM appointment, breakfast was not ready at the time, puffer call light attached to bed by maintenance and cannot come off the bed. EMS must have seen roommates call light. SW #68 did not substantiate these allegations. On 02/06/18 at 1:15 PM, an interview with Staff#5, responsible for logging resident's appointments, revealed the Veterans Administration Medical Center (VAMC) has a contract with an ambulance service (name of local ambulance service) to transport all residents that are veterans, to any of their appointments. The VAMC is responsible for setting up and paying transport for any appointment no matter where it is. When asked what the process was to assure residents get to their appointments, Staff#5 explained the contact person at the VAMC calls at least once a month, and goes over all appointments residents who are veterans have, where the appointments are, and tells me what time the ambulance is to pick up the resident. Staff#5 said she writes the resident's name, date and time of the appointment, and the time the ambulance is to pick up the resident on the appointment calendar book. Staff#5 said, then the charge nurse has the appointment calendar book and lets the nurse aides know when they need to have the residents cleaned up and ready to go. Review of the appointment calendar book for the month of (MONTH) (YEAR), with Staff#5, revealed Resident #92 had appointments four (4) different days in December. The appointments noted on 12/26/17, revealed Resident #92 had labs at 7:30 AM and an appointment at 9:00 AM at the VAMC Spinal Injury Clinic. Also, noted on the calendar was the time the ambulance was to pick up Resident #92, which was 7:00 AM on 12/26/17. Staff#5 said the VAMC always uses the same ambulance service for transports. When asked if the ambulance service ever is late or comes early, the receptionist replied, The ambulance service (the name of) is real good about being right on time. Staff#5 confirmed EMS ambulance was scheduled to arrive to pick Resident#92 up at 7:00 AM on 12/26/17. The facility investigation resulted in the allegations being unsubstantiated, however the investigation did not appear to be thorough. The facility's appointment calendar, clearly documented the ambulance was to pick the resident up at 7:00 AM to transport the resident for 7:30 AM labs, and that there was a second appointment at 9:00 AM. The facility's investigation Witness statements verified the ambulance arrived as scheduled and the resident was not cleaned up and ready to be transported. Resident #92 was cleaned and his catheter emptied, only after the NA was told by the nurse to clean him up for his appointment, after the ambulance crew arrived and waited. There was no evidence the resident needed to be fasting for his lab tests, nor any evidence that any breakfast had been offered to the resident, or any arrangements made to provide him a breakfast or snack. The resident did not get On 02/06/18 at 10:15 AM, after multiple failed attempts for observations and interview with Resident #92 due to not finding him in his room or elsewhere in the facility, an interview with the Administrator revealed Resident #92 was transferred to Veterans Administration Medical Center (VAMC) yesterday, 02/05/18. Administrator said this was a plan discharge that the resident had been on a waiting list to become a resident at the VAMC's facility, and an opening came available yesterday evening. Interview with the Coordinator of Health Information Management (HIMC Staff#73), on 02/07/16 at 10:00 AM, revealed Resident #92 had said he wanted to transfer to a facility closer to his ex-girlfriend so she could visit him. HIMC Staff#73 said the girlfriend told him there was one close to her that the Veterans Administration (VA) would pay for. HIMC Staff#73 said, the facility told him multiple times there was not one in that area the girlfriend was referring to, but he did not believe them, and would get upset about it each time. On 02/08/18 at 11:03 AM, an interview with VAMC Social Worker, VAMC SW#302 revealed she reported the situation because she is a mandatory reporter. VAMC SW#302 said, I was concerned for the resident because of his recent [DIAGNOSES REDACTED]. VAMC SW#302 said she reported to all the appropriate agencies, and spoke by phone to the facility's Director of Nursing (Nurse Executive Director) and SW #68 concerning these allegations on 12/26/17. VAMC SW#302 said she first saw the resident, on 12/26/17, after first being asked to see him, by the VAMC Nurse Practitioner (Family Nurse Practitioner Certification - FNPC), VAMC FNPC#304. VAMC SW#302 said, When I saw him (Resident #92) he was laying on a stretcher, unshaven, with a neck brace on. The resident was alert and oriented and was asking to go to another nursing home closer to his family. The resident said the nursing home he lived at did not beat him, but they don't take care of him. The ambulance crew reported the facility knew he was being picked up for a doctor's appointment, but he was not cleaned up. The ambulance crew said his call bell was across the room where he could not reach it. They had to ask someone to empty his catheter bag, and when it was emptied no one looked to see if anything else needed cleaned. He had not been given breakfast. The ambulance crew said he was upset because he wanted to be shaven and cleaned up before leaving for his appointment. Review of VAMC SW#302 Notes dated 12/26/17, revealed the ambulance crew reported, (Name of facility) knew we were picking him up for a doctor appointment today. When we arrived he was not cleaned up. His call bell was across the room where he could not reach it. He had no breakfast. We had to ask someone to empty his catheter bag. When staff emptied the bag they did not look under the covers to check to see if anything else needed taken care of. Further review of records (facility and VAMC records) revealed alternate placement was discussed with the resident several times. The resident had discussed moving to a nursing home closer to his family and girlfriend. When the resident discovered there was not another nursing home the Veterans Administration was contracted to pay for in the area close to his family and girlfriend, Resident #92 did not want to personally pay and choose to return to the facility. The Ombudsman was interviewed via phone, on 02/08/18 at 2:30 PM, for concerns regarding these allegations. Interview with Ombudsman revealed during her interview at the facility with Resident #92 and facility staff, on 01/03/18, the resident said he lied about his head being stuck in the bed rails, that he lied just because he was mad. The Ombudsman said Resident #92 bragged on the care he receives at the facility, appeared [MEDICATION NAME] pleased, and had no complaints against the facility. After record review, abuse and neglect policy review, staff interview, VAMC staff interview, and review of the facility's investigation record, the evidence revealed some of the allegations were substantiated. There is not enough evidence to substantiate the allegation the resident's special blow call light was not in reach of the resident. The resident denied, in front of multiple witnesses, his head was hitting the side rail on his bed, and someone shut the door without providing any care. The resident said he falsely made these accusations because he was mad. The facility did neglect to ensure Resident #92 was; cleaned up and shaven; catheter drainage bag was emptied; and resident was ready to be transported for medical appointments via ambulance, as was scheduled on the facility's appointment calendar book for 12/26/17 at 7:00 AM. The resident did not have breakfast, and the facility did not provide or make any arrangements for the resident to have breakfast or a snack on a day the resident was scheduled to be out of the facility for medical appointments. The catheter drainage bag was emptied by a nurse aid (NA) after the ambulance crew arrived and only after a nurse had to instruct the NA to clean up the resident. b) Baths and shaving On 02/06/18 at 9:05 AM, review of grievance and concerns revealed a grievance dated 09/12/17 revealing one of the issues was not being shaven adequately to allow for the use of the diathermy machine to be placed on his face. Resolution to the concerns were completed by 09/ 27/17 with staff being educated, Kardex being updated with the resident's preferences. The KARDEX provides specific instructions for the nursing assistants concerning individualized care to be provided for a resident. Review of Resident #92's Kardex showed it was important for resident to choose between a tub bath, shower, bed bath, or sponge bath, and under skin care it was noted as written ****Shave Resident daily****. Review of care plan, on 02/08/18 at 4:40 PM, revealed under the care area of self-care deficit an intervention to ****Shave Resident daily**** initiated 10/26/17. Resident #92 a legally blind paraplegic, totally dependent for all care, was to receive a shave and bed bath daily. The resident was incontinent of bowel and had a Foley catheter. Review of the ADL (activities of daily living) Record, on 02/07/18 at 4:00 PM, revealed during the month of (MONTH) (YEAR), Resident#92 had a minimum of twenty-five (25) opportunities to receive a bed bath and he only received fifteen (15) according to the ADL Record. There are thirty-one (31) days in December, and the resident was at the hospital on [DATE] until 12/04/17, on 12/11/17 until 12/13/17, and on 12/26/17 until 12/28/17, a total of six (6) days out of the facility (Note - It is possible the resident could have had or needed a bed bath on the days he went to the hospital and/or returned from the hospital. It is also possible an incontinent resident might need more than one bed bath per day). The resident received bed baths on fourteen days in December, on one day (12/05/17) he received two (2) baths. There was no evidence the resident refused any bed baths or refused being shaven. On 02/08/18 at 3:27 PM, interview with Nurse Aid (NA#40) revealed Resident #92 loved bed baths. NA#40 said, Resident #92 loved bed baths, they relaxed him and helped him sleep, he would take a two (2) hour nap after he got one. NA#40 denied ever knowing Resident #92 refusing a bed bath. Interview with NA#39, on 02/08/18 at 3:38 PM, revealed NA#39 stated, Resident #92 loved bed baths. I never knew of him refusing a bed bath. On 02/08/18 at 4:47 PM, an interview with two (2) Licensed Practical Nurse (LPN) LPN#44 and LPN#70 revealed the following information. When asked, as nurses, what their expectations of how often a totally dependent resident, incontinent of bowel should receive bed baths from nurse aides, both LPNs said at least daily, if not more depending on the resident's incontinence episodes. Both LPN#44 and LPN#70 said the nurse aides should have instruction on the resident's care plan and the Kardex for bathing and hygiene care. |
2020-09-01 |