| 11539 |
GREENBRIER MANOR |
515185 |
ROUTE 2, BOX 159A |
LEWISBURG |
WV |
24901 |
2010-09-03 |
520 |
J |
|
|
LWGO11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, review of self-reported events, staff interview, review of quality assessment and assurance (QAA) committee meeting minutes offered by the facility, medical record review, review of incident / accident reports, and review of the facility's policy and procedure room transfers, the facility's quality assessment and assurance (QAA) committee failed to implement an action plan to ensure the safety of residents sharing a room with Resident #26, upon his return from a psychiatric hospital after being evaluated for possible aggressive tendencies towards others. Resident #26 shared a 3-bed room with Residents #38 and #77. On the early morning of [DATE], staff responding to Resident #26's call light found Resident #38 on the floor positioned with his pads, bed linens, and positioning wedge placed on and under him as if he were still in bed; Resident #38 was not capable of having transferred out of bed himself. On the late night of [DATE], staff found Resident #38's legs had been repositioned in bed in a different position than one in which staff had put him during their previous rounds. The nurse directed staff to monitor all residents in this room every twenty (20) minutes, because Resident #38 was not physically able to move himself, Resident #77 was not physically able to independently transfer out of his own bed, and Resident #26 was behaving in a suspicious manner. During these monitoring rounds, in the early morning hours of [DATE], staff found Resident #38's legs again had been repositioned, and staff found a pillow had been placed over the face of Resident #77. In [DATE], Resident #26 had shared this same room with another resident (#87) who was also found by staff at that time to have a pillow placed over his face. In response to these findings, the facility met with Resident #26's guardian, who agreed to allow him to be evaluated at a psychiatric hospital. Prior to his transfer on [DATE], the facility stationed a staff member in the room at all times to monitor the residents for safety. Resident #26 returned to the facility on [DATE], to the same room shared with Residents #38 and #77. Although the aftercare plan from the psychiatric hospital included the recommendation that the nursing home "observe / assess need for further treatment", the facility failed to review / revise Resident #26's care plan to address this. Upon his return, no additional supervision and/or assistive devices were put into place to monitor Resident #26 (especially at night) and/or ensure the ongoing safety of Residents #38 and #77. This placed Residents #38 and #77 in immediate jeopardy. The facility's QAA committee failed, upon Resident #26's return to the facility, to implement measures to ensure the safety of Residents #38 and #77, even though staff strongly suspected Resident #26 of having removed Resident #38 from his bed on the early morning on [DATE], repositioned Resident #38 in his bed on the late evening of [DATE], and placed a pillow over the face of Resident #77 on the early morning of [DATE], especially in light of having found a previous roommate of Resident #87 with a pillow over his face in [DATE]. Facility census: 87. Findings include: a) Residents #26, #38, and #77 1. Observation, during tour beginning at 9:30 a.m. on [DATE], found Residents #26, #38, and #77 sharing the same 3-bed room. - 2. On [DATE] at 10:25 a.m., review of events self-reported by the facility to the State survey and certification agency during the previous three (3) months revealed the following "unusual occurrence": "On [DATE] at 2:30 a.m. the C.N.A. (certified nursing assistant) had entered the room to respond to Resident (#26) call light when Resident (#38) was found on floor beside his bed. Resident (#38) was found on floor still covered in blankets with pink pad under him and wedge cushion behind his back. " ... due to Resident (#38) need for total assistance with ADL's that (sic) this incident did not appear to be the result of the resident falling out of bed. There is concern that he may have had assistance from his roommate. ... Residents in room will be monitored by staff at more frequent intervals. ... "Another incident occurred in this same room on the this same date of [DATE] where Resident (#77) was observed by nursing staff with a pillow over his face during the early a.m. (morning) interval checks. Resident (#77) did not know how the pillow got on his face. There were no apparent injuries to either resident." According to a message confirmation report, this "unusual occurrence" was faxed to the State survey agency at 2:45 p.m. on [DATE]. - 3. Review of the medical records for Residents #38 and #77 found entries in the nursing notes relating the same information as stated in the unusual occurrence report mentioned above. - Review of Resident #38's most recent resident assessment, a Medicare 14-day assessment with an assessment reference date (ARD) of [DATE], revealed this [AGE] year old male was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. He was alert with long and short term memory problems, he was not oriented to person, place, or season, he was unable to communicate with others, and he was totally dependent upon staff for all ADLs, including bed mobility and transferring. - Review of Resident #77's most recent resident assessment, a quarterly assessment with an ARD of [DATE], revealed this [AGE] year old male was admitted to the facility on [DATE]. He was alert and oriented and independent with his cognitive skills for daily decision-making, and he required extensive assistance with bed mobility and transfers, did not ambulate, and was totally dependent on staff for locomotion. His [DIAGNOSES REDACTED]. - Review of Resident #26's most recent resident assessment, a quarterly assessment with an ARD of [DATE], revealed this [AGE] year old male was admitted to the facility on [DATE]. Resident #26 was alert, oriented to person, place, and season, had short-term memory problems, and his cognitive skills for daily decision-making were assessed as being "modified independence"; he was independent with ADLs. His [DIAGNOSES REDACTED]. - Review of nursing notes in Resident #26's record found no entry by the nurse on the night shift from [DATE] to [DATE]. An entry, recorded by the nurse during the night shift from [DATE] to [DATE] (at 2:00 a.m. on [DATE]), stated, "Resident up most of the night walking around the room. Denies pain or discomfort." - Review of Resident #26's Plan of Care Kardex for the month of [DATE] found several notes recorded by nursing assistants, starting on [DATE], regarding Resident #26's behavior towards his roommates. On [DATE] (no time or shift noted), a nursing assistant wrote: "Res (resident) was standing behind the curtain between his bed and (Resident #38 ' s) bed, ask (sic) him what he was doing & Resident stated he wasn't doing anything. CNA (initials of nursing assistant) ask (sic) him to go lay down in his bed or if he couldn't sleep to sit in his chair, that he just couldn't mess with his Room-mate (sic) (Resident #38) or Room-mates (sic) things. He said all right." Another note on [DATE] (identified as being written on the 7:00 a.m. to 3:00 p.m. shift) stated, "Res stands behind curtains when your (sic) trying to give care to roommate." On [DATE], a nursing assistant wrote: "Res standing behind the curtain when giving care to roommate" Another entry (no date / time) stated, "Resident got upset when taking roommate to Bathroom (sic)." - On the reverse side of Resident #26's [DATE] ADL flow record, a nursing assistant wrote, on [DATE], "Resident behind curtain looking and trying to see the patient when staff was giving care." - Review of the physician's progress notes for Resident #26 found the following entries: - On [DATE]: "I was called last night by (facility) to call (name of administrator), which I did. She related they had a concern about (Resident #26), that in the room he has 2 other roommates, (Resident #38) and (Resident #77). (Resident #38) was found in the floor twice reported by staff. (Resident #38) is not able to move himself. The staff became suspicious then they went over to see (Resident #77) and a pillow was on his head. When they asked (Resident #77) if he was ok (sic) he said yes (sic) and they asked him how the pillow got there (sic) and he related he did not know how. (Resident #26) had been up during the night. He had gone to the bathroom, (sic) in the morning it was reported to (name of administrator) that something suspicious was going on and they fear it would be (Resident #26). They discussed it with the daughter (of Resident #26) who was upset. They discussed there was (sic) odd behaviors that had gone on with he (sic) and (Resident #87 - previous roommate who is now deceased ) (sic) however they did not get along. I called to talk to the daughter and she was at (facility). She wanted me to come down and talk to her (sic) which I did, this was about 8pm. ... I told her we should have an evaluation by doctor in (name of psychiatric hospital). ..." (Interview with the administrator, on the morning of [DATE], verified that Resident #38 was found on the floor only once, contrary to what was stated above, although his feet were found to have been moved towards the side of the bed on two (2) separate occasions - which the resident was not capable of doing himself.) - On [DATE]: "We had a family conference today with the daughter, sister, (name of regional ombudsman), Director (sic) of nurses and myself. We discussed (Resident #26). My recommendation is that he got to (city name) to be evaluated. ... I did discuss with her (daughter / guardian of Resident #26) the night before that he and (Resident #87 - previous roommate no longer at the facility) had some disagreements ... At one time there was a pillow that was found beside (Resident #87) and a pillow was found over his face. ... She knows (Resident #38) was found in the floor. He can not (sic) move himself. Then (Resident #77) was found with a pillow over his head. ... The daughter understands we did not see (Resident #26) do this. We do not know what happened. ... I told her to be safe it was important for him to evaluated. ..." - 4. A quality assurance (QA) committee plan of correction, generated on [DATE] and provided for review to the surveyor by the facility's administrator at 8:00 a.m. on [DATE], revealed the incident involving Resident #38 occurred on the night shift that ran from [DATE] to [DATE], and the incident involving Resident #77 occurred on the night shift that ran from [DATE] to [DATE]; they did not occur within the same 8-hour shift on [DATE]. This [DATE] QA committee plan of correction stated: "On Monday morning, [DATE], (name) DON (director of nursing) was notified by the nursing staff that there had been a concern with residents in room (Number of room shared by Residents #26, #38, and #77) on Sunday and in the early morning hours of Monday. At approximately 2:30 a.m. resident (#26) had rung his call bell. When the staff responded they observed resident (#38) lying in the floor. When they asked resident (#26) what he needed he said 'nothing'. Resident (#38) was lying in the floor with his under pads, covers and wedge cushion in place. On [DATE] at approximately 11:30 p.m. resident (#38) was observed with his feet over the right side of the bed and at 12:15 a.m. on [DATE] resident (#38) was again observed with his feet over the left side of the bed. Resident (#77) was observed at 12:30 a.m. with a pillow over his face. ... "INVESTIGATION FINDINGS AND INTERVENTIONS TO CORRECT THE PROBLEM: "- Resident (#38) is totally dependent upon staff for bed mobility, transfers, ADLS (activities of daily living) and feeding. "- Call bell is in place for resident (#38) at all times; however, resident does not use call bell independently. "- Resident (#38) is turned and repositioned q2hrs (every two hours) by staff. "- Resident (#77) voices needs and wants to staff, rings call bell independently, requires extensive assist of one with bed mobility, transfers with two and dressing, personal hygiene and bathing with the assist of one. "- Resident (#26) is independent with all ADLs, mobility, ambulates through out (sic) the facility independently, voices needs and wants to staff and rings call bell for assistance as needed. "- Resident (#26) has documented behaviors related to past roommates. ..." According to the administrator, due to Resident #26's past behaviors towards roommates and Resident #38's inability to move on his own and his position on the floor with covers and wedge in place, staff questioned whether Resident #26 was involved in removing Resident #38 from bed to floor and his moving feet over the sides of the bed. Staff also questioned whether Resident #26 placed the pillow over Resident #77's face. Checks of the room shared by these three (3) residents were made every twenty (20) minutes for the remainder of the night shift ending on the morning of [DATE]. Staff communicated with the responsible parties of all residents involved and made arrangements to transfer Resident #26 to a psychiatric hospital for evaluation. Until this transfer could be accomplished, the facility assigned a staff member to remain at all times in the room shared by these three (3) residents, since the responsible parties of the residents all refused to allow their family member to be relocated for safety. - 5. Resident #26's guardian agreed to allow him to be transferred to a psychiatric unit for evaluation. According to the nursing notes, the resident was transferred from the facility to the psychiatric hospital at about 2:30 p.m. on [DATE]. - 6. Resident #26 was readmitted to the facility on [DATE] and was placed back into the same room with his previous roommates, Residents #38 and #77. Review of the aftercare plan from the psychiatric hospital, dated [DATE], found the resident was initially admitted for agitation, aggression, and sexually inappropriate behavior. Under the heading "Patient Treatment Goals / Progress", staff at the psychiatric hospital wrote: "Patient has not displayed any agitation or aggression since admission and had not had any sexually inappropriate behavior for several days." Under the heading "Diagnosis" was written: "Axis I: Dementia, AD ([MEDICAL CONDITION]) type /c (with) depressed mood and behavioral disturbance. Axis II: Schizoid Personality D/O (disorder). ... Axis IV: NH (nursing home) placement. ..." Under the heading "Discharge Recommendations / Plan" was written: "NH to observe and assess for further treatment." An interview with the administrator, on [DATE] at 4:00 p.m., found Resident #26's guardian refused to allow the resident to be moved. She also indicated Residents #38's responsible party and Resident #77 (who had capacity) did not want to change rooms. - 7. In an interview on [DATE] at 8:30 a.m., the medical director acknowledged her awareness of the situation regarding Resident #26. She had questions about the ability to move a resident to another without the health care decision maker's consent. On [DATE] between 8:30 a.m. and 9:45 a.m., intermittent observations made with the medical director found all three (3) residents together in the same room with no specific measures in place to ensure the safety of the roommates. At 9:45 a.m. on [DATE], the facility's "Resident Transfer" policy (no date), was requested of and provided for review by the administrator. Review of the policy revealed the following: "Policy: 1. Transfer of Residents Within the Manor: ... C. In the case of emergency the facility reserves the right to make a move but will notify the resident or their responsible party." "Procedure: Transfer of Patient: ... 8. Due to changes in patient's condition, we reserve the right to transfer the patient to the area where we can best meet his or her needs." This information was shared with the medical director. - 8. One (1) of the facility's social workers, (Employee #52) was interviewed at 10:30 a.m. on [DATE]. She sat in on a meeting with Resident #26, his daughter / guardian, and his sister on [DATE]. The resident was sent to the psych unit to determine if he had tendencies to be physically aggressive towards other residents. - 9. Employee #19 (the LPN who completed the above-referenced incident reports for Residents #38 and #77) provided handwritten notes, as well as documentation of observations made by staff of Residents #26 and #38 every twenty (20) minutes from 1:00 a.m. to 6:20 a.m. on [DATE], to the director of nursing (DON) on [DATE]. The DON provided copies of this documentation for review to this nurse surveyor at 10:40 a.m. on [DATE]. The first note stated: "On [DATE] at 2:30 AM (sic) The CNA's were responding to (Resident #26)'s call light. When they went into the room he said he didn't need anything and that's (sic) when they found (Resident #38) lying on the floor. On the (L) side of the bed on his back. He still had his pads underneath him & his blankets were wrapped around him and the wedge they place behind his back was tucked under his (L) side. Both bedrails were also up. Prior to him being in the floor (sic) (Resident #38) was positioned in bed on his (R) side /c (with) the wedge behind his back. I am letting you know about this b/c (because) I find his falling in the floor suspicious and don't see how he could have ended up in the floor like that on his own." - The second note stated: "Just for clarification - On ,[DATE] @ 2:30 AM (Resident #38) was in the floor on the (L) side of his bed in between the bed & the rocker chair. He was on his back /c pads underneath him & blankets wrapped around his legs & the wedge was underneath his (L) hand side. His bed rails were up & his bed was in (sic) low position. Prior to him being in the floor he was positioned on his (R) side /c wedge behind him on the left side of his back. "On ,[DATE] @ 1130 PM when walking up the hall his feet were pulled to the (R) side of the bed and he was laying (sic) on his (R) side. "At 12:15 AM - now [DATE] Resident was lying on (R) side and his feet were pulled to the (L) side of the bed. "After that is when we found (Resident #77) with the pillow on his face. "That's (sic) when I initiated the 20 minute check paper for the CNA to fill out." (During an interview on [DATE] at 5:15 p.m., Employee #19 verified her statements.) - 10. The DON, when interviewed on [DATE] at 10:45 a.m., reported a resident service provider (RSP) was assigned to provide one-on-one supervision of Resident #26 from [DATE] at 2:30 p.m. through [DATE] at 2:30 p.m., when he went to the hospital. The DON reported became suspicious of Resident #26's behavior after she reviewed the 24-hour shift reports for [DATE] and [DATE], which indicated Resident #38 was found on the floor during the early morning hours on [DATE] (on the night shift starting on [DATE]) and was found two (2) times with his feet hanging off the bed during the night shift starting on [DATE]. Documentation on the 24-hour shift report for [DATE] stated, "[DATE] 2:30 a.m. Resident (#38) found in floor no apparent injury. Family (MPOA) needs to be notified" and "fell last noc (night). Be sure he is in middle of bed." For Resident #77, staff recorded "Lethargic". There was no entry for Resident #26. Documentation on the 24-hour shift report for [DATE] for Resident #38 stated, "Ntd (noted) feet off bed 2X's (two times) throughout night ... call family any time day and night." For Resident #77, staff recorded, "Lethargic [DATE]; wouldn't take 6 a.m. meds [DATE] c/o (complaint of) pain; admitted to hosp with UTI." For Resident #26, staff recorded, "Restless up in room several X's throughout night." - 11. Review of the closed record of Resident #87 (identified in the [DATE] physician ' s progress note as Resident #26's previous roommate) found a nursing note, dated [DATE] at 2:10 p.m., stating, "CNA reported as she came up the hall (sic) resident had a pillow across his face. ..." At the time of this occurrence, Resident #87 shared the same 3-bed room with Resident #26, and the third bed was unoccupied. The DON verified, in an interview at 10:30 a.m. on [DATE], there were no other residents in the room at the time of this incident. Review of Resident #26's thinned records from 2009 found the following regarding his interactions with Resident #87: On [DATE] (no time given), " ... Later, resident came up to nurse's med cart, watched as nurse was attempting to give roommate (Resident #87) his med. Roommate accidentally ran over nurse's foot. Resident then states to nurse (sic) know what you should do /c the 'bastard'. I've popped him a couple of times. (sic) I asked resident if (sic) had hit the roommate, he stated yes. ..." - 12. Review of Resident #26's care plan, revised on [DATE] with target dates for goal achievement of [DATE], found the following problem (P), goal (G), and interventions (I) with an initiation date of [DATE]: P: "Mood problem AEB (as evidence by): Resident becomes easily annoyed with staff and others (particularly his roommate) at times R/T (related to) depression, and dementia, [MEDICAL CONDITION] diagnosis, hx (history) of episodes of agitation." G: "Will have improved mood state AEB: calmer appearance, with no more then (sic) 2 episodes weekly of becoming easily annoyed with his roommate or any other S/S (signs / symptoms) of depression, anxiety or sad mood by review date." (The revised review date for this goal was [DATE].) I: "Assist in developing more appropriate methods of coping and interacting. Encourage to express feelings appropriately, let staff know when s/he (sic) is getting upset; Administer medications as ordered and monitor for side effects, effectiveness; Observed mood patterns and document S/S of depression, anxiety, sad mood; Ongoing assessment, attempt to determine if problems seems to be related to external causes, ie medications, treatments, concerns over diagnosis, noise level or pain; Spend time talking to resident, family. Encourage to express feelings; Assist resident to identify strengths, positive coping skills and reinforce these; Invite to attend activities and encourage participation." The interdisciplinary team also addressed the following problem, also with an initiation date of [DATE]: "Potential for increased behavior problems R/T: [DIAGNOSES REDACTED]." The goal for this problem statement was: "Resident will continue to have not episodes of socially inappropriate behavior weekly by review date." (The revised review date for this goal was [DATE].) The interventions included: " ... Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, situations. Document behavior and potential causes; Intervene as needed to protect the rights and safety of others. Approach / speak in calm manner. Divert attention. Remove from situation and take to another location as needed. ..." The care plan did not describe what these "socially inappropriate behaviors" were. There was no evidence to reflect the care plan was revised upon Resident #26's return to the facility on [DATE], to address the need to "observe / assess for further treatment" - as directed in the aftercare plan resulting from his stay at the psychiatric hospital. There was no plan to reinstitute either of the monitoring activities that had been in place prior to his transfer to the psychiatric facility (every twenty (20) minutes beginning on [DATE] or direct supervision of the room shared by these three (3) residents at all times beginning on [DATE]) - especially at night. - 13. At [DATE] at 11:00 a.m., the administrator, medical director, DON, social worker (Employee #52), and the clinical care coordinator (Employee 33) were informed the nurse surveyor identified that Residents #38 and #77 were in immediate jeopardy, as Resident #26 returned to the same room following his discharge from the psychiatric hospital, and the facility failed to implement any measures (e.g., additional monitoring / supervision) to ensure the residents in this room were safe. A plan of correction was requested. - 14. A plan of correction, given to the surveyor on [DATE] at 11:20 a.m., was reviewed and returned to the administrator for revision. At 11:40 a.m., a revised plan of correction was given to the surveyor, reviewed, and accepted at 11:45 a.m. The revised plan of correction stated: "To correct the safety issues identified during the survey this date, with residents (#26), (#18), and (#77), a room change will be made. Resident (#26) will be moved into room (number of room on second floor). Resident (name) who is currently in room (number of room now occupied by Resident #26) will be moved to (number of room previously occupied by Resident #26). "Monitoring of resident (#26) will be accomplished by the following: Resident will be in a room by himself. This room is located close to the nurses (sic) station in direct line of all traffic. Nurses or Certified Nursing Assistants will check on him on an hourly basis for any abnormal behaviors. Psychiatric evaluation or placement will be pursued if behavior warrants. Documentation of all abnormal behavior will be monitored on a daily basis by nursing staff." - 15. On [DATE] at 1:30 p.m., after Resident #26 was relocated and this was verified by direct observation, the administrator was notified the immediate jeopardy was lifted. - 16. During an interview on [DATE] at 6:45 p.m., a nursing assistant (Employee #34) confirmed he found a pillow over Resident #77's face at about 12:30 a.m. on [DATE]. He indicated he had last checked on the resident at 12:00 a.m. on [DATE]. He documented twenty (20) minute checks on Residents #26 and #38 from 1:00 a.m. through 6:20 a.m. on [DATE]. (A copy of this documentation was provided by the DON on [DATE] at 10:40 a.m.). - 17. On [DATE] at 9:00 a.m., the administrator presented evidence that inservices were held [DATE] with staff who provide care to Resident #26. The memorandum on which this inservice was documented, issued by the DON, had in its subject line: "Precautions related to (Resident #26)". In the body of the memorandum was: "(Resident #26) needs to be monitored every hour for behaviors that may affect self or others and documented on appropriate form. (Resident #26) needs to be documented on each shift in the nurses notes related to behaviors whether there are any or not. "Concerns for (Resident #26) possibly being of danger to other residents has (sic) prompted this." The bottom of the memorandum contained the signatures of nursing staff. - The facility also revised the care plan for Resident #26 on [DATE], to include the following: P - "Potential for increased behaviors (physical aggressive (sic) staff or residents) (sexual inappropriate (sic) with staff) (attempting to harm residents) R/T (related to) [DIAGNOSES REDACTED]." G - "Resident will have less than weekly episodes of socially inappropriate behaviors by review date." G - "Resident will have no episodes of attempting harm other residents through review date." Interventions included: "Nursing staff will do hourly checks on resident for behaviors. Nurses will document q (every) shift on behaviors; Resident has been moved to a private room. Psychiatric evaluation and treatment as ordered." - 18. The facility's QAA committee failed, upon Resident #26's return to the facility, to implement measures to ensure the safety of Residents #38 and #77, even though staff strongly suspected Resident #26 of having removed Resident #38 from his bed on the early morning on [DATE], repositioned Resident #38 in his bed on the late evening of [DATE], and placed a pillow over the face of Resident #77 on the early morning of [DATE], especially in light of having found a previous roommate of Resident #87 with a pillow over his face in [DATE]. |
2014-01-01 |