cms_WV: 3610
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| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 3610 | NELLA'S INC | 51A010 | 499 FERGUSON ROAD | ELKINS | WV | 26241 | 2017-12-07 | 742 | D | 0 | 1 | HHMR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation and staff interview, the facility failed to ensure a resident who displays psychosocial adjustment difficulty receives the appropriate person-centered treatment and services to correct the assessed problem. Resident #84's behaviors towards self and others were not addressed. Individualized care plans were not developed to address the resident's' assessed emotional and psychosocial needs. Goals that were established were not stated in measurable terms to enable determination of the effectiveness of interventions, and interventions did not provide guidance to the direct care giver. This was found for one (1) of two (2) residents reviewed for behaviors and had the potential to affect more than a limited number of residents. Resident identifier: #84. Facility census: 87. Findings include: a) Resident #84 Review of the medical record on 12/05/17 at 9:00 a.m., revealed Resident #84 was admitted to the facility in (MONTH) (YEAR). The Minimum Data Set (MDS) comprehensive assessment with an assessment reference date (ARD) of 01/23/17, noted the resident had a Brief Interview Mental Status (BIMS) of 10, indicating moderately impaired mental function. He was assessed to wander daily and that his wandering put him at a significant risk of getting into a potentially dangerous place. His [DIAGNOSES REDACTED]. He was not prescribed any medications and did not receive any psychological therapies by licensed mental health professionals. The quarterly MDS with an ARD 10/23/17 again noted Resident #84 did not receive any psychological therapies by licensed mental health professionals. In addition, his BIMS score declined to 4 indicating severe cognitive impairment. Resident #84 was evaluated at the mental health clinic on 02/09/17. The target symptoms were noted to be behavioral symptoms of dementia with a goal to improve agitation without hospitalization s. The physician's note stated, Per chart review has been placed at (Name) and had a fall yesterday. Staff was confused regarding appointments and he was fit in for a visit today. Has had 2 falls per staff .Unsure of his appetite or sleeping at night, but he does nap some during the days. He often is trying to leave or looking for his vehicle. Having more difficulty in afternoon/evening .Notes reviewed and significant for periods of confusion. He receives [MEDICATION NAME] from time to time for agitation. The recommendations resulting from this visit, included starting, a trial of [MEDICATION NAME] (antidepressant) 25 milligrams (mg) every evening for behavioral symptoms of dementia and avoid [MEDICATION NAME] as able since it is likely to increase his fall risk. Follow up in 4 months or sooner if problems arise. A handwritten prescription signed by the psychiatrist stated, Consider a trial of [MEDICATION NAME] 25 mg q (every) evening for behavioral symptoms of dementia .It is likely he will no longer require additional medications if [MEDICATION NAME] is started and given time to be effective. Resident #84 returned to the mental health clinic on 03/01/17. The notes regarding this visit included his current medications and [MEDICATION NAME] 50 mg every evening, staff reported no concerns, and that Resident #84 was doing well with the [MEDICATION NAME]. He is somewhat impatient, and has had no falls or behaviors per facility notes. Receiving [MEDICATION NAME] for [MEDICAL CONDITION]. The assessment notes indicate worsening of Resident #84's major neurocognitive disorder of the Alzheimer's type. Recommendations are to continue the [MEDICATION NAME] 50 mg every evening for behavioral symptoms of dementia and avoid [MEDICATION NAME] since it is likely to increase his fall risk. Follow up in six (6) months or sooner if problems arise. On 09/07/17, Resident #84 returned to the mental health clinic. A review of the current medications with staff noted, [MEDICATION NAME] has been discontinued for unknown reason. Staff reports his behavior worsens as the day progresses. He is sarcastic and is irritable since he cannot walk. He sometimes is physically aggressive .He will eat when he wants to .He is not sleeping well at night. Recommendations are to restart [MEDICATION NAME] 25 mg every evening for one week and then increase to 50 mg every evening for behavioral symptoms of dementia since it was helping in the past. Move the medication to the morning if necessary and avoid benzodiazepines since they will increase his risk for falls. Return in three (3) months or sooner if problem arises. The Nurse's notes identify the following documented behaviors since 08/26/17: --08/26/17 7:00 a.m. Resident has yelled out loud. Cursed at staff and other residents. Has beat his fist and pounded his tray table .Unable to redirect . --08/31/17 5:00 a.m. Resident has been awake all shift. He has been belligerent - verbally abusive to staff and has made sexually inappropriate comments to female staff. Unable to redirect behavior. --09/04/17 5:00 a.m. Resident has been rude - verbally abusive belligerent and combative to staff and other residents .One on one supervision provided by staff. Unable to redirect behavior. --09/07/17 8:00 p.m. Resident _____ yelling at staff and other residents. Attempting to grab at other residents. Toileting and snacks provided with no change in behaviors. --09/07/17 8:45 p.m. Staff walking past resident. Resident kicked staff in leg. Moved resident away from high traffic area. Cursing and yelling at staff . --09/07/17 9:10 p.m. CNA (certified nursing assistant) walking past carrying linens. Resident reached out and grabbed CNA by right wrist squeezing and attempting to twist arm while attempting to disengage resident bit the undersigned on the left upper arm. --09/07/17 9:20 p.m. Dr. (name) returned call - advised of residents increased agitation and combative behavior. Order received and noted for [MEDICATION NAME] 5 mg IM (intramuscular) times one dose. --09/09/17 6:00 a.m. Resident has been belligerent - verbally abusive to staff and combative. Unable to redirect behavior. --09/20/17 12:00 a.m.propelling self up and down hallways - attempting to go into other residents' rooms - redirects with difficulty .Encouraged him to allow staff to assist him to bed without success. --09/20/17 6:40 a.m. Resident hitting, kicking, attempting to bite staff, knocked everything off the med cart; going in other residents' rooms - very difficult to redirect. --09/20/17 9:00 a.m.in wheel chair propelling self throughout facility. Resident aggressive towards staff and other residents . --09/24/17 11:00 p.m.Resident has been belligerent and verbally abusive to staff and other residents. Unable to redirect behavior. --10/23/17 3:00 a.m. Resident has been awake most of shift. He has been rude and verbally abusive to staff. Unable to redirect behavior. --10/24/17 12:00 a.m.sitting in chair at nurses' station pounding on wall and bedside table - table moved out of his reach - cursing at staff . --11/02/17 12:00 a.m.sitting in chair at nurses' station yelling out, cursing staff attempting to hit, kick, bite while staff attempting care . --11/07/17 5:00 a.m. Resident has been awake all night. Yelling out. Talking to self and people not there. Going Here kitty-kitty-kitty to his feet. Rambling thoughts and flights of ideas. Unable to redirect. --11/08/17 9:00 p.m.knocking over over-the-bed table multiple times yelling out and cursing at staff, unable to redirect. --11/09/17 2:00 a.m. Combative, physically and verbally abusive to staff - hitting, kicking, and biting. Resistant to any type of redirection. Dr. (name) notified no new orders. --11/09/17 9:20 a.m. Resident combative with staff upon trying to assist into bathroom. Unable to redirect. --11/09/17 9:50 a.m. Resident continuously attempting to stand/transfer self when in wheelchair without assistance. When redirection/education attempted resident becomes verbally abusive with staff. --11/13/17 6:15 p.m. Resident attempting to go behind nurses' desk. When undersigned attempted to redirect resident .resident states Do you want slugged and struck undersigned in the abdomen with his right fist . --11/15/17 3:00 a.m. Resident has been belligerent and combative and verbally abusive. Unable to redirect . --11/16/17 12:30 a.m. Resident yelling at other residents attempting to hit, kick, and bite staff. Very difficult to redirect . --11/19/17 3:00 a.m. Remains awake - sitting in chair at nurses' station - yelling out, banging on over bed table .offered to assist him to bed without success. --11/24/17 8:00 p.m. Resident combative physically and verbally abusive toward staff, hitting, kicking, spitting in staff faces and biting staff on hands. Resistant to all types of redirection. Attempted G-chair, resident broke table top and attempted to use bar off table as weapon to strike staff offered ADL (activities of daily living) care, offered one on one interaction without success. --11/27/17 2:00 a.m. Resident being belligerent and verbally abusive to staff and other residents . --11/28/17 06:30 a.m. Resident has been belligerent and has tried numerous times to get out of his chair and put himself on the floor. Unable to redirect .continues with negative behavior. --12/03/17 3:30 p.m. Resident entered other residents' rooms, upon redirection resident attempted to strike undersigned in stomach. Resident then attempted to scratch CNA staff. Redirected with difficulty. --12/03/17 4:35 p.m. Resident attempting to move food warmers from hallway .Resident became agitated and bit CNA on right forearm. Redirected with much difficulty. --12/03/17 6:00 p.m. Dr. (name) made aware of behavior, no new orders . The (MONTH) Medication Administration Record [REDACTED]. Attempted to redirect and resident struck undersigned in abdomen with fist x (times) 2 times .Redirection and reorientation with much difficulty. The Activities of Daily Living (ADL) sheets completed by the nursing assistants note the following behaviors: --July (YEAR) - Resident #84 demonstrated socially inappropriate behaviors daily: These behaviors include: sexually inappropriate behaviors, hoarding, rummaging, and taking clothes off in public. In addition, he is noted to be restless and calling out often, with disorganized thinking. --August (YEAR) - Socially inappropriate behaviors includes rummaging and taking clothes off in public daily. He displays restlessness and calls out often, and continues to demonstrate disorganized thinking. --September (YEAR) - Socially inappropriate behaviors includes rummaging and taking clothes off in public daily. In addition, Resident #84 is noted to be easily annoyed, with anger regarding nursing home placement and anger at staff on all three shifts and all 30 days of the month. He continues to demonstrate signs of restlessness daily and was physically abusive twice this month. --October (YEAR) - Socially inappropriate behaviors of rummaging and removing clothing in public occurred every day but three (3). There is no documentation related to fits of anger. Resident #84 experienced delusions and hallucinations on 14 of 31 days and is noted to be restless daily. He demonstrated physical abuse on two (2) days. --November (YEAR) - Socially inappropriate behaviors of rummaging and removing clothing in public occurred every day but two (2). There is no documentation related to anger and he experienced delusions and hallucinations 10/30 days. Remained restless daily and was physically abusive twice this month. --December 1-6, (YEAR) - Socially inappropriate behaviors include screaming, removing clothes in public, sexually inappropriate behaviors, and smearing food or feces and occur daily. Delusions and hallucinations occurred on one of six days and anger is noted on part of each six days. In addition, he is noted to be resisting care daily and continues to be restless with physical and verbal abuse on 5 of the 6 days reviewed. The physician's orders [REDACTED]. --01/25/17 [MEDICATION NAME] (antianxiety) was started at 1 mg twice a day as needed for agitation, hitting, kicking, biting, danger to self and others. --02/03/17 [MEDICATION NAME] was changed from twice a day as needed to 1 mg every day at 5:00 p.m. --02/09/17 [MEDICATION NAME] was discontinued per the psychiatrist recommendation because of falling and [MEDICATION NAME] (antidepressant) was started at 25 mg every evening for behavioral symptoms of dementia. --03/05/17 an order was given for a one-time dose of [MEDICATION NAME] 1 mg for aggressive behaviors hitting, kicking, and punching at staff and other residents. --04/27/17 the [MEDICATION NAME] was discontinued and [MEDICATION NAME] 400 mg twice a day for fourteen (14) days was started for appetite stimulant and weight loss. *[MEDICATION NAME] was not restarted despite psychiatric recommendations on 02/09/17, 03/01/17 and 09/07/17. The care plan notes dated 10/23/17 states: .Received order to restart [MEDICATION NAME] in 09/07/17 and Dr. (name) felt we needed to monitor before restarting and resident has been doing good without [MEDICATION NAME]. The current care plan with a revision date of 10/23/17, identified wandering that he rummaged through other residents' belongings as a problem. The goal was, Safety will be maintained AEB (as evidenced by) resident will not injure/harm self-secondary through wandering through next review. The approaches included to approach from the front, assure proper foot attire, avoid over-stimulation, obtain a psyche consult, remove from other residents' rooms and unsafe situations, and provide comfort measures for basic need. The care plan also listed a disturbed thought process as a goal noting Resident #84 was unaware of the location of his room or names of staff, he was easily distracted, and had periods of altered perception or awareness of surroundings, and wandered throughout the facility. The goal was, Cognitive status will be improved AEB resident will be able to locate own room by next review date. The approaches included assist to find room, encourage small group programs, provide special environment stimuli, structure daily programs around physical aspects of resident's life, provide cues when trying to remember something and minimize distractions. The care plan failed to identify Resident #84's signs of distress. The care plan lacked individualized goals related to his behavioral health needs and lacked specific approaches for staff to utilize in response to his physical and verbal outbursts, sexually inappropriate comments, removing of close in public, entering other residents' rooms, and confusion related to his environment. During a random observation on 12/04/17, Resident #84 attempted to exit the building through the B-hall dining room and was halted by two staff members. On 12/06/17, he again attempted to exit the building through the locked door by the kitchen hall. He sat by the door and waited for someone to unlock the door and attempted to follow them out by grabbing the door edge. Staff were alerted of this attempt when another surveyor voiced concern that his fingers might get mashed by the door. At 3:30 p.m. on 12/06/17, he was observed wandering around A-hall in his wheelchair. Staff intervened when he attempted to hit Resident #83 who was sitting quietly along the wall in the hall near the nurses' desk. He continued to wander around the halls on A-hall until a staff member escorted him back to B-hall. During an interview on 12/04/17 at 2:45 p.m., Licensed Practical Nurse (LPN) #31 confirmed Resident #84 is verbally and physically abusive at times. Nurse Aids #74 and #19 were interviewed on 12/06/17 at 8:40 a.m., and confirmed Resident #84 hasd combative behaviors and attempts to escape at times. He displays a few behaviors during the day but most of them are during the evenings and nights. NA #19 stated he has sundowners. Diversions include offering a snack or drink or toileting. The NAs said, Sometimes they work and sometimes they don't. Staff were unfamiliar with the resident's past work or social history. The Director of Nursing and the Social Worker reported during an interview on 12/06/17 at 10:45 a.m., that Resident #84's primary care physician did not always follow the psychiatrist's recommendations. When asked why the psychiatrist was not consulted about his increased behaviors towards staff and other residents, the Social Worker stated, The resident is on Medicaid and can only have a psychiatric visit every 90 days. LPN #15 acknowledged she was unsure of Resident #84's past work and social history other than he was a boss, during an interview on 12/07/17 at 9:00 a.m. She reported he hasd had an increase in falls since admission. He can no longer walk unassisted and rolls around in a wheel chair. His wandering and exit seeking has decreased and his agitation has increased. His behaviors are worse in the evenings and during the nights. LPN #15 agreed the care plan was not individualized to meet Resident #84's behavioral health needs and lacked specific approaches for staff to utilize in response to his physical and verbal outbursts, sexually inappropriate comments, removing of close in public, entering other residents' rooms, and confusion related to his environment. Resident #84 was admitted to the facility with anxiety, depression and non-Alzheimer's dementia. He began exhibiting behaviors during the first month of his stay and was referred to an outpatient psychiatrist on 02/09/17. He was started on [MEDICATION NAME] per the psychiatrist's recommendations. Behaviors were noted to have improved with the administration of [MEDICATION NAME] 50 mg every evening. On 04/27/17 the [MEDICATION NAME] was discontinued by the primary care physician and [MEDICATION NAME] was started for 14 days for weight loss and appetite stimulation. Resident #84's [MEDICATION NAME] was not restarted after the prescribed 14 days of [MEDICATION NAME]. The psychiatric note dated 09/07/17 noted Resident #84's behaviors worsened as the day progressed, and a recommendation was made to restart the [MEDICATION NAME]. The primary physician declined to restart the [MEDICATION NAME]. Resident #84 continued to display signs of distress including agitation, wandering, aggression, yelling out, and delusions. The plan of care lacked any individualized approaches for staff to utilize in response to his behaviors. The care plan lacked any reference to the psychiatric goal of improving agitation without hospitalization and failed to address Resident #84's emotional and psychosocial needs. | 2020-09-01 |