Humboldt House Rehabilitation and Nursing Center
September 7, 2017 Complaint Survey

Standard Health Citations

FF10 483.25(d)(1)(2)(n)(1)-(3):FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES

REGULATION: (d) Accidents. The facility must ensure that - (1) The resident environment remains as free from accident hazards as is possible; and (2) Each resident receives adequate supervision and assistance devices to prevent accidents. (n) - Bed Rails. The facility must attempt to use appropriate alternatives prior to installing a side or bed rail. If a bed or side rail is used, the facility must ensure correct installation, use, and maintenance of bed rails, including but not limited to the following elements. (1) Assess the resident for risk of entrapment from bed rails prior to installation. (2) Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation. (3) Ensure that the bed?s dimensions are appropriate for the resident?s size and weight.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: September 7, 2017
Corrected date: October 16, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review conducted during an Abbreviated survey (Complaint # NY 412) completed on 9/7/17, the facility did not ensure that the resident environment is free from accident hazards as possible and each resident receives adequate supervision and assistive devices to prevent accidents. One (Resident #1) of three residents reviewed had issues. Specifically, the resident with a history of falls did not have interventions in place to maintain the resident's safety. The finding is: 1. Resident #1 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 6/29/17 revealed the resident is severely cognitively impaired. Review of the Care Plan dated 6/23/17 revealed the resident is non-ambulatory, extensive assist of 2 for bed mobility, extensive assist of 2 with gait belt for transfers, low bed with floor mats and stationary chair with lap buddy when out of bed. Under the focus problem, Behavioral Issues revealed the resident was non-compliant with the call light, will self-transfer and crawl on floor, can be physically aggressive with hands on care. Puts self on floor. Interventions included to approach/ speak in calm manner. Divert attention. Remove from situation and take to alternate location as needed. Move to less stimulating environment. Review of an Accident & Incident report dated 7/6/17 at 1:00 PM written by Registered Nurse (RN #2) revealed the resident was observed in the dining room to get out of her wheelchair unassisted and started to push another chair near her when she lost her balance and fell without injury. Further review of the revised Care Plan revealed the resident had an actual fall on 7/6/17 with interventions to monitor/ document/ report as needed x 72 hours to physician for signs/symptoms: Pain, bruises, change in mental status, New onset: confusion, sleepiness, inability to maintain posture, and agitation. Review of an undated Certified Nurse Aide (CNA) care guide revealed the resident is non-ambulatory, extensive assist of 2 for bed mobility, extensive assist of 2 with a gait belt for transfers, low bed with floor mats and a stationary chair with lap buddy when out of bed. Under Precautions/Safety revealed to be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Review of a Licensed Practical Nurse (LPN) Progress Note revealed an Incident Note dated 7/7/17 at 7:32 PM that the resident was FOF (found on floor) in her room laying on her back. Bed in low position and mat next to bed. Abrasion noted to right knee. Area was cleansed and a Band-Aid applied. Supervisor notified. Review of an Incident Note dated 7/8/17 at 1:14 AM written by RN #2 revealed the resident was FOF. The resident sustained [REDACTED]. Cleansed with NS (normal saline) and a Band-Aid was applied. There were no other injuries. The Physician and family were notified. Review of a prompt Care plan updated? revealed Not at this time. Review of a LPN Progress Note dated 7/18/17 at 4:23 AM revealed the resident was seen walking from her room without any clothes on at approximately 4:15 AM. This writer went to assist resident, but resident fell to the floor before reached. Supervisor on the unit to assess. No apparent injury noted. Resident resistive to hands on care with assist from the floor. Resident assisted back to bed, bed in low position. Unable to obtain blood pressure due to resident's constant movement of upper extremities. Review of an Incident Note dated 7/18/17 at 4:56 AM written by RN #1 revealed writer called to floor to assess resident who apparently fell to the floor in the hallway. No apparent injury. Physician and family notified. Review of a prompt Care plan updated? revealed Not at this time. During an interview on 8/31/17 at 9:30 AM, the RN Resident Care Coordinator (RCC) stated that she did not think the Care Plan had to be changed after the 7/7/17 & 7/18/17 incidents because of the blanket statement on the Care Plan that the resident has behaviors and crawls on the floor. During a phone interview on 8/31/17 at 3:20 PM, RN #1 stated that he did not make Care Plan changes after the 7/7/17 & 7/18/17 incidents because the RCC makes the changes. During a follow-up interview on 8/31/17 at approximately 2:00 PM, the RN RCC stated, After two falls out of bed, and with the resident's history of falls the Care Plan could've been updated to monitor closely or to check every 15 minutes. 415.12(h)(1)

Plan of Correction: ApprovedSeptember 28, 2017

RN #2 was educated and disciplined regarding the need to implement care plan changes at the time of occurrence to ensure that the resident's environment is free from accident hazards as possible, that the resident receives adequate supervision and assistive devices to prevent further accidents.
The Resident Care Coordinator (RCC) was also educated regarding the need to review all accident and incidents to ensure adequate care plan revisions have been implemented to ensure that the resident's environment is free from accident hazards as possible, that the resident receives adequate supervision and assistive devices to prevent further accident.
To identify other residents who may be affected by this deficiency:
DON/Designee will review the 72 hour report every Monday and the 24 hour report Tuesday through Friday to follow up on any accident and incident which may have occurred,
All Accident and Incidents will be logged with date of occurrence, type of incident and resident's name.
To ensure these deficient practices do not re-occur, the following measures will be completed:
DON/Designee will educate all RN Supervision staff regarding the requirement to implement care plan changes at the time of occurrence to ensure that the resident's environment is free from accident hazards as possible, that the resident receives adequate supervision and assistive devices to prevent further accidents.
DON/Designee will educate all Resident Care Coordinator (RCC) regarding the need to review all accident and incidents to ensure adequate care plan revisions have been implemented to ensure that the resident's environment is free from accident hazards as possible, that the resident receives adequate supervision and assistive devices to prevent further accident.
All Accident and Incident reports will be reviewed on a daily basis with the interdisciplinary team to ensure appropriate interventions are put in place to ensure that the resident's environment is free from accident hazards as possible, that the resident receives adequate supervision and assistive devices to prevent further accidents.
100% audit was conducted on all residents who experienced a fall within the last 30 days.
DON/Designee will audit all accident and incident reports for falls will be audited daily for 30 days, then weekly for 2 months to ensure appropriate interventions are put in place to ensure that the resident's environment is free from accident hazards as possible, that the resident receives adequate supervision and assistive devices to prevent further accidents.

The results of these audits will be discussed at the facility's QAPI meeting to demonstrate success of the plan or the need to provide additional education or ongoing auditing as warranted.
Date of correction and the title of the person responsible for the correction of this deficiency:
Director of Nursing

FF10 483.12(a)(3)(4)(c)(1)-(4):INVESTIGATE/REPORT ALLEGATIONS/INDIVIDUALS

REGULATION: 483.12(a) The facility must- (3) Not employ or otherwise engage individuals who- (i) Have been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law; (ii) Have had a finding entered into the State nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property; or (iii) Have a disciplinary action in effect against his or her professional license by a state licensure body as a result of a finding of abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property. (4) Report to the State nurse aide registry or licensing authorities any knowledge it has of actions by a court of law against an employee, which would indicate unfitness for service as a nurse aide or other facility staff. (c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: (1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. (2) Have evidence that all alleged violations are thoroughly investigated. (3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. (4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: September 7, 2017
Corrected date: October 16, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review conducted during an Abbreviated survey (Complaint # NY 412) completed on 9/7/17, the facility did not ensure that accidents are thoroughly investigated. One (Resident #1) of three residents reviewed for accidents lacked investigations for the resident who fell on [DATE] and 7/18/17. The finding is: 1. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 6/29/17 revealed the resident is severely cognitively impaired. Review of the Care Plan dated 6/23/17 revealed the resident is non-ambulatory, extensive assist of 2 for bed mobility, extensive assist of 2 with a gait belt for transfers, low bed with floor mats and stationary chair with lap buddy when out of bed. Under the focus problem, Behavioral Issues revealed the resident is non-compliant with call light use, will self-transfer and crawl on floor, can be physically aggressive with hands on care. Puts self on floor. Interventions included to approach/ speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. Move to less stimulating environment. Review of an Accident & Incident (A&I) report dated 7/6/17 at 1:00 PM written by Registered Nurse (RN #2) revealed the resident was observed in the dining room to get out of her wheelchair unassisted and started to push another chair near her when she lost her balance and fell without injury. Further review of the revised Care Plan revealed the resident had an actual fall on 7/6/17 with interventions to monitor/ document/ report as needed x 72 hours to physician for signs/symptoms: Pain, bruises, change in mental status, New onset: confusion, sleepiness, inability to maintain posture, and agitation. Review of an undated Certified Nurse Aide (CNA) care guide revealed the resident is non-ambulatory, extensive assist of 2 for bed mobility, extensive assist of 2 with gait belt for transfers, low bed with floor mats and stationary chair with lap buddy when out of bed. Under Precautions/Safety revealed to be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Review of a Licensed Practical Nurse (LPN) Progress Note revealed an Incident Note dated 7/7/17 at 7:32 PM that the resident was FOF (found on floor) in her room laying on her back. Bed in low position and mat next to bed. Abrasion noted to right knee. Area cleansed and Band- Aid applied. Supervisor notified. Review of an Incident Note dated 7/8/17 at 1:14 AM written by RN #2 revealed the resident was FOF. The resident sustained [REDACTED]. The abrasion was cleansed with NS (normal saline) and a Band-Aid was applied. There were no other injuries. The Physician and family were notified. Review of a prompt Care plan updated? revealed Not at this time. There was no A&I report initiated for the 7/7/17 incident. Review of a LPN Progress Note dated 7/18/17 at 4:23 AM revealed resident seen walking from her room without any clothes on at approximately 4:15 AM. This writer went to assist resident, but resident fell to the floor before reached. Supervisor on the unit to assess. No apparent injury noted. Resident resistive to hands on care with assist from the floor. Resident assisted back to bed, bed in low position. Unable to obtain blood pressure due to resident's constant movement of upper extremities. Review of an Incident Note dated 7/18/17 at 4:56 AM written by RN #1 revealed writer called to floor to assess resident who apparently fell to the floor in the hallway. No apparent injury. Physician and family notified. Review of a prompt Care plan updated? revealed Not at this time. There was no A&I report initiated for the 7/18/17 incident. During an interview on 8/30/17 at approximately 3:00 PM, the Director of Nursing (DON) stated that all Incident Notes are reviewed by herself and the interdisciplinary team in morning report. When there is an Incident Note there should also be an A&I report that she needs to follow-up on. Once the A&I is completed the DON and the Administrator sign the reports. The DON stated she did not know how she missed the 7/7/17 & 7/18/17 incidents. During an interview on 8/31/17 at 9:30 AM, the RN Resident Care Coordinator (RCC) stated that she did not think A&I reports were needed after the 7/7/17 & 7/18/17 incidents because of the blanket statement on the Care Plan that the resident has behaviors and crawls on the floor. During an interview on 8/31/17 at 11:45 AM, the Director of Strategic Planning and Development stated, Staff know the process to generate/ complete A&Is when an Incident Note is written; and when the Incident Note is reviewed/ discussed in morning report the DON knows to look for a correlating A&I which needs to be signed by the DON and Administrator. They were all trained. During a phone interview on 8/31/17 at 3:20 PM, RN #1 stated that he did not initiate the A&I reports for the 7/7/17 & 7/18/17 incidents because it was an oversight; he was busy. Review of a facility policy entitled Accidents and Incidents - Investigating and Reporting dated 2/2014 revealed all accidents or incidents involving residents occurring on our premises shall be investigated and reported to the Administrator. The Nurse Supervisor/Charge Nurse and/or the department director or supervisor shall complete a Report of Incident/ Accident form and submit the original to the DON within 24 hours of the incident or accident. The DON shall ensure that the Administrator receives a copy of the Report of Incident/ Accident form for each occurrence. 415.4(b)(3)

Plan of Correction: ApprovedSeptember 28, 2017

What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice:
Resident #1 was discharged from the facility on 8/22/2017.
The closed chart was reviewed by the Director-of-Nursing to identify any issues involving accidents and incidents not thoroughly investigated.
RN no.2 received education and progressive discipline for failing to complete Accident/Incident forms per policy.
All full/part time licensed nurses will be rein-serviced on the facility's Accident/Incident policy to include timely completion and thorough investigation.
How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken:
Director of Nursing will audit all accidents and incidents in the past 60 days to ensure all accidents/incidents were thoroughly investigated and forms completed per policy. Any discrepancies identified will have appropriate follow-up as warranted.
What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur.
The DON/ADON will audit the twenty-four hour report and high risk progress notes on a daily basis to ensure all incidents/ accidents are thoroughly investigated and forms completed per policy.
How the corrective action(s) will be monitored to ensure the deficient practice will not recur
The Administrator of the facility will conduct weekly audits for 8 weeks to ensure all incidents/accidents identified from the 24 hour report and high-risk progress notes have appropriate forms completed per policy and have been thoroughly investigated.
The results of these audits will be discussed at the facility's QAPI meeting to demonstrate success of the plan or the need to provide additional education or ongoing auditing as warranted.
The Administrator will be ultimately responsible to ensure that the total P(NAME) for this tag is accomplished.