Medford Multicare Center for Living
January 17, 2018 Complaint Survey

Standard Health Citations

FF11 483.21(b)(1):DEVELOP/IMPLEMENT COMPREHENSIVE CARE PLAN

REGULATION: §483.21(b) Comprehensive Care Plans §483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following - (i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and (ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6). (iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record. (iv)In consultation with the resident and the resident's representative(s)- (A) The resident's goals for admission and desired outcomes. (B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose. (C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 17, 2018
Corrected date: April 20, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review during an abbreviated survey (Complaint Number: NY 366) the facility did not implement a comprehensive person-centered care plan for each resident. Specifically, one (Resident #1) of three residents reviewed for Comprehensive Care Plan (CCP), was assessed as requiring two-person assistance for personal hygiene. However, the Certified Nursing Assistant instructions documented care was to be provided with one-person assistance for personal hygiene. The findings are: The facility Policy and Procedure titled Activities of Daily Living (ADL), dated 6/1/2002 and revised on 03/31/2016, documented that the resident would be expected to maintain reasonable standards of hygiene and grooming during their stay at the facility and would be offered all necessary supplies and assistance to do so. When autonomy and independence were no longer possible or feasible, resident care staff would provide necessary support in all ADL functioning. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set 3.0 (MDS- an assessment tool) dated 12/06/2017 documented the resident's cognitive status as being severely impaired. The MDS assessment also identified that the resident had impairment in range of motion of bilateral upper and lower extremities and required total assistance of 2 persons with bed mobility, transfer, dressing, toilet use and personal hygiene. The Comprehensive Care Plan (CCP) titled ADLs dated 06/04/2016 included an intervention that the resident required total assist of 2 persons with personal hygiene. The undated Resident Nursing Instructions (Resident Care Profile) that was in use in (MONTH) (YEAR) documented Resident #1 required one-person physical assistance for personal hygiene. The Certified Nursing Assistant Accountability Record for the months of (MONTH) (YEAR) and (MONTH) (YEAR) were signed to indicate that one-person provided personal hygiene care to the resident 144 times out of 144 opportunities. The Registered Nurse Clinical Care Coordinator (CCC) was interviewed on 12/27/2017 at 11:37 AM and stated she was responsible for developing the care plans and completion of certain assessments that did not include MDS assessment for each resident on the unit. Resident #1 required total physical assistance of one-person for personal hygiene and dressing. The CCC stated that the Resident Care Profile (RCP) and care plan should match. The CCC also stated she did not know when the RCP was initiated and updated for Resident #1. The CCC stated that she usually updated the care plan but not always the RCP. CNA #2 was interviewed on 12/27/17 at 12:19 PM and stated that she had cared for Resident #1 occasionally. She checked the RCP to determine what care was needed for each resident assigned to her prior to providing care. Resident #1 required total assistance with all ADL care. CNA #2 stated that she checked the RCP for all care needs of each resident and followed the instructions provided in the RCP. CNA #3 was interviewed on 12/27/17 at 12:28 PM and she stated that Resident #1 was not on her assignment, however, she assisted other CNAs providing care to Resident #1. CNA #3 stated that Resident #1 required two persons assistance with all ADL care. When providing personal hygiene care Resident #1 tightened up his body and that was why two people were needed to provide any care to him. CNA #3 stated that she checked RCP for each assigned resident to ascertain their care needs prior to providing care. CNA #4 was interviewed on 12/27/17 at 12:45 PM and CNA #4 stated Resident #1 required one-person physical assistance with his personal hygiene care. CNA #4 sometimes called for assistance of other CNAs when rendering personal hygiene to Resident #1 because his contractures made it difficult to care for him. The Director of Rehab (DOR) was interviewed on 12/27/2017 at 2:00 PM and stated Resident #1 was totally dependent on staff for ADL care based on Physical Therapy evaluation. The DOR stated that the therapy department did not usually denote the number of persons required to complete a task. The number of persons required to complete a task, was decided by nursing. The Director of Nursing (DON) was interviewed on 12/27/2017 at 1:01 PM, he reviewed the MDS, CCP and RCP and stated that that the MDS, CCP documented two persons assistance with personal hygiene; the RCP documented one person assistance for Resident #1. The DON stated that the MDS, Care Plan and the RCP should match to reflect the accurate number of care givers needed to provide care to this resident. 415.11(c)(1)

Plan of Correction: ApprovedMarch 14, 2018

The Medford Multicare Center (MMC) for Living submits that its policies, procedures and systems are in place to ensure all residents have a person-centered care plan consistent with resident rights with measurable objectives and timeframes to meet each resident?s medical, nursing and mental & psychosocial needs are identified in the comprehensive assessment.
This Plan of Correction is required by federal and state regulations and is not to beaccurate or that at the time of the survey the facility did not have policies, procedures and systems in place to maintain compliance with all requirements. In an effort to enhance the care furnished to our residents, we have augmented some of our existing policies, procedures and systems.
Corrective action(s) for resident(s) affected:
Resident #1 is no longer at the facility.
Identification of residents that could be affected by the deficient practice:
All residents of MMC are at risk to be affected by this deficient practice.
? 100% of all resident care plans will be reviewed to ensure that all residents have a person-centered care plan that accurately reflects each resident?s care needs, specifically the amount of assistance required for in bed mobility and for transfer in the CNA instructions/assignments.
? Any care plan deficient absent of amount of assistance required for care and/or bed mobility and transfer will be corrected and revised immediately.

Systemic Measures to prevent recurrence:
All clinical staff; Nurses, CNAs and therapists will be educated by
William Poscocello, Consultant, on 3.16.18 & 3.21.18 on each shift following a Department Head on 3.16.18 will be educated on:
? The development & implementation of a person-cent? The CNA instructions/assignments;
specifically the amount of assistance required by a resident for care, specifically for bed mobility and transfer
? The revised policy & procedure including the on the new RED # 2 symbol created in the electronic medical record;
? A RED # 2 symbol was added to the electronic medical record (EMR) and the CNA assignment indicating a two (2) person assist is required for bed mobility.
? All new admissions will be assessed in accordance with policy and procedures and include bed mobility and transfer assistance and will be reflected in each residents individual care plan for the within the first 24-48 hours of admission.
Quality Assurance & Improvements with On-going Monitoring:
The DNS/ Designee will perform an initial audit on 100% of resident care plans to ensure:
? They accurately reflect the needs of the resident and the amount of assistance required for bed mobility, transfers and all care needs of the individual as indicated by the assessment.
? The CNA assignment accurately reflects the care plan and needs of the resident including bed mobility and transfers.
? An audit will be conducted on 25% of the care plans every month x 3 months and quarterly thereafter to ensure the care plans accurately reflect the assistance required by each resident for bed mobility, transfers and all care needs as indicated by the assessment.
? Results of this audit will be provided to the DNS and reported to QAPI.
? The Clinical Care Coordinators will rectify any discrepancies s at the time of the audit. The DNS/ Designee will report findings of
ered care plan that accurately reflects each resident?s care needs, specifically the amount of assistance required for in bed mobility and transfer;
construed as an admission that the cited deficiencies are Responsible Person: Assistant Director of Nursing will ensure the P(NAME) has been followed and audited.

Completion Date: 4/26/2018

FF11 483.12(a)(1):FREE FROM ABUSE AND NEGLECT

REGULATION: §483.12 Freedom from Abuse, Neglect, and Exploitation The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. §483.12(a) The facility must- §483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion;

Scope: Isolated
Severity: Actual harm has occurred
Citation date: January 17, 2018
Corrected date: April 20, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review during an abbreviated survey (Complaint Number: NY 366), the facility did not ensure resident rights to be free from neglect. Specifically, one (Resident #1) of three residents reviewed for neglect, required two-person assistance for bed mobility and mechanical lift (Hoyer) for transfers as documented in the Comprehensive Care Plan (CCP). A Certified Nursing Assistant (CNA #1) willfully neglected to implement the CCP. CNA #1 placed a Hoyer sling under Resident #1 by herself and did not call for assistance. This negligence resulted in Resident #1 falling out of bed; the resident sustained [REDACTED]. Resident #1 was transferred to the hospital and diagnosed with [REDACTED].#1 died at the hospital on [DATE]. This resulted in actual harm to Resident #1 that is not Immediate Jeopardy. The Findings are: The Policy and Procedure titled Hoyer Lifter dated [DATE] and revised on [DATE] documented that a transfer with the aid of a Hoyer lifter was always a two-person lift, at minimum. The procedure documented placing the sling under the resident by side-rolling the resident with at least 2 staff members. The Policy and Procedure titled Activities of Daily Living (ADL) dated [DATE] revised on [DATE] defined Bed mobility as how a resident moved to and from lying position, turned side to side and positioned body while in bed or chair. The Policy and Procedure titled Resident Abuse, Mistreatment, Neglect and Exploitation revised ,[DATE] defined neglect as failing to provide timely, consistent, safe, adequate and appropriate services, treatment and/or care to a resident of a residential care facility while resident is under the supervision of the facility. The policy also documented a federal definition of neglect as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE] documented the resident's cognitive status as being severely impaired. He required total assistance of 2 persons with bed mobility, transfer, dressing, toilet use and personal hygiene and had impairment in range of motion on bilateral upper and lower extremities. The undated lesson plan titled Hoyer-Lesson Plan documented a procedure to complete a Hoyer transfer correctly and safely by placing the sling with two assistants and placing resident on sling by turning from side to side. The Fall Risk assessment dated [DATE] documented the resident was at risk for falls. The CCP titled Falls/Injury dated [DATE] documented the resident was at risk for falls/injury related to history of falls, loss of voluntary movement, impaired balance, impaired gait and dementia. Interventions included to instruct/reinforce safety measures including transfer technique. The CCP was updated on [DATE] and documented the resident fell after personal care and sustained a laceration to left eyebrow approximately ½ inches to ¾ inches and bleeding. Resident was sent to the hospital. The CCP titled ADLs dated [DATE] documented resident was non-ambulatory. Interventions included mechanical lift with assist of 2 for transfers. An intervention dated [DATE] documented the resident required total assist of 2 persons with bed mobility and personal hygiene. The Resident Nursing Instructions (Resident Care Plan-RCP) documented Resident #1 required 2-person total assistance for bed mobility and one-person physical assistance for personal hygiene. The Nursing Progress Notes (NPN) dated [DATE] at 1:29 PM documented the resident was out of the facility to hospital ER at 11 AM secondary to fall with [MEDICAL CONDITION]. The NPN dated [DATE] at 3:10 PM documented the Registered Nurse Clinical Care Coordinator (CCC) was called to resident's room by CNA to assess patient status [REDACTED]. Resident had a laceration to left eyebrow approximately ½ inches to ¾ inches and bleeding. The NPN dated [DATE] at 7:40 PM documented that the resident was admitted to the hospital at 7:00 PM with [DIAGNOSES REDACTED]. The facility's Investigative Summary (undated) documented on [DATE] at 10:40 AM, the RN was called to evaluate Resident #1 since he was witnessed falling out of bed. Upon the RN's arrival to the room, the resident was lying on his left side, next to his bed and floor mat. According to the aide attending to the resident, she had just completed care on the resident and was attempting to place Hoyer pad under his body and he rolled off the air mattress and fell in between the bed and the floor mat. Resident #1 sustained a laceration to his left eyebrow and he was transferred to the hospital. The facility investigative summary also documented that the Certified Nursing Assistant (CNA) was interviewed and ascertained the resident required an assist of two for bed mobility and transfer per plan of care and resident care profile. The caregiver was suspended pending investigation due to the break in resident's plan of care. The CNA was given an in-service on the need to follow the comprehensive care plan and resident care profile and need to use an assist of 2 when placing on Hoyer pad. The CCC was interviewed on [DATE] at 11:37 AM and stated Resident #1 required total assistance of two persons for bed mobility (boosting and turning). On [DATE] around 10:30 AM CNA #1 came to her and told her that Resident #1 fell . Upon assessment Resident #1 was found to have a small laceration to his left eyebrow and was bleeding. He was non-verbal, awake and conscious. CNA #1 told the CCC that she was placing the Hoyer pad underneath Resident #1 and he rolled off the bed. The CCC stated that placing the Hoyer pad underneath a resident was considered bed mobility, CNA #1 was expected to have another person to assist for placing a Hoyer pad underneath Resident #1. CNA #2, CNA #4, CNA #5 were interviewed on [DATE] at 12:37 PM. The CNAs stated they provided care with Resident #1 at times but were not assigned to Resident #1 on [DATE]. They stated when placing a pad underneath Resident #1, two persons assistance was required. They stated that CNA #1 did not ask for their assistance for Resident #1's care on [DATE]. LPN #2 was interviewed on [DATE] at 1:30 PM and stated Resident #1 was not on her assignment. She was administering treatment with another resident when the CNA (name not recalled) called her name and told her that the CCC needed her in Resident #1's room. Upon entering Resident #1's room she observed Resident #1 laying on the floor with small amount of blood on the floor. She assisted the CCC and transferred Resident #1 back to bed. LPN #2 called the MD (physician). LPN #2 stated that CNA #1 did not ask for her assistance with Resident #1 prior to the fall. The Director of Nursing (DON) was interviewed on [DATE] at 3:49 PM. The DON stated that the staff including CNA #1 were in-serviced and had demonstrated proper procedures regarding Hoyer lift transfers on [DATE]. The DON stated that he was notified of the incident on [DATE]. Upon investigation the facility concluded that the plan of care for Resident #1 was not followed by CNA #1. The DON stated that during reenactment of the incident CNA #1 placed the Hoyer pad underneath Resident #1 by herself. The DON stated CNA #1 was aware that Resident #1 required 2 persons assistance with bed mobility and transfers. The DON stated that CNA #1 did not follow the plan of care and was suspended and was going to be terminated. CNA #1 stated to the DON that she did not believe she needed two persons assistance because she was not transferring the resident but was placing the Hoyer sling under Resident #1. The DON stated the Hoyer lift competency that was completed on [DATE] documented that when placing sling under a resident, 2 persons assistance was required. The competency record was signed by CNA #1. 415.4 (b)

Plan of Correction: ApprovedMarch 14, 2018

The Medford Multicare Center (MMC) for Living submits that its policies, procedures and systems are in place to ensure residents are free from abuse, neglect, misappropriation of resident property, and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat. This Plan of Correction is required by federal and state regulations and is not to be construed as an admission that the cited deficiencies are accurate or that at the time of the survey the facility did not have policies, procedures and systems in place to maintain compliance with all requirements. In an effort to enhance the care furnished to our residents, we have augmented some of our existing policies, procedures and systems.
Corrective action(s) for resident(s) affected:
Resident #1 is no longer at the facility.
CNA #1 was terminated from MMC.

Identification of residents that could be affected by the deficient practice:
All residents requiring a two person assist in bed or for bed mobility that the potential to be affected by this practice.
All residents currently residing in MMC will be reassessed for bed mobility.
Systemic Measures to prevent recurrence:
All clinical staff; Nurses, CNAs and therapists will be educated by
William Poscocello, Consultant, on 3.16.18 & 3.21.18 on each shift following a Department Head on 3.16.18:
? The revised policy & procedure including the on the new RED # 2 symbol created in the electronic medical record;
? The need to follow care plan and CNA instructions re: all aspects of care for a resident, including but not limited to the number of assists for bed mobility, transfers and assistance for care;
? Need of 2 assistants for every resident requiring a mechanical lift AND including placing the resident on the ?lift pad? under the resident prior to transfer;
? Potential risks to resident(s) and/or staff if policy/procedure is not followed;
? Clinical Care Coordinators (CCC?s) will be responsible for maintaining and updating the alert as needed per the revised Policy & Procedure.
? Educator will have participants complete a post-test with group discussion to ensure understanding of revised policy & procedure.
A RED # 2 symbol was added to the electronic medical record (EMR) and the CNA assignment indicating a two (2) person assist is required for bed mobility.
All new admissions will be assessed in accordance with policy and procedures and include bed mobility and transfer assistance and will be reflected in each residents individual care plan for the within the first 24-48 hours of admission.
Quality Assurance & Improvements with Ongoing Monitoring:
The Assistant Director of Nursing and/or designee will conduct an initial audit on 100% of the residents records requiring a two person assist with bed mobility to:
? Ensure compliance with the new policy/procedure;
? Ensure the RED # 2 symbol is in
the EMR per the revised Policy & Procedure;
The Assistant Director of Nursing and/or designee will complete and audit of 25% sample every month for three months and quarterly thereafter.
? All deficiencies will be corrected immediately;
? 1:1 employee education will be completed at the time a deficiency is identified.
The CCC?s/Designee will conduct an observational audit on 50% on all residents requiring two person assist with bed mobility/transfer every week for one month and every 3 months thereafter until 100% compliance is achieved.
The DNS/ Designee will report findings of the audits at the monthly QAPI meeting.

Responsible Person: Director of Nursing
Completion Date: 4/26/2018


FF11 483.25(d)(1)(2):FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES

REGULATION: §483.25(d) Accidents. The facility must ensure that - §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents.

Scope: Isolated
Severity: Actual harm has occurred
Citation date: January 17, 2018
Corrected date: April 20, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review during an abbreviated survey (Complaint Number: NY 366) the facility staff did not effectively implement interventions to prevent an avoidable accident. Specifically, one (Resident #1) of three residents reviewed for accident required two persons assistance for bed mobility. On 12/19/17, the assigned Certified Nursing Assistant (CNA #1) placed a mechanical lift sling under Resident #1 by herself. Resident #1 rolled out of bed and sustained laceration to his left eyebrow. Resident #1 was transferred to the hospital and was diagnosed with [REDACTED]. This resulted in acutual harm to Resident #1 that is not Immediate Jeopardy. The findings are: The Policy and Procedure titled Hoyer Lifter dated 6/1/2012 and revised on 05/13/2013 documented that a transfer with the aid of a Hoyer lifter was always a two person lift, at minimum. The procedure documented placing the sling under the resident by side-rolling the resident with at least 2 staff members. The Policy and Procedure titled Activities of Daily Living (ADL) dated 6/1/ 2002 revised on 03/31/2016 defined bed mobility as how a resident moves to and from lying position, turns side to side and positions body while in bed or chair. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE] documented the resident's cognitive status as being severely impaired. He required total assistance of 2 persons with bed mobility, transfer, dressing, toilet use and personal hygiene. Resident had impairment in range of motion on bilateral upper and lower extremity. The undated lesson plan titled Hoyer-Lesson Plan documented a procedure to complete a Hoyer transfer correctly and safely by placing sling with two assistants and placing resident on (Hoyer) sling by turning from side to side. The Fall Risk assessment dated [DATE] documented resident was at risk for falls. The Comprehensive Care Plan (CCP) titled Falls/Injury dated 06/04/2016 documented resident at risk for falls/injury related to history of falls, loss of voluntary movement, impaired balance, impaired gait and dementia. Interventions included to instruct/reinforce safety measures including transfer technique. The CCP titled ADLs dated 06/04/2016 included an intervention that the resident required total assist of 2 persons with personal hygiene. The Resident Nursing Instructions (Resident Care Plan-RCP) documented Resident #1 required 2-person total assistance for bed mobility and one-person physical assistance for personal hygiene. The interim physician order [REDACTED]. The Medical Progress Note (MPN) dated 12/19/2017 at 11:35 AM documented MD was called by the nurse because the patient had fall from his bed and he had injury and laceration on his temporal area. Resident was transferred to hospital for CT scan of the head specifically because resident was on [MEDICATION NAME] full dose blood thinner; to rule out intra-cranial bleeding. The NPN dated 12/19/2017 at 3:10 PM documented resident was called to resident's room by CNA to assess patient status [REDACTED]. Resident had a laceration to left eyebrow approximately ½ inches to ¾ inches and bleeding. The NPN dated 12/19/17 at 7:40 PM documented Resident was admitted to the hospital at 7:00 PM with [DIAGNOSES REDACTED]. The undated facility's Investigative Summary documented that on 12/19/2017 at 10:40 AM, the RN was called to evaluate Resident #1 since he was witnessed falling out of bed. Upon the RN's arrival to the room, the resident was lying on his left side, next to his bed and floor mat. According to the aide attending to the resident, she had just completed care on resident and was attempting to pace Hoyer pad under his body and he rolled off the air mattress and fell in between the bed and the floor mat. resident sustained [REDACTED]. The facility investigative summary also documented that the Certified Nursing Assistant #1 (CNA #1) was interviewed and ascertained that the resident required an assist of two for bed mobility and transfer per plan of care and resident care profile. The hospital Computerized Tomographic (CT) scan dated 12/20/17 documented new large left hemispheric intraparenchymal hemorrhage (intracranial bleeding). The hospital discharge summary dated 1/10/18 documented the patient was presented to the emergency room (ER) after a fall. CT showed very large subdural hematoma. The patient was admitted to the trauma service. On 12/25/17 patient with status pot traumatic head injury, underwent [MEDICAL CONDITION]. Final Diagnosis: [REDACTED]. The CCC was interviewed on 12/27/2017 at 11:37 AM and stated Resident #1 required total assistance of two persons for bed mobility (boosting and turning). On 12/19/17 around 10:30 AM CNA #1 came to her and told her that Resident #1 fell . Upon assessment Resident #1 was found to have a small laceration to his left eyebrow and was bleeding. He was non-verbal, awake and conscious. CNA #1 told the CCC that she was placing the Hoyer pad underneath Resident #1 and he rolled off the bed. The CCC stated that placing the Hoyer pad underneath a resident was considered bed mobility, CNA #1 was expected to have another person to assist for placing a Hoyer pad underneath Resident #1. CNA #2 was interviewed on 12/27/17 at 12:19 PM and stated that she had cared for Resident #1 occasionally. She checked the RCP to determine what care was needed for each resident assigned to her prior to providing care. Resident #1 required total assistance with all ADL care. CNA #2 stated that she checked the RCP for all care needs of each resident and followed the instructions provided in the RCP. CNA #2 stated when placing a pad underneath, Resident #1 required 2 persons assistance. CNA #2 stated that CNA #1 did not ask for her assistance for Resident #1's care on 12/19/2017. CNA #3 was interviewed on 12/27/17 at 12:28 PM and she stated that Resident #1 was not on her assignment, however, she assisted other CNAs providing care to Resident #1. CNA #3 stated that Resident #1 required two persons assistance with all ADL care. When providing personal hygiene care Resident #1 tightened up his body and that was why two people were needed to provide any care to him. CNA #3 stated that she checked the RCP for each assigned resident to ascertain their care needs prior to providing care. CNA #3 stated when placing a pad underneath, Resident #1 required 2 persons assistance. CNA #3 stated that CNA #1 did not ask for her assistance for Resident #1's care on 12/19/2017. CNA #4 was interviewed on 12/27/17 at 12:45 PM and stated CNA #4 stated when placing a pad underneath. Resident #1 required assistance of two persons. CNA #4 stated that CNA #1 did not ask for her assistance for Resident #1's care on 12/19/2017. LPN #2 was interviewed on 12/27/2017 at 1:30 PM, she stated Resident #1 was not on her assignment and she was administering treatment with another resident when the a CNA called her name and told her that the CCC needed her in Resident #1's room. Upon entering Resident #1's room she observed Resident #1 laying on the floor with small amount of blood on the floor. She assisted the CCC and transferred Resident #1 back to bed. LPN #2 called the MD (physician). LPN #2 stated that CNA #1 did not ask for her assistance with Resident #1. The Director of Nursing (DON) was interviewed on 12/27/2017 at 3:49 PM. The DON stated that the staff including CNA #1 were in-serviced and had demonstrated proper procedures regarding Hoyer lift transfers on 12/4/17. The DON stated that he was notified of the incident on 12/19/17. Upon investigation the facility concluded that the plan of care for Resident #1 was not followed by CNA #1. The DON stated that during reenactment of the incident CNA #1 placed the Hoyer pad underneath Resident #1 by herself. The DON stated CNA #1 was aware that Resident #1 required 2 persons assistance with bed mobility and transfers. The DON stated that CNA #1 did not follow the plan of care and was suspended and was going to be terminated. CNA #1 stated to the DON that she did not believe she needed two persons assistance because she was not transferring the resident but was placing the Hoyer sling under Resident #1. The DON stated the Hoyer lift competency that was completed on 12/4/2017 documented that when placing sling under a resident, 2 persons assistance was required. The competency record was signed by CNA #1. The Primary Care Physician (PCP) was interviewed on 1/2/18 at 1:08 PM, and stated that he was the assigned PCP for Resident #1. On 12/19/17 he got a call from a nurse who informed him that Resident #1 had fallen and hit his head. The PCP stated that he worried about intracranial bleeding because Resident #1was on [MEDICATION NAME] and he ordered to transfer Resident #1 to the hospital for a CT scan. After 3 hours, he called the ER (emergency room ) to follow up on CT scan result. The ER staff informed him that CT scan revealed subdural hematoma. The facility was later informed by the hospital that Resident #1 (date not recalled) passed away. 415.4 (b)

Plan of Correction: ApprovedMarch 14, 2018

The Medford Multicare Center (MMC) for Living submits that its policies, procedures and systems are in place to ensure resident environments are free from accident hazards and they receive adequate supervision to prevent accidents. This Plan of Correction is required by federal and state regulations and is not to be construed as an admission that the cited deficiencies are accurate or that at the time of the survey the facility did not have policies, procedures and systems in place to maintain compliance with all requirements. In an effort to enhance the care furnished to our residents, we have augmented some of our existing policies, procedures and systems.
Corrective action(s) for resident(s) affected:
Resident #1 is no longer at the facility.
CNA #1 was terminated from MMC.

Identification of residents that could be affected by the deficient practice:
All residents requiring a two person assist in bed or for bed mobility that the potential to be affected by this practice.
All residents currently residing in MMC will be reassessed for bed mobility.Systemic Measures to prevent recurrence:
All clinical staff; Nurses, CNAs and therapists will be educated by
William Poscocello, Consultant, on 3.16.18 & 3.21.18 on each shift following a Department Head on 3.16.18:
? The revised policy & procedure including the on the new RED # 2 symbol created in the electronic medical record;
? The need to follow care plan and CNA instructions re: all aspects of care for a resident, including but not limited to the number of assists for bed mobility, transfers and assistance for care;
? Need of 2 assistants for every resident requiring a mechanical lift AND including placing the resident on the ?lift pad? under the resident prior to transfer;
? Potential risks to resident(s) and/or staff if policy/procedure is not followed;
? Clinical Care Coordinators (CCC?s) will be responsible for maintaining and updating the alert as needed per the revised Policy & Procedure.
? Educator will have participants complete a post-test with group discussion to ensure understanding of revised policy & procedure.
A RED # 2 symbol was added to the electronic medical record (EMR) and the CNA assignment indicating a two (2) person assist is required for bed mobility.
All new admissions will be assessed in accordance with policy and procedures and include bed mobility and transfer assistance and will be reflected in each residents individual care plan for the within the first 24-48 hours of admission.
Quality Assurance & Improvements with Ongoing Monitoring:
The Assistant Director of Nursing and/or designee will conduct an initial audit on 100% of the residents records requiring a two person assist with bed mobility to:
? Ensure compliance with the new policy/procedure;
? Ensure the RED # 2 symbol is in
the EMR per the revised Policy & Procedure;
The Assistant Director of Nursing and/or designee will complete and audit of 25% sample every month for three months and quarterly thereafter.
? All deficiencies will be corrected immediately;
? 1:1 employee education will be completed at the time a deficiency is identified.

The CCC?s/Designee will conduct an observational audit on 50% on all residents requiring two person assist with bed mobility/transfer every week for one month and every 3 months thereafter until 100% compliance is achieved.
The DNS/ Designee will report findings of the audits at the monthly QAPI meeting.

Responsible Person: Director of Nursing
Completion Date: 4/26/2018