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Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: December 10, 2024
Corrected date: February 10, 2025
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during an abbreviated survey (NY 935), the facility did not ensure a resident received treatment and care in accordance with professional standards of practice necessary to maintain or improve the resident's highest practicable physical, mental, and psycho-social well-being. This was evident for 1 of 3 residents (Resident #1) reviewed for quality of care. Specifically, it cannot be determined that Resident #1 who had a deteriorating pressure ulcer of the right heel was assessed weekly by a qualified professional between 9/29/22 and 11/23/ 22. In addition, there was no evidence that the Physician was notified of the deteriorating status of the wound, or any new interventions were applied to prevent stabilize the pressure ulcer during this period. The findings are: The facility Policy and Procedure titled Administration of Treatments with a revision date of 5/30/2022 documented the purpose of the policy is to provide proper and timely care to residents in keeping with accepted nursing practice. Nurses should document in Nurse's Notes when treatments are done, result of treatment, how resident tolerated treatment. Resident #1 was first admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS - a resident assessment tool) dated 7/13/22 documented Resident #1 had a BIMS score of 9, indicating moderate cognition impairment. Resident #1 required two-person physical extensive assist for bed mobility and toileting. Resident #1 was at risk for developing pressure ulcers, had 1 unhealed pressure ulcer, had 2 unstageable pressure injuries presenting as deep tissue injury (DTI), and had Moisture Associated Skin Damage (MASD). The Braden assessment dated [DATE] documented Resident #1 was at mild risk (17) for pressure ulcers. Review of Vohra Wound Physicians progress note dated 9/21/22 documented Resident #1 wound size 1. 5 x 2. 0 x Not Measurable cm. Resident #1 was not seen on 9/28/22 due to hospitalization for Covid. Resident #1 returned to the facility on ,[DATE]/ 22. There were no weekly wound care progress notes between 9/29/22 and 11/23/ 22. Review of wound physician progress notes [REDACTED].#1 wound as unstageable DTI of the right heel full thickness. Wound size was 5. 5 x 6. 4 x Not Measurable cm and assessed with [REDACTED]. Wound progress was noted as deteriorated. Review of the facility Wound Round log for dates 10/17/22, 10/24/22, 11/4/22, and 11/18/22 documented wound progress as not improving. There was no log documented for 11/11/ 22. There is no documented evidence of who assessed the resident, any changes made in treatment to address deterioration, and if the MD was notified of the condition of the wound Review of the (MONTH) 2022 and (MONTH) 2022 Treatment Administration Record (TAR) documented no evidence that changes were made to pressure ulcer treatment. Review of Pressure Ulcer/Injury Comprehensive Care Plan (CCP) dated 7/26/22 documented Resident #1 was at risk for skin breakdown. Resident #1 will be maintained with current skin integrity as evidenced by freedom from skin breakdown. Treatment Interventions included Certified Nursing Assistant (CNA) evaluation of skin condition daily during care, off load extremities, and provide incontinent care. The care plan did not address the wound care consult treatment recommendations. During an interview on 5/18 at 12:46 PM, the administrator stated if the resident was not seen by the wound care physician it may have been due to Covid. However, there is no evidence in the EMR that the resident had Covid during this period. During an interview conducted with the Unit Manager (UM) on 5/18/23 at 12:47 PM, UM stated they could not find any documentation regarding Resident #1 having covid after 10/12/ 22. Resident #1 was on quarantine following hospitalized from [DATE] to 10/12/ 22. As per the UM, residents should still be assessed by an RN or physician weekly even if they have tested positive for COVID. During a follow up interview on 5/19/23 at 8:44 AM, UM confirmed there are no progress notes in the medical record written by RN or NP measuring wound size and documenting condition of wound. There are also no progress notes informing MD that the condition of the wound worsened. During a follow up interview conducted with the UM on 5/25/23 at 11:52 AM, the UM stated the floor nurses are responsible for completing the Wound Round Progress log. The floor nurse also assesses the wound with the wound care doctor. However, there were no physician notes to corroborate the dates of the Wound Round Progress logs on (10/17/22, 10/24/22, 11/4/22 amd 11/18/22) completed for Resident# 1. 483. 25 (b)(1) | Plan of Correction: ApprovedDecember 27, 2024 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. Corrective Action for Affected Resident/Area A. Immediately after the incident, Resident #1 was assisted to safety on the Unit for RN Assessment. Resident #1 refused the body check, but the Supervisor reported that no visible injury was noted and there were no complaints of pain. The Designated Representative was informed and the Physician Ordered to transfer the Resident out to the Hospital for further evaluation of uncontrolled agitative behavior. The Security Guard, who did not follow the Facility's Policy and Procedure for Abuse Prohibition??ÿ was immediately removed from duty and his assignment at the Home was terminated by the Contract Vendor. B. Immediately after the incident, Resident #4 was assessed by the RN. There were no visible signs of injury or complaints of pain reported. The Certified Nursing Assistant who did not follow the Facility's Policy for Abuse Prohibition??ÿ was immediately removed from direct Resident care duties and placed on Administrative Leave pending an Investigation. II. Identification of other Areas/Residents Potentially Affected. ??? The Facility respectfully states that no other residents were identified with Abuse, Neglect, or Mistreatment concerns. The Director of Nursing/Designee performed an Audit of all other residents, to ensure that they have an Abuse Prevention/Prohibition and Resident Centered Care Plan in place. Any Resident identified with missing alleged Abuse Care Plans will be promptly updated. ??? The Facility will provide comprehensive Abuse prohibition??ÿ re-training for all staff members to effectively manage and support residents exhibiting behaviors associated with dementia and other behaviors. Rein-service/Competency will continue until all employees are re-trained. III. Address what measures will be put in place or Systemic Change made to ensure that the Deficient practice will not Recur/System change and Measure to prevent Recurrence. ??? The Facility changed the Systems for monitoring Abuse Prohibition??ÿ to include a process that during Shift Change Huddles, the Charge Nurse will also reinforce adherence to the Abuse Prohibition??ÿ Policy and practices and remove triggers for residents who have potential for escalating verbal outburst or violent physical aggression. ??? The Home will select front-line staff to serve as ambassadors in specialized Dementia Care and Behavioral Management, who will provide support and guidance to other team members. ??? The Facility's Policy and Procedure for Abuse Prohibition??ÿ was reviewed by the Acting Administrator and was found to be compliant. All current employees will be rein-serviced immediately on the Policy and annually thereafter. New employees will be In-service during Orientation. Lesson Plan will include, but will not be limited to: ??? The Facility will not knowingly and intentionally hire individuals found guilty of Abuse, Mistreatment of [REDACTED]. ??? Employees shall adhere to the reporting mechanism as outlined in the law and regulations. ??? Employees are made aware that any derogatory language or remarks towards Residents and any other potential Abuse, Neglect issues will lead to immediate suspension/termination. ??? The Facility will train staff to safely care for combative residents, emphasizing de-escalation techniques and ensuring that they do not retaliate to physical aggression. ??? The Facility requires that Potential Abuse cases are reported and investigated immediately once brought to the attention of a Supervisor. ??? Employees are instructed on appropriate and safe interventions of care to be used with aggressive residents with behaviors. ??? Employees shall report occurrences that may be interpreted as acts of Abuse, Neglect, Mistreatment, Adverse Event, Exploitation and Misappropriation of Residents Property. ??? Ensuring staff understanding of Residents' behaviors that could lead to physical violence, and Behavioral Management measures to de-escalate such behaviors. ??? Licensed staff members are educated on how to document and fully describe unusual events that could be interpreted as a situation of Potential Abuse. ??? Administrative Management and Supervisory personnel monitor staff interaction with residents on an ongoing basis to ensure residents' safety. In-service and Competencies will be filed in the employees Personnel History Folder for reference and validation. IV. How does the Facility plan to monitor its performance to make sure that Solutions are Sustained/Monitoring of Corrective Actions ??? The Director of Nursing and the Director of Social services developed an Abuse Prohibition Compliance Audit Tool??ÿ to identify high risks resident for alleged potential abuse, and staff interventions for such behaviors. ??? The Audit Tool will be used Daily by the Associate Director of Nursing/Designee and the Social Workers/Designee, to monitor and document alleged cases of Potential Abuse, Neglect, Mistreatment, Adverse Event, Exploitation and Misappropriation of Residents Property. Any case found out of compliance will warrant an immediate on the spot correction/rein-service by the Supervisor, followed by a formal Report, employee Statements, and an Investigation. ??? The Director of Nursing and the Director of Social Services will review the Audit Tool Weekly for compliance. The Tool will be filed in a Binder in the Nursing Administration Office after it is reviewed, for reference and validation. 1V. QA Monitoring ??? The person responsible to correct this issue is the Director of Nursing and the Director of Social Services. The Associate Director of Nursing/Designee will report findings Monthly to the QAPI Committee for 12 Months. |