February IDR Committee Notes

IDR Committee Meeting 2-4-20

F 561 E Promote Self-Determination through Resident Choice   Sustained

Two residents left facility to attend a luncheon. They did not sign out or notify facility that they were leaving. Facility notified police and was looking for the two. Upon return to the facility the residents expressed displeasure with the policy requiring them to sign out and the need for a practitioners order.  They stated the policy treated them like children. Sustained                                                                                  The three nursing home representatives on the committee voted to delete this stating that facilities are required to ensure the safety of their residents. Simply requiring that they sign out was not infringing on their rights but rather ensuring the facility the ability to oversee their safety. It is of note that one of the two residents was sent to the ER related to his diabetes shortly after returning to the facility.

F 584 E Promote a Homelike Environment    Sustained

Per committee discussion the facility only had one towel rack for two residents and did not provide towels except by request to residents. Facility claimed that paper towels were provided for daily use and fabric towels were available for showers and when needed. Resident claimed that there were time they could not shower because they did not have a towel. The committee unanimously determined that based on resident reports the deficiency should be sustained.

F 600 D Ensure the Resident’s Right to be Free from Abuse   Sustained

Per committee discussion the facility failed to report or investigate a male resident’s touching of a female resident’s buttock and breasts due to his cognitive impairment. The committee unanimously sustained the deficiency.

F610 D Evidence That all Allegations of Abuse are Investigated    Sustained

Per committee discussion a female resident reported two separate incidences of other residents saying unkind words to her. Resident was upset by the incidents and began self-isolating. Facility did not investigate because they did not feel it was verbal abuse they felt it was hurt feelings.

F 677 D Ensure that residents receive the necessary support with ADLs.   Sustained

Per committee discussion surveyor observed resident in DR who per care plan required assist with eating, per surveyor observation the resident did not receive any eating assist throughout survey. The same resident was observed to have dark matter under her nails throughout the survey. The committee voted unanimously to sustain.

F 679 D Program to Support Residents to Pursue Activities of Interest   Sustained

Per discussion facility failed to offer person centered activities to one resident who was blind. Facility had audio books but did not have documentation that other engagements were offered to resident.

F 688 D Resident with limited ROM should receive services to avoid decline. Sustained

There was no documentation to support that one resident, who was in a vegetative state, received passive ROM or exercises to upper and lower extremities. The committee unanimously sustained the deficiency.

F 689 J Environment Should Remain Free of Accident Hazards   Sustained       Reduced to G level.

One resident sustained 25 falls in a 6 month period. The facility addressed the falls however could not stop the falls. The facility performed over 82 medication reviews, had several PT and OT evals and provided 1 to 1 supervision for a period of time during which the resident continued to fall. Resident had dx of dementia and neuropathy and per discussion restraining the resident would likely be the only way to keep him from falling.  Committee felt that additional investigation should have been performed after each fall along with a root cause analysis to see if they could prevent some of the falls. Please note: Although the IDR committee voted to reduce to a “G”, The Department overturned that decision and changed it back to a “J”.

F 697 D  Pain Management  Sustained

Resident stated to surveyor that he had requested non-pharmacological interventions to help with his pain. There was no evidence that any non-pharm approaches were offered or tried with this resident.

F725 E Sufficient Staff to Meet the Acuity Needs of Their Residents.  Sustained

Several residents reported long wait times for call light response. One resident stated there was no help available between 7:30 and 9:30 in the morning.

F 759 E Medication Error Rate Must Be Below 5%.    Sustained

Two of 25 medications administered were in error. Insulin that was ordered for 8am was administered after breakfast and a topical applied to an ear lobe had no physicians order.

F865 G Maintain Effective QA to Identify and Address Areas of Concern   Sustained Reduced to “D”

Per discussion, although there was no data driven analysis there was evidence of improvement in some areas, such as a decrease in falls. The facility had some action plans in place and although several of the deficiencies are repeat, there appears to be some improvement.

F 552 D Protect the right to be informed of care and risk before changing the treatment plan. Sustained

Per discussion the facility failed to inform MDPOA of a medication reduction prior to implementing that change.

F 610 D Investigate allegations of abuse. Sustained

Resident sustained a skin tear during transfer that resident said caused pain. The facility brought CNAs into resident to help identify the CNA that transferred her. Resident stated that was upsetting to her, and that she never heard anything more about it from facility. Facility stated they interviewed and questioned residents and staff but had no documentation of those and could not recall time frame.

F 689 G Free from accident hazards. Sustained

Resident sustained facial burn from smoking with O2 on. Facility was aware that resident had smoked with O2 on in the past and yet did not complete smoking assessment, develop care plan or provide supervision.

F 791 D Assist residents with getting dental care as needed.  Sustained

Resident readmitted to facility from hospital had apparently lost denture in hospital. Family claimed they alerted SS to the missing denture however no dental referral was made until 20 days after readmit, when resident reported to surveyor that she was missing denture. Per discussion resident was A & O Xs 3 and performed her own dental care.