IDR Committee Meeting-January 2020

IDR Meeting 1-8-20

F 600 D Residents have the right to be free from abuse. Per discussion there were not any person centered, individualized interventions added to female residents care plan after a male resident grabbed her. Staff was not aware of the incident, per surveyor interviews, and the female resident expressed ongoing worry that the male resident would approach her again. Sustained

F 600 IJ Right to be free from abuse. Alleged non-compliance placed residents at serious risk and there was need for immediate action to relieve the risk. Resident was resistive to ADL care. CP directed that if resident refused care to leave her alone and return later. Per discussion CNA #3 placed resident on bed pan against her will and resident reported to second CNA that CNA #3 tried to choke her. CNA #3 continued to provide care to other residents, without additional supervision, following the allegation of abuse. Sustained

F 692 H Ensure nutritional status be maintained unless otherwise indicated by medical condition. Per discussion one resident removed his G tube and the facility did not provide sufficient interventions to nutritionally support resident without tube feeding. A second resident with the diagnosis of dementia did not receive enough support at meals, as called for in CP, to maintain nutritional status.  A third resident, totally dependent on staff assistance for meals did not receive needed assistance nor was resident provided supplements. Sustained

F 604 D Protect residents from physical restraints. Facility admitted resident that used a lap belt in wc related to spastic cerebral palsy diagnosis. Facility failed to get an order for belt, care plan for belt and assess the safety of belt use. Sustained

F 658 D Services that meet professional standards. Resident that received dialysis had an order to notify Doctor if resident gained 3 pounds in 24 hours or 5 pounds in a week. Although the resident did gain weight that met the directive of the order, the facility did not notify Dr as they stated it was related to the dialysis schedule and the weight reduced following dialysis. Per discussion the order should have been dc’d or followed. Sustained

F584 D Protect property from loss or theft. The facility did not inventory resident’s personal belongings. Resident discharged to the hospital, family filed a missing property report several days later for resident’s hearing aids. Family had filed grievances while resident was in nursing home, therefore had knowledge of the process. Committee discussion determined the time lapse between discharge and report was too long and did not allow facility to properly investigate. Deleted

F 692 G Provide sufficient fluids to maintain hydration. Resident had feeding tube and depended on staff to administer fluids to maintain hydration. Resident had change in mentation and upon assessment, at hospital, was found to be dehydrated. Sustained

F 657 D Resident sustained several falls and yet CP was not updated with new approaches to try and avoid future falls. Sustained

F 725 E Sufficient staff to meet resident needs. Residents reported long call light wait times, missed showers and performing tasks that were care planned to be provided by staff. Acuity in facility was high and although they averaged 4.31 PPD, deficiency sustained based on resident interviews.  Sustained

F 756 D Drug regimen review requirement.  Although the facility did have drug regimen reviews, the recommendations were not always followed up on in a timely manner. One review performed on Nov. 13 had not been addressed when surveyor found the recommendation on Nov. 20.  Sustained

F 610 D Free from abuse. Resident was found with three quarter size bruises in thigh which apparently occurred when CNA spread resident legs to provide care. Although resident CP called for “allowing time for resident to perform tasks” there was no evidence that CNA was aware of that plan. Facility did not investigate the bruises or interview other residents regarding treatment. Sustained

F 745 D Resident wanted to leave facility just after admission, said he would jump out the window if necessary. Facility did not provide mental health support or additional supervision to ensure resident was safe. Per committee discussion there was no evidence this resident was threatening to commit suicide, he was just spouting his anger at being in the facility. Deleted

F 880 E Infection Control  Surveyor observed staff using a gate belt with several residents and not disinfecting between uses. Per committee discussion it might be best practice to have single use gate belts but using a belt without disinfecting was not deemed to be an IC risk. Deleted

F 692 G Maintain Nutritional Status Resident had documented weight loss. There was no documentation of physician notification. Resident was a Hospice patient and weight loss can often be expected. Per committee discussion there was comprehensive note submitted from physician after the facility was cited that helped explain the weight loss. Committee agreed the physician’s note should have been in the chart before deficient practice was cited. Deficiency sustained but downgraded to a “D”

Please note that in almost every review the failure to update CP or document seemed to be at the heart of the issue.  F 725, insufficient staff, is low lying fruit for the surveyors. It might seem like overkill but several communities are reporting success through interviewing their residents weekly in an attempt to hear their perception of timely care. Note in F692, above, a resident receiving Hospice care had a weight loss, likely expected, but there was not documentation to that effect nor was there documented physician notification.

CHCA will be hosting a “Care Planning and Documentation” intensive on February 25, 2020.