Wisconsin Department of Health Services C 12/13/2016

Transcription

1 (X1) PROVER/SUPPLIER/LIA ENTIFIATION NUMBER: (X3) SURVEY D NAME OF PROVER OR SUPPLIER PRAIRIE RGE ASSISTED LIVING (X4) REGULATORY OR LS ENTIFYING INFORMATION) PROVER'S PLAN OF ORRETION N 000 Initial omments N 000 Surveyor: On 12/01/2016, Surveyors and X0123 conducted a complaint investigation at Prairie Ridge Assisted Living. Five deficiencies were identified. The complaint was substantiated. ensus: 21 N (2)(a) aregiver: Investigating abuse & neglect N 158 Investigating and reporting abuse, neglect, or misappropriation of property. aregiver. 1. When a BRF receives a report of an allegation of abuse or neglect of a resident, or misappropriation of property, the BRF shall take immediate steps to ensure the safety of all residents. 2. The BRF shall investigate and document any allegation of abuse or neglect of a resident, or misappropriation of property by a caregiver. If the BRF ' s investigation concludes that the alleged abuse, or neglect of a resident or misappropriation of property meets the definition of abuse or neglect of a resident, or of misappropriation of property, the BRF shall report the incident to the department on a form provided by the department, within 7 calendar days from the date the BRF knew or should have known about the abuse, neglect, or misappropriation of property. The BRF shall maintain documentation of any investigation. This Rule is not met as evidenced by: Surveyor: Based on interview and record review, the facility LABORATORY DIRETOR'S OR PROVER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) If continuation sheet 1 of 16

2 (X1) PROVER/SUPPLIER/LIA ENTIFIATION NUMBER: (X3) SURVEY D NAME OF PROVER OR SUPPLIER PRAIRIE RGE ASSISTED LIVING (X4) REGULATORY OR LS ENTIFYING INFORMATION) PROVER'S PLAN OF ORRETION N 158 ontinued From page 1 N 158 did not ensure an allegation of caregiver misconduct was reported to the Department on a form provided by the Department within 7 calendar days from the date the facility knew or should have known about the allegation. The facility identified an allegation of caregiver misconduct on 11/18/2016. This allegation was not reported to the Department. Findings include: On 12/1/2016, Surveyors and X0123 conducted an on-site complaint investigation. This complaint alleged concerns of medication errors conducted by aregiver. During this review, Administrator A disclosed to the survey team that he was investigating an allegation of caregiver misconduct involving aregiver and Resident 1. Administrator A informed Surveyors (21806 and X0123) that he began his administrative duties on/around November 16, On 11/18/2016, he had received a note indicating that on 10/3/2016, aregiver struck Resident 1 on his/her hand, yelled and then later that same evening, aregiver reportedly removed Resident 1's cane from his/her possession. Surveyor questioned as to why there was a delay in the investigation. Administrator A stated that he couldn't find any indication that the previous administrator began or documented an investigation from the October incident, so after receiving the report on 11/18/2016 and then a second report on 11/23/2016, indicating that aregiver had been sleeping on the job, Administrator A and are oordinator D began investigating both incidences. If continuation sheet 2 of 16

3 (X1) PROVER/SUPPLIER/LIA ENTIFIATION NUMBER: (X3) SURVEY D NAME OF PROVER OR SUPPLIER PRAIRIE RGE ASSISTED LIVING (X4) REGULATORY OR LS ENTIFYING INFORMATION) PROVER'S PLAN OF ORRETION N 158 ontinued From page 2 N 158 Surveyor questioned Administrator A as to the facility policy for protecting residents during an abuse investigation. Administrator A stated, "I should have taken her right off the schedule and suspended her. With all the changes I thought staff were out to get her, staff didn't like her. I normally suspend and then continue with the investigation. We did meet with her and at first she denied slapping (Resident 1), but then later she thought maybe she did hit (his/her) hand. (aregiver ) did admit she took the cane away, because she claimed (Resident 1) struck her with it." Surveyor questioned if aregiver was still employed by the facility. Administrator A stated, "Yes." Surveyor requested to review aregiver 's timesheet's from 11/18/16-11/30/16. Upon review, it was noted that during this 12 (twelve) day period, aregiver worked a total of 14 (fourteen) shifts. On 12/1/2016 during the facility exit, Surveyor discussed the 10/3/2016 witnessed allegation received by Administrator A on 11/18/16 and expressed concerns that the facility did not report this allegation, did not begin an investigation until after receiving another concern (11/23/2016) regarding aregiver sleeping and did not take immediate steps to ensure the safety of all residents following their knowledge of potential misconduct. Administrator A stated, "We plan on terminating (aregiver 's) employment." On 12/06/2016 the Department received a If continuation sheet 3 of 16

4 (X1) PROVER/SUPPLIER/LIA ENTIFIATION NUMBER: (X3) SURVEY D NAME OF PROVER OR SUPPLIER PRAIRIE RGE ASSISTED LIVING (X4) REGULATORY OR LS ENTIFYING INFORMATION) PROVER'S PLAN OF ORRETION N 158 ontinued From page 3 N 158 'self-report' regarding the allegations pertaining to aregiver. In this report, Administrator A indicated that aregiver was terminated on 12/2/2016. On 12/12/2016, Surveyor contacted are oordinator B and inquired if the facility filled out the required Department form, aregiver Misconduct Incident Report, #F-62447, and submitted that to the Department. are oordinator B informed Surveyor that she wasn't sure, but she would let Administrator A know how to access the forms. On are oordinator B informed Surveyor that Administrator A did find the correct forms and would be filling them out as required. Summary The facility did not ensure an allegation of caregiver misconduct was reported to the Department on a form provided by the Department within 7 calendar days from the date the facility knew or should have known about the allegation (5)(a) Notification: incident, injury, changes. The BRF shall immediately notify the resident's legal representative and the resident's physician when there is an incident or injury to the resident or a significant change in the resident's physical or mental condition. If continuation sheet 4 of 16

5 (X1) PROVER/SUPPLIER/LIA ENTIFIATION NUMBER: (X3) SURVEY D NAME OF PROVER OR SUPPLIER PRAIRIE RGE ASSISTED LIVING (X4) REGULATORY OR LS ENTIFYING INFORMATION) PROVER'S PLAN OF ORRETION ontinued From page 4 This Rule is not met as evidenced by: Surveyor: Based on observation, interview and record review the facility did not immediately notify a resident's physician when there was an incident or injury to the resident or a significant change in the resident's physical or mental condition for one of two (Resident 3) sampled residents. Findings include: On 10/28/16, the Department of Health Services (the Department) received a complaint alleging concerns including lack of personal cares and lack of toileting which resulted in a resident 'getting rashes.' On 12/1/2016, Surveyor and X0123 conducted a complaint investigation. The resident identified in the complaint is no longer residing at the facility, that resident is deceased. During the facility entrance, Surveyor questioned and reviewed with staff those residents requiring staff assistance for toileting needs and personal cares. Resident 3 was identified as someone requiring assistance with toileting and identified as currently having 'a patch on his/her bottom.' Observation On 12/1/2016 at 9:37 AM, Surveyors and X0123 observed aregivers E and F assist Resident 3 with toileting needs. Surveyor noted tremors in Resident 3's bilateral upper and lower extremities with constant trunk movements. This movement causes stress on the skin, which can contribute to pressure injuries. If continuation sheet 5 of 16

6 (X1) PROVER/SUPPLIER/LIA ENTIFIATION NUMBER: (X3) SURVEY D NAME OF PROVER OR SUPPLIER PRAIRIE RGE ASSISTED LIVING (X4) REGULATORY OR LS ENTIFYING INFORMATION) PROVER'S PLAN OF ORRETION ontinued From page 5 During this toileting task, Resident 3 stood and aregiver E lowered Resident 3's clothing in preparation for toileting. Surveyor noted an intact dressing to Resident 3's upper coccyx/buttock region. aregiver E removed this dressing. Surveyor noted Resident 3's upper coccyx/ buttock area, the right side upper coccyx/buttocks with scattered excoriated red areas and left side of upper coccyx/buttocks with several scattered open areas. Upon completion of toileting, Resident 3 stood while aregiver E cleansed her/his buttock region, dried the areas, applied a topical barrier cream to both buttocks areas and then applied an Optifoam gentle adhesive dressing to Resident 3's upper right coccyx/buttock. aregiver E did not apply a dressing to the left buttock region, which had scattered open pressure injuries. aregiver F questioned if aregiver E was going to apply a dressing to Resident 3's left buttock region. aregiver E stated, "We only have the one, that's where I put it this morning." Record review Resident 3 was admitted to the facility in December 2014 with diagnosis including Parkinson's disease and restless leg syndrome. Resident 3 receives Hospice services. Resident 3 relies on caregivers for assistance with all activities of daily living. Resident 3's ISP (Individual Service Plan), dated 9/15/2016, includes: Other - cleanse coccyx wound daily with soap and water, pat dry and apply wound dressing daily... If continuation sheet 6 of 16

7 (X1) PROVER/SUPPLIER/LIA ENTIFIATION NUMBER: (X3) SURVEY D NAME OF PROVER OR SUPPLIER PRAIRIE RGE ASSISTED LIVING (X4) REGULATORY OR LS ENTIFYING INFORMATION) PROVER'S PLAN OF ORRETION ontinued From page 6 Upon record review, Surveyor could not locate a physician notification or physician order for treatments related to Resident 3's open pressure injuries. Surveyor asked are oordinator B for physician orders related to Resident 3's wound care. are oordinator B could not locate the orders. Surveyor reviewed Resident 3's MAR (Medication Administration Record) for November Noted scheduled medications/treatments included: Wound dressing to coccyx. Start date - 5/17/2016. Also noted were entries for 11/26 AM and 11/29/16 AM, with both entries indicating - Wound dressing to coccyx - "not needed" there was no additional documentation or narrative regarding why the dressing was 'not needed.' While the facility staff noted on 11/29/2016 that the wound dressing to coccyx was 'not needed,' a hospice aide visit note, dated 11/29/2016, indicated: Pain - yes - coccyx...narrative note: (text message) RN notified of sore on pts (patient) coccyx starting to reopen, pt c/o (complain) pain from coccyx... Interviews On 12/1/2016 at 2:50 PM, Surveyor met with Resident 3. Surveyor noted extreme involuntary movements of Resident 3's upper/lower extremities. Surveyor questioned if Resident 3 was experiencing pain. Resident 3 stated, "bad, bad, sore butt, when I sit down, it's sore." During the facility exit, Surveyors reviewed concerns regarding Resident 3's open areas, pain related to those areas, staff application of a dressing to one area, but not the area where If continuation sheet 7 of 16

8 (X1) PROVER/SUPPLIER/LIA ENTIFIATION NUMBER: (X3) SURVEY D NAME OF PROVER OR SUPPLIER PRAIRIE RGE ASSISTED LIVING (X4) REGULATORY OR LS ENTIFYING INFORMATION) PROVER'S PLAN OF ORRETION ontinued From page 7 open areas (Stage II) were noted and if Resident 3's physician was contacted for potential treatments/orders. are oordinator B stated, "I did not call the physician. The Hospice aide contacted the nurse and we were instructed to put a patch on it." Summary Resident 3 has impaired mobility, tremors and a history of pressure injuries. Hospice staff identified a 'reopening' to Resident 3's coccyx area. While the facility indicates that a Hospice nurse instructed the staff to place a 'patch' on the wound. Facility staff applied a dressing to one area (right side), but not the area where open areas (Stage II) pressure injuries (left side) were noted and Resident 3's physician was not contacted for potential treatments/orders. N (2)(e) Notify within 7 days of administrator change N 200 The licensee shall notify the department within 7 days after there is a change in the administrator. This Rule is not met as evidenced by: Surveyor: Based on record review and interview, the Licensee did not notify the Department within 7 days after there was a change in the administrator. Findings Include: On 12/1/16, Surveyors and X0123 conducted a complaint investigation at the facility. During the entrance meeting, are oordinator B If continuation sheet 8 of 16

9 (X1) PROVER/SUPPLIER/LIA ENTIFIATION NUMBER: (X3) SURVEY D NAME OF PROVER OR SUPPLIER PRAIRIE RGE ASSISTED LIVING (X4) REGULATORY OR LS ENTIFYING INFORMATION) PROVER'S PLAN OF ORRETION N 200 ontinued From page 8 N 200 commented that the facility had a new administrator, (Administrator A), and that he had been hired approximately two weeks prior. Surveyor then met with Administrator A who confirmed that he began employment approximately 2 weeks ago (November 16th). Surveyor informed Administrator A that the Department did not receive, nor did it have documentation from the Licensee indicating a change in administrator status. As of, the Department had yet to receive notification regarding a change in the administrator for this facility. Summary The facility Licensee did not notify the department within 7 days after Administrator A assumed the role of administrator for the facility (3)(h) Rights of Residents: Receive medication In addition to the rights under s , Stats., each resident shall have all of the following rights: Receive medication. Receive all prescribed medications in the dosage and at intervals prescribed by a practitioner. The resident has the right to refuse medication unless the medication is court ordered. This Rule is not met as evidenced by: Surveyor: Based on record review and interview, the facility did not ensure that 4 of 4 (Residents 4, 5, 6 and 7) sampled residents received medications in the dosage and at intervals as ordered by a If continuation sheet 9 of 16

10 (X1) PROVER/SUPPLIER/LIA ENTIFIATION NUMBER: (X3) SURVEY D NAME OF PROVER OR SUPPLIER PRAIRIE RGE ASSISTED LIVING (X4) REGULATORY OR LS ENTIFYING INFORMATION) PROVER'S PLAN OF ORRETION ontinued From page 9 practitioner. Findings include: On 8/29/2106, Department received a complaint alleging concerns including medication errors and residents not receiving their medications as prescribed. On 12/1/2016, Surveyors and X0123 conducted a complaint investigation. Resident 4, as identified in the complaint, no longer resides at the facility. Resident 4 was discharged in August On 12/1/2016 at 10:55 AM, Surveyor reviewed concerns related to medication errors and omission of medications with Administrator A and are oordinator B. During this review, are oordinator B acknowledged medications concerns and stated, "We noticed an increase in errors and we realized we needed to make changes." Administrator A and are oordinator B indicated that they had been in their perspective positions/roles for approximately 2 weeks. During this time, Administrator A and are oordinator B acknowledged a noted "increase" in medication error reports and because of this increase, the management team decided they "needed to do something." Administrator A stated, "We noticed significant errors, including back in July when (Resident 2) received the wrong medications. That was significant. Lots of things fell through the cracks and needed to be addressed." If continuation sheet 10 of 16

11 (X1) PROVER/SUPPLIER/LIA ENTIFIATION NUMBER: (X3) SURVEY D NAME OF PROVER OR SUPPLIER PRAIRIE RGE ASSISTED LIVING (X4) REGULATORY OR LS ENTIFYING INFORMATION) PROVER'S PLAN OF ORRETION ontinued From page 10 Administration A also stated, "(aregiver ) will be terminated." Surveyor questioned if the termination was related to the med error in July. Administrator A responded, "Yes that and she was caught dozing on the job, we are investigating that now." Surveyor requested to review medication occurrence/error reports pertaining to Resident 4 and any other recent medication error reports, specifically omission of medications. The following errors were identified: Resident 4 * 8/20 and 8/21/ Noon - Gabapentin 600 mg (pain medication) - Medication charted but not given. * 8/20/ PM - Oxycodone/APAP - 7/5 mg mg (pain medication) - Medication charted but not given - Other - forgotten. There was no documentation to indicate that Resident 4's physician was notified of the medication omission error. Resident 5 * 11/22/ :00 PM - Hydralazine HL 25 mg - Medication charted but not given. On 11/23/2016, the facility notified Resident 5's physician of the omission error. Resident 6 * 11/17/2016-9:40 PM - alcium 600 with Vitamin D, Ferrous Sulfate 325 mg tab (tablet), If continuation sheet 11 of 16

12 (X1) PROVER/SUPPLIER/LIA ENTIFIATION NUMBER: (X3) SURVEY D NAME OF PROVER OR SUPPLIER PRAIRIE RGE ASSISTED LIVING (X4) REGULATORY OR LS ENTIFYING INFORMATION) PROVER'S PLAN OF ORRETION ontinued From page 11 Fish Oil 1000 mg capsule and Vitamin D 2000 IU (international units) soft gel - Medication charted but not given. Other - meds found in top drawer of med cart. On 11/18/2016, the facility notified Resident 6's physician of the medication omission error. Resident 7 * 10/22/ Bedtime - Memantine (cognitive enhancing medication) and pain reliever, PM cap (capsule). Other - was not administrated (sic) at all (still in blister pack). There was no documentation to indicate that Resident 7's physician was notified of the medication omission error. Interview During the facility exit conference, Administrator A and are oordinator B again confirmed a noted "increase" in medication error reports and because of this increase, the management team decided they "needed to do something." are oordinator B stated that they "removed some staff from the medication pass until they could retake the test, pass the medication class and prove competent and some staff were "written up" due to errors." Administrator A continued, "We held an inservice yesterday, November 30th. We are reviewing our policy/procedure and we decided to get our nurse more involved in the process." Summary The facility did not ensure that prescribed If continuation sheet 12 of 16

13 (X1) PROVER/SUPPLIER/LIA ENTIFIATION NUMBER: (X3) SURVEY D NAME OF PROVER OR SUPPLIER PRAIRIE RGE ASSISTED LIVING (X4) REGULATORY OR LS ENTIFYING INFORMATION) PROVER'S PLAN OF ORRETION ontinued From page 12 medications were dispensed in the dosage and at intervals prescribed by a practitioner. ross reference: N410 - DHS 83.37(1)(k) N (1)(k) Medication error or adverse reaction. N 410 Medication error or adverse reaction. 1. The BRF shall document in the resident ' s record any error in the administration of prescription or over-the-counter medication, known adverse drug reaction or resident refusal to take medication. 2. The BRF shall report all errors in the administration of medication and any adverse drug reactions to a licensed practitioner, supervising nurse or pharmacist immediately. Unless otherwise directed by the prescribing practitioner, the BRF shall report to the prescribing practitioner, supervising nurse or pharmacist as soon as possible after the resident refuses a medication for 2 consecutive days. This Rule is not met as evidenced by: Surveyor: Based on interview and record review, the facility did not ensure all errors in the administration of prescription or over-the-counter medications were documented in the resident's record. The facility did not report all errors in the administration of medications and any adverse drug reactions to a licensed practitioner, supervising nurse or pharmacist immediately. Findings include: On 8/29/2016, the Department received a complaint alleging concerns that aregiver If continuation sheet 13 of 16

14 (X1) PROVER/SUPPLIER/LIA ENTIFIATION NUMBER: (X3) SURVEY D NAME OF PROVER OR SUPPLIER PRAIRIE RGE ASSISTED LIVING (X4) REGULATORY OR LS ENTIFYING INFORMATION) PROVER'S PLAN OF ORRETION N 410 ontinued From page 13 N 410 dispensed the wrong medications to Resident 2. On 12/1/2016 Surveyors and X0123 conducted a complaint investigation. On 12/1/2016 at 1:35 PM, Surveyor interviewed Resident 2. During this interview, Resident 2 commented that back in July, somebody "gave me the wrong meds." Surveyor questioned Resident 2 about the error. Resident 2 stated, "She came in here with the meds on a spoon, I knew they were the wrong ones. I took them." Surveyor questioned if Resident 2 became ill. Resident 2 responded, "Not ill, became agitated. I know my meds well and they always say, "(Resident 2) we gave you your meds." Surveyor reviewed the concern with are oordinator () B. While B indicated she was new to her role, she was aware of an incident involving Resident 2. Surveyor requested to review the medication error as noted in July are oordinator B provided the following: Medication Occurrence/Error Report, Resident name: (Resident 2), Date of occurrence: 7/16/2016; Time of occurrence: 7:10 PM; Name of medication - Quetiapine 100 mg - 2 tablets, Metoprolol 25 mg - one table, Hydrocodone APAP 5/325 mg - one table, Gabapentin mg - one tablet, Buspirone 15 mg - one tablet, Alprazolam 0.5 mg - one tablet and arbidopa 25/200 mg - one tablet. Did the resident have any adverse effects from medication error? No; heck below the variance involved in the error: Wrong Medication and Wrong Resident. What variance from proper medication procedure occurred? Improper identification of resident and Other - two pill cups, If continuation sheet 14 of 16

15 (X1) PROVER/SUPPLIER/LIA ENTIFIATION NUMBER: (X3) SURVEY D NAME OF PROVER OR SUPPLIER PRAIRIE RGE ASSISTED LIVING (X4) REGULATORY OR LS ENTIFYING INFORMATION) PROVER'S PLAN OF ORRETION N 410 ontinued From page 14 N 410 I got mixed up, only one resident given wrong meds...event occurred due to: Administering and Other - med (medication) given to wrong resident. Physician notified: N/A (not applicable)... Observation notes reviewed, specifically for 7/16/2016, with no documentation noted regarding the medication error. There is no documentation that Resident 2's physician, a supervising nurse or a pharmacist was contacted immediately following the incident. There was no documentation to indicate the facility monitored Resident 2's health status following the medication error. During the facility exit conference, Administrator A and are oordinator B indicated that they had been in their perspective positions/roles for approximately 2 weeks. During this time, Administrator A and are oordinator B acknowledged a noted "increase" in medication error reports and because of this increase, the management team decided they "needed to do something." are oordinator B stated that they "removed some staff from the medication pass until they could retake the test, pass the medication class and prove competent and some staff were "written up" due to errors." Administrator A continued, "We held an inservice yesterday, November 30th. We are reviewing our policy/procedure and we decided to get our nurse more involved in the process." Summary Resident 2's record did not include documentation of all errors in medication If continuation sheet 15 of 16

16 (X1) PROVER/SUPPLIER/LIA ENTIFIATION NUMBER: (X3) SURVEY D NAME OF PROVER OR SUPPLIER PRAIRIE RGE ASSISTED LIVING (X4) REGULATORY OR LS ENTIFYING INFORMATION) PROVER'S PLAN OF ORRETION N 410 ontinued From page 15 N 410 administration, including reporting the error to a licensed practitioner, supervising nurse or pharmacist immediately. If continuation sheet 16 of 16