Alabama Department of Public Health

Transcription

1 (X1) PROVER/SUPPLIER/CLIA ENTIFICATION NUMBER: (X3) SURVEY D NAME OF PROVER OR SUPPLIER A 000 Initial Comments A 000 There were three complaints investigated during the survey. The following complaints were investigated, substantiated and deficiencies were cited directly related to the complaints: LC# , LC# and LC# This is a 16 bed Specialty Care Assisted Living Facility with a census of 6 on the survey date. Deficiencies were cited during this survey for failure to operate the facility in accordance with the State Board of Health's (SBOH) Rules for Specialty Care Assisted Living Facilities (SCALF's), Chapter , Alabama Administrative Code. These deficient practices resulted in resident harm and widespread noncompliance. A (1)(a) Administration A 301 (1) The Specialty Care Assisted Living Facility Governing Authority. (a) A specialty care assisted living facility shall have an identified sole proprietorship, corporation, partnership, limited partnership, or other business entity that is its governing authority, or it shall have a designated individual or group of designated individuals who serve as its governing authority. The governing authority shall be responsible for implementing policies for the management and operation of the facility, and for appointing and supervising the administrator who is responsible for overall management and day-to-day operation of the facility. In a family and group specialty care assisted living facility, the governing authority and the administrator may be the same individual. A facility must give complete information to the Department identifying: LABORATORY DIRECTOR'S OR PROVER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) If continuation sheet 1 of 53

2 (X1) PROVER/SUPPLIER/CLIA ENTIFICATION NUMBER: (X3) SURVEY D NAME OF PROVER OR SUPPLIER A 301 Continued From page 1 A each person who has an ownership interest of 10% or more of the governing authority; 2. each person or entity who has an ownership interest of 10% or more in the real property or building used by the specialty care assisted living facility to offer its services; 3. each officer and each director of the corporation if the governing authority is a corporation; and 4. each partner, including any limited partners, if the governing authority is a partnership. This Rule is not met as evidenced by: Based on observations, interviews and record reviews, the governing authority and administrator, Janie Baker Clarke, failed to operate the facility in a responsible manner when she did not provide a nurse to administer medications to the residents of the facility; retained in the facility, residents that required medication administration but did not provide for those needs; appointed an unlicensed staff member to administer medications to the residents and also misled the ADPH when she repeatedly told the ADPH supervisor and the surveyor that she had nurses available to administer medications. Ms. Clarke also failed in her responsibility to attain and maintain compliance with the SBOH rules by not correcting deficient practices cited during the August 7, 2013 survey. These widespread failures resulted in harm to residents; residents being denied necessary care and services; and registered nurse and licensed nurse duties not being If continuation sheet 2 of 53

3 (X1) PROVER/SUPPLIER/CLIA ENTIFICATION NUMBER: (X3) SURVEY D NAME OF PROVER OR SUPPLIER A 301 Continued From page 2 A 301 performed. THIS DEFICIENCY WAS CITED AS A RESULT OF A COMPLAINT INVESTIGATION. Findings: On January 6, 2014, the supervisor for the ADPH ALF unit received an from Janie Baker Clarke informing the Department that she had, that morning, terminated Employee Identifier (EI)#2, the facility nurse that was responsible for administering residents' medications and that EI#3, Certified Nurse Aide/Activity Director, would be responsible for the residents' morning medications. Ms. Clarke also wrote in the , "I know this is a clear violation of our rules, but it was the only emergency plan for the next few hours. I hope to have the new nurse in place in the afternoon." The ALF unit supervisor responded to Ms. Clarke's on the same day informing Ms. Clarke that administration of medications by unlicensed staff is a serious safety concern and not an acceptable practice. Ms. Clarke was made aware that the facility must provide for the health and safety needs of the residents and if the facility was unable to provide the services necessary for the health and safety of the residents, the facility should relocate the residents and discontinue operations. The supervisor requested Ms. Clarke provide the Department with the name and license number of the "new" nurse and provide a status report of the situation in the building that day. Ms. Clarke did not respond to the request until the next morning, January 7, 2014, when she sent the supervisor another . This stated, "6:43am. Will contact you as soon as I get to work." If continuation sheet 3 of 53

4 (X1) PROVER/SUPPLIER/CLIA ENTIFICATION NUMBER: (X3) SURVEY D NAME OF PROVER OR SUPPLIER A 301 Continued From page 3 A 301 Ms. Clarke did not contact the ADPH supervisor. At 3:13 PM on January 7, 2014, the supervisor called the facility. When asked if nurses were administering residents' medications, Ms. Clarke told the supervisor that nurses from home health and hospice agencies were "helping out." Ms. Clarke also volunteered that she had hired EI#7, RN, to begin work tomorrow, January 8, 2014, to work part-time administering medications. On January 8, 2014, at 12:45 PM, the ADPH ALF surveyor phoned Ms. Clarke requesting medication administration records (MARs) be faxed to the Department. During review of the medication administration records, the surveyor observed morning medications for this date were again administered by EI#3, an unlicensed staff member. On January 13, 2014, at 11:15 AM, the surveyor arrived unannounced at the facility. The surveyor explained to Ms. Clarke that an investigation into the facility not having a nurse to administer medications would be performed. On January 13, 2014, at 11:20 AM, EI#3 told the surveyor that she was the activity director. When the surveyor asked who had administered medications to the residents that morning, EI#3 replied that she (EI#3) and Ms. Baker Clarke both had administered medications to residents and that Resident Identifier (RI)#2's hospice nurse had administered RI#2's medications. Ms. Clarke and EI#3 were both asked where the nurse for the facility was. Ms. Clarke stated the nurse had other obligations, but had administered medications over the weekend. On January 13, 2014, at 11:43 AM, during a If continuation sheet 4 of 53

5 (X1) PROVER/SUPPLIER/CLIA ENTIFICATION NUMBER: (X3) SURVEY D NAME OF PROVER OR SUPPLIER A 301 Continued From page 4 A 301 phone interview, EI#5, licensed practical nurse (LPN), stated she had other commitments to meet and would not be available to the facility full time until Thursday, January 16, 2014 and that she had explained this to Ms. Clarke when she was hired on January 8, EI#5 then volunteered she was told that Ms. Clarke had obtained permission from the "State" to allow a staff member to administer the medications as it was an "emergency" situation. On January 13, 2014, at 12:10 PM, the surveyor asked Ms. Clarke and EI#3 if they were licensed to administer medications. Both replied, "No." On January 13, 2014, at 3:25 PM, EI#3 was asked who administered the medications at 12:00 PM. EI#3 stated since there was not a nurse that none of the residents received their 12:00 PM medications. This directly affected RI#3, RI#5 and RI#6. EI#3 was asked who would administer the 5:00 PM medications to the residents. EI#3 stated most of the residents would not receive their 5:00 PM medications today as there would not be a nurse to administer them. EI#3 volunteered that RI#2's hospice nurse would administer RI#2's evening medications and that RI#4's home health nurse would probably administer RI#4's evening medications. Note: RI#4's home health nurse did not administer RI#4's 8:00 AM medications for that date, EI#3 administered them. On January 13, 2014, at 3:30 PM, Ms. Clarke was asked who would administer the 5:00 PM medications to the residents that day. Ms. Clarke replied the medications would either be administered by EI#3 (unlicensed) or a nurse from a home health agency. The surveyor explained to Ms. Clarke that a licensed person must administer the medications. Ms. Clarke then If continuation sheet 5 of 53

6 (X1) PROVER/SUPPLIER/CLIA ENTIFICATION NUMBER: (X3) SURVEY D NAME OF PROVER OR SUPPLIER A 301 Continued From page 5 A 301 stated that a home health nurse might be willing to do it. The surveyor again explained to Ms. Clarke that a licensed person must administer the medications. A review of the MARs revealed that residents had pain medications ordered every four to six hours as needed. On January 13, 2014, at 4:55 PM, Ms. Clarke was asked how a resident received medications at night. Ms. Clarke replied that no residents required medications at night. Ms. Clarke was then asked, if a resident wanted pain medication during the hours when a nurse was not available in the facility, how would the resident receive it. Ms. Clarke replied she would be interviewing another licensed person the next day to hire. Ms. Clarke volunteered that EI#5, LPN, would be available from 8:30 AM until 4:30 PM, but lived too far away to return to the facility after the last medication pass each day. Refer to the following deficiencies for additional information: 403 Ms. Clarke denied the residents a safe environment by failing to provide a licensed person to administer medications. 415 Ms. Clarke failed to ensure that five of six current residents who required medication administration were safely transferred or discharged to a setting where their needs could be met. 416 Ms. Clarke failed to ensure that facility staff members observed one of six current residents for health and physical ability changes. 417 Ms. Clarke failed to ensure that plans of care were current and appropriate for three of five If continuation sheet 6 of 53

7 (X1) PROVER/SUPPLIER/CLIA ENTIFICATION NUMBER: (X3) SURVEY D NAME OF PROVER OR SUPPLIER A 301 Continued From page 6 A 301 residents. 418 Ms. Clarke failed to ensure that deficient practices cited during the August 7, 2013 survey were corrected and maintained in a corrected manner. 424 Ms. Clarke allowed staff members to use restraints in the facility. 512 The facility RN failed to develop appropriate written plans of care for three residents. THIS IS A REPEAT DEFICIENCY FROM THE SURVEY CONDUCTED ON AUGUST 7, Outside provider's certifications and plans of care for all residents were not present in the facility. 522 Ms. Clarke was negligent in the care of the residents in the facility by failing to provide a licensed nurse to administer medications; failing to provide nursing care and services to treat wounds; and failing to provide a safe environment without the use of restraints. This placed all residents at significant risk for harm and RI#4 actually sustained harm. 538 Survey findings and plan of corrective action for the previous survey performed on August 7, 2013 were not posted in a prominent location in the facility. 601 All residents' medical care was not under the direction and supervision of a physician. 605 The facility's RN failed to perform her duties. THIS IS A REPEAT DEFICIENCY FROM THE SURVEY CONDUCTED ON AUGUST 7, If continuation sheet 7 of 53

8 (X1) PROVER/SUPPLIER/CLIA ENTIFICATION NUMBER: (X3) SURVEY D NAME OF PROVER OR SUPPLIER A 301 Continued From page 7 A Facility care and services were not consistent with community standards of practice. 613 RI#4 was mechanically restrained by facility staff. 625 Medications were not administered by a nurse and medications that were not ordered by a physician were administered to RI# All medications administered to residents in the facility were not contemporaneously recorded on the facility's medication administration records. 630 All controlled substances in the facility's possession were not accounted for or secured under a double lock. 634 All cleaning supplies and poisons were not attended or secured at all times. THIS IS A REPEAT DEFICIENCY FROM THE SURVEY CONDUCTED ON AUGUST 7, There was no potable water in the facility for use during emergencies. A (3) Personnel and Training A 403 (3) The governing authority and administrator of a specialty care assisted living facility shall likewise employ sufficient staff, ensure sufficient staff are on duty, and manage and direct staff activities in a manner that results in maintenance of a neat, clean, orderly, and safe environment at all times. If continuation sheet 8 of 53

9 (X1) PROVER/SUPPLIER/CLIA ENTIFICATION NUMBER: (X3) SURVEY D NAME OF PROVER OR SUPPLIER A 403 Continued From page 8 A 403 This Rule is not met as evidenced by: Based on observation, interview and record review, Janie Baker Clarke, the facility's governing authority and administrator, denied the six current residents a safe environment when she failed to provide a nurse to administer medications. THIS DEFICIENCY WAS CITED AS A RESULT OF A COMPLAINT INVESTIGATION. Findings: On the morning of January 6, 2014, Ms. Clarke fired EI#2, the LPN who administered medications to the residents on a daily basis. Ms. Clarke then failed to provide a licensed person to administer medications to the six residents of the facility even though she admitted she was aware that non-licensed staff members administering medications in a SCALF was in violation of the SBOH rules. In fact, Ms. Clarke had EI#3, an unlicensed staff member, administer medications to the six residents on January 6, January 7, January 8, January 10 and yet again on the morning of January 13, 2014, prior to the surveyor arriving at the facility. A (7)(a) 3. Personnel and Training A The administrator shall ensure that residents who have health or safety needs beyond the capability of the facility will be safely transferred or discharged to an appropriate setting. If continuation sheet 9 of 53

10 (X1) PROVER/SUPPLIER/CLIA ENTIFICATION NUMBER: (X3) SURVEY D NAME OF PROVER OR SUPPLIER A 415 Continued From page 9 A 415 This Rule is not met as evidenced by: Based on observation, interview and record review, the administrator, Ms. Clarke, failed to ensure that five of six current residents who required medication administration were safely transferred or discharged to a setting that could provide safe medication administration. This failure placed RI#'s 1, 2, 3, 4, and 6 at significant risk for medication error by unlicensed staff who were administering medications. The administrator also did not discharge a resident (RI#4) to a setting that could provide the necessary safety measures required by the resident. THIS DEFICIENCY WAS CITED AS A RESULT OF A COMPLAINT INVESTIGATION. Findings: RI#1 is a 90 year old female with a diagnosis of Alzheimer's dementia. RI#2 is an 84 year old female with diagnoses to include dementia. RI#3 is an 87 year old female with a diagnosis of dementia. RI#4 is an 81 year old female with a diagnosis of Alzheimer's dementia. RI#4 was also restrained by the facility. RI#6 is a 57 year old male with Parkinson's dementia. Ms. Clarke failed to either provide a nurse to administer their medications at all times or transfer or discharge the residents to a setting that could provide their specialized care needs. A (7)(a) 4. Personnel and Training A The administrator shall ensure that facility staff If continuation sheet 10 of 53

11 (X1) PROVER/SUPPLIER/CLIA ENTIFICATION NUMBER: (X3) SURVEY D NAME OF PROVER OR SUPPLIER A 416 Continued From page 10 A 416 members observe each resident for changes in health and physical abilities and obtain appropriate medical attention when needed. This Rule is not met as evidenced by: Based on observation, interview and record review, the facility administrator and governing authority, Ms. Clarke, failed to ensure that facility staff members observed one of six current residents for health and physical ability changes (RI#4). These failures resulted in harm to RI#4 and placed the remaining residents at risk for harm. Findings: Record review revealed RI#4 was admitted to the facility on October 23, 2013, and sustained three falls in the facility in December of On January 13 and January 14 of 2014, RI#4 was observed to have her right arm secured to her side by an immobilizer. RI#4 required assistance to eat and go to the toilet. On January 14, 2014, at 8:00 AM, RI#4 was observed to have a large pressure wound on her sacral area. On January 14, 2014, at 8:15 AM, during an interview, Ms. Clarke stated RI#4 had come to the facility with the wound and agreed that RI#4's wound had become large. RI#4 did not receive treatment for the wound until January 10, A (7)(a) 5. Personnel and Training A The administrator shall ensure that plans of If continuation sheet 11 of 53

12 (X1) PROVER/SUPPLIER/CLIA ENTIFICATION NUMBER: (X3) SURVEY D NAME OF PROVER OR SUPPLIER A 417 Continued From page 11 A 417 care for all residents are current and appropriate. This shall include the prearranged discharge plan. This Rule is not met as evidenced by: Based on observation, interview, and record review, the administrator, Ms. Clarke, failed to ensure that plans of care were current and appropriate for three of five residents whose plans of care were reviewed. Findings: RI#2's plan of care was not updated to include her inability to stand and support her weight; her need for two persons to manually transfer her and her need to have someone propel her wheelchair. RI#4's plan of care was not updated to include care required for her decubitus ulcer; impaired ability to feed herself due to her right arm being immobilized; impaired balance due to the immobilized right arm and physical safety for which the facility restrained her. RI#5's plan of care did not address his chronic pain and did not provide him with a way to obtain pain medication during the night time hours when a nurse was not available to administer the medications. A (7)(a) 6. Personnel and Training A The administrator shall ensure that all deficient practices cited by the Department of Public Health are corrected in a timely manner. If continuation sheet 12 of 53

13 (X1) PROVER/SUPPLIER/CLIA ENTIFICATION NUMBER: (X3) SURVEY D NAME OF PROVER OR SUPPLIER A 418 Continued From page 12 A 418 This Rule is not met as evidenced by: Based on observation and interview, Ms. Clarke failed to ensure that all deficient practices cited during the August 7, 2013 survey were corrected and maintained in a corrected manner to be in compliance with the SBOH's rules. THIS DEFICIENCY WAS CITED AS A RESULT OF A COMPLAINT INVESTIGATION. Findings: Three deficient practices cited in the August 7, 2013 survey were repeated during this complaint survey: 512 EI#4, the facility's RN, did not update three residents' plans of care with written interventions to address residents' specific problem areas. 605 EI#4, did not perform her RN duties to identify each resident's specific problems and establish appropriate written interventions for the direct care staff to follow to provide care to the residents. 634 All cleaning supplies and poisons were not attended or secured at all times. A (11)(b) Personnel and Training A 424 (b) All staff who have contact with residents, including the administrator, shall have initial training prior to resident contact. Initial training shall be followed up with refresher training as necessary. An RN shall identify staff refresher If continuation sheet 13 of 53

14 (X1) PROVER/SUPPLIER/CLIA ENTIFICATION NUMBER: (X3) SURVEY D NAME OF PROVER OR SUPPLIER A 424 Continued From page 13 A 424 training needs and shall provide or arrange for needed training. Prior to providing any resident care, all staff shall complete The DETA (Dementia Education and Training Act) Brain Series Training developed by the Alabama Department of Mental Health and Mental Retardation or equivalent training approved by the State Health Officer. The training shall be appropriately documented by the facility. In addition, the facility shall ensure that, prior to resident contact, all staff members receive training on the subject matter listed below: 1. State law and rules on assisted living facilities and specialty care assisted living facilities. 2. Identifying and reporting abuse, neglect and exploitation. 3. Basic first aid. 4. Advance Directives. 5. Protecting resident confidentiality. 6. Safety and nutritional needs of the elderly. 7. Resident fire and environmental safety. 8. Understanding the Aging Mind. 9. Basic Brain Function. 10. Common Neuropsychiatric Disorders in the Elderly. 11. Basic Evaluation of the Dementia Patient. 12. Cognitive Symptoms of Dementia. If continuation sheet 14 of 53

15 (X1) PROVER/SUPPLIER/CLIA ENTIFICATION NUMBER: (X3) SURVEY D NAME OF PROVER OR SUPPLIER A 424 Continued From page 14 A Psychiatric Symptoms of Dementia. 14. Behavioral Problems Associated with Dementia. 15. End of Life Issues in Dementia. 16. Dementia Other than Alzheimer's. 17. Research and Dementia. 18. Nutrition and Hydration Needs of the Resident with Dementia to include Feeding Techniques. 19. Safety Needs of Residents with Dementia. This Rule is not met as evidenced by: Based on observation, interview and record review, Ms. Clarke and five of the staff members observed, EI#'s 3, 5, 6, 8 and 9, failed to demonstrate training in state law and rules on assisted living facilities and specialty care assisted living facilities when they used restraints on RI#4. Findings: Ms. Clarke, EI#3, EI#5, EI#6, EI#8 and EI#9 used physical restraints as a care intervention for RI#4 instead of providing proper treatment or transfer to a safer environment. A (3)(d) 1. & 2. Records and Reports A 512 (d) Plan of Care. Based on the individual resident If continuation sheet 15 of 53

16 (X1) PROVER/SUPPLIER/CLIA ENTIFICATION NUMBER: (X3) SURVEY D NAME OF PROVER OR SUPPLIER A 512 Continued From page 15 A 512 assessment, an RN, in conjunction with the facility staff and the resident's sponsor or responsible family member, shall develop appropriate written plans of care to address the specific problems identified. The nurse shall evaluate both the facility's implementation and the resident's response to the plan of care. The plan of care shall be modified when necessary to meet the needs of the resident, and the resident's sponsor or responsible family member shall be notified of such changes. In addition to other items that may be required by the facility's own policies and procedures, it shall contain the following: 1. A listing of the resident's needs or problems that require intervention by the facility, such as behavioral symptoms, weight loss, falls, and therapeutic diets. 2. A description of the assistance with activities of daily living required by the resident including bathing, dressing, ambulation, feeding, toileting, grooming, medication assistance, diet, and risk to personal safety. As changes in medication and personal services become necessary, the plan of care shall be promptly updated and all changes shall be documented. This Rule is not met as evidenced by: Based on observation, interview and record review, the facility RN, EI#4, failed to develop appropriate written plans of care with written interventions to address residents' specific problem areas for three of five residents whose plans of care were reviewed. THIS IS A REPEAT DEFICIENCY FROM THE If continuation sheet 16 of 53

17 (X1) PROVER/SUPPLIER/CLIA ENTIFICATION NUMBER: (X3) SURVEY D NAME OF PROVER OR SUPPLIER A 512 Continued From page 16 A 512 SURVEY CONDUCTED ON AUGUST 7, Findings: EI#4 did not update RI#2's plan of care to include her special needs of two persons to manually transfer, one person to propel her wheelchair and RI#2's inability to stand and support her weight. RI#2's regular diet with pureed meats ordered on December 4, 2013 was not identified nor addressed on the plan of care. EI#4 did not update RI#4's plan of care to include RI#4's decubitus ulcer on her sacral area; impaired ability to feed herself due to her right arm being immobilized; impaired balance due to the immobilized right arm and RI#4's physical safety needs. EI#4 did not address on RI#5's plan of care, his pain control needs during the night time hours when a nurse was not available to administer the medications. In fact, RI#5's pain and interventions to address his pain were not identified on his plan of care. Ms. Clarke's plan to correct this deficiency when it was cited on August 7, 2013 was "... On August 8th through August 15th, all remaining resident care plans have been reviewed by the RN and the LPN and any supplements made in all areas of concern. 4. A new policy and procedure has been put into place to ensure that all care plans are current. This policy and procedure plan is attached to this proposed correction to this citation. The care plans for all residents shall be made available to all employees and stored in the laundry room shelving. Every staff member will sign the back of any care plan to indicate they are familiar with the plan. In the week following If continuation sheet 17 of 53

18 (X1) PROVER/SUPPLIER/CLIA ENTIFICATION NUMBER: (X3) SURVEY D NAME OF PROVER OR SUPPLIER A 512 Continued From page 17 A 512 August 7th, the RN has been trained by the administrator on the Care Plan Policy and Procedure. 5. The Administrator will continuously monitor all care plans at the time of any change in resident care needs and at the time of the monthly assessments as completed by the RN, and in conjunction with outside care providers, physicians, residents, sponsors and care givers to determine the completeness, success and possible modifications or supplements to the care plans as to all issues. Evidence of the Administrator's continuous monitoring shall be by her initialing each care need change and at least at the time of the monthly assessment and documented at the bottom right corner of the RN's signature location." The "Policy and Procedure: Plan of Care" attached to the plan of correction documented " Based upon the individual resident assessment, the RN... shall develop appropriate written plan of care to address the specific problems identified on admission, at the time of any change in condition and at least monthly The RN shall evaluate both the facility's implementation and the resident's response to the plan of care at least monthly The plan of care shall be modified when necessary to meet the needs of the resident The plan of care shall contain a listing of the resident's needs or problems that require intervention by the facility The plan of care shall contain a description of the assistance with activities of daily living required by the resident including bathing, dressing, ambulation, feeding, toileting, grooming, medication assistance, diet and risk to personal safety. As changes in medication and personal services become necessary, the plan of care shall be promptly updated and all changes shall be documented. 6. There shall be written If continuation sheet 18 of 53

19 (X1) PROVER/SUPPLIER/CLIA ENTIFICATION NUMBER: (X3) SURVEY D NAME OF PROVER OR SUPPLIER A 512 Continued From page 18 A 512 documentation that the facility has devised a plan to transfer the resident to a hospital, nursing home or other appropriate setting if and when the facility becomes unable to meet the resident's needs The care plan shall contain a copy of any outside care, such as the current Home Health Certification and Plan of Care... for each resident receiving care from an outside provider...." A (3)(d) 5. Records and Reports A A copy of any outside provider's certification and plan of care, such as the current Home Health Certification and Plan of Care (HCFA Form 485/487) for each resident receiving care from an outside provider. This Rule is not met as evidenced by: Based on observation, interview and record review, Ms. Clarke failed to ensure that all residents' outside provider's certification and plan of care was in the facility. Findings: RI#4 had been admitted to Amedisys of Ft. Payne's home health service on October 30, 2013, according to RI#4's record review, but the home health agency certification, including the physician's orders and plan of care, were not in RI#4's record. On January 14, 2014, at 8:15 AM, the surveyor requested that Ms. Clarke and EI#3 locate the home health information for RI#4. Ms. Clarke and EI#3 were unable to locate the requested information in the facility. On January 14, 2013, at 10:25 AM, EI#11, LPN, and Amedisys manager came to the facility. If continuation sheet 19 of 53

20 (X1) PROVER/SUPPLIER/CLIA ENTIFICATION NUMBER: (X3) SURVEY D NAME OF PROVER OR SUPPLIER A 514 Continued From page 19 A 514 When asked by the surveyor, EI#11 stated she had brought information from the home health agency regarding RI#4 that had been requested earlier that same morning by the facility staff. EI#11 showed the surveyor the Home Health Certification and Plan of Care for RI#4. The certification and plan of care had a start of care date of October 30, 2013 and the ending date of December 28, 2013 with the primary diagnosis of Alzheimer's disease. A (3)(g) 2. Records and Reports A 522 Every resident shall have the right to live in a safe and decent environment, to be free from abuse, neglect, and exploitation, and to be free from chemical and physical restraints. This Rule is not met as evidenced by: Based on observation, interview and record review, Ms. Clarke, administrator and member of the governing authority, was negligent in the care of the residents in the facility by failing to provide a licensed nurse to administer medications; failing to provide nursing care and services to treat wounds; and failing to provide a safe environment without the use of restraints. All residents were placed at significant risk of harm by these negligent practices and RI#4 sustained actual harm. THIS DEFICIENCY WAS CITED AS A RESULT OF A COMPLAINT INVESTIGATION. If continuation sheet 20 of 53

21 (X1) PROVER/SUPPLIER/CLIA ENTIFICATION NUMBER: (X3) SURVEY D NAME OF PROVER OR SUPPLIER A 522 Continued From page 20 A 522 Findings: On January 6, 2014, Ms. Clarke fired the facility's licensed nurse, EI#2, LPN, who administered the residents' medications each day. Ms. Clarke notified the ADPH assisted living facilities supervisor and admitted that an unlicensed person would be administering medications even though Ms. Clarke was aware this was in violation of the rules under which her facility was licensed. Ms. Clarke told the supervisor that she hoped to have a nurse administer medications that afternoon. An investigation was conducted beginning on January 13, 2014, into three complaints regarding allegations of Ms. Clarke allowing an unlicensed person to repeatedly administer medications and residents requiring care above the level of the facility's license and above the level of the staff's training. The three complaints were substantiated and deficiencies were cited at the conclusion of the investigation. On January 13, 2014, at 11:15 AM, the surveyor arrived unannounced at the facility. On that same date at 11:20 AM, EI#3, when asked, stated she was an unlicensed staff member and that she and Ms. Clarke (who also admitted she was not licensed as a nurse) had administered the medications ordered for 8:00 AM that morning to RI#3, RI#4, RI#5 and RI#6. EI#3 also admitted she had administered medications to RI#1, RI#2, RI#3, RI#4, RI#5, RI#6 and RI#7 numerous times since the facility's nurse had been fired on January 6, NOTE: This was one week after Ms. Clarke notified the ADPH supervisor that the unlicensed staff would be administering medications. If continuation sheet 21 of 53

22 (X1) PROVER/SUPPLIER/CLIA ENTIFICATION NUMBER: (X3) SURVEY D NAME OF PROVER OR SUPPLIER A 522 Continued From page 21 A 522 RI#4's medications: A review of RI#4's medication administration records (MARs) beginning January 1, 2014 through January 31, 2014, revealed that no staff member had signed or initialed the MARs as having administered medications to RI#4 from January 1 through January 5, EI#3 identified her initials on the MARs and stated she had administered the following medications to RI#4, a severely cognitively impaired resident: "Stock Supply Mapap 500 milligrams (mg)" on January 7, There was no physician's order in RI#4's record for this medication to be administered. On January 14, 2014, at 4:50 PM, EI#3 admitted during an interview that RI#4 had complained of a headache so she, EI#3 had given the Mapap (acetaminophen). Note: EI#3 was not licensed to administer medications and was not qualified to assess a resident's needs. (Xanax) alprazolam 0.5 mg one tablet three times daily on January 6th and 7th; EI#3 administered the medication two times on January 8th and administered it again at 8:00 AM on January 10, (Aricept) donepezil hcl 10 mg at 5:00 PM, on January 6th and 7th. Note: This medication was not on any of the signed physician's medication orders for RI#4 since her admission to the facility on October 23, Fentanyl 50 micrograms per hour patch on January 6, (Neurontin) gabapentin 300 mg one capsule three times daily on January 6th and 7th and twice on January 8, Note: This medication was If continuation sheet 22 of 53

23 (X1) PROVER/SUPPLIER/CLIA ENTIFICATION NUMBER: (X3) SURVEY D NAME OF PROVER OR SUPPLIER A 522 Continued From page 22 A 522 discontinued three times a day and ordered at bedtime only by RI#4's physician on December 13, 2013 and again on December 18, (Lortab) hydrocodone/apap 5/500mg one tablet at 5:00 PM on January 6th and 7th, 10:30 AM on January 8th and at 8:00 AM and 4:00 PM on January 10, On January 14, 2014, at 4:50 PM, during an interview, EI#3 admitted she, EI#3, would give it (Lortab) when RI#4 complained of hurting badly. Again, EI#3 was not licensed to administer medications and was not qualified to assess RI#4's needs. Note: This medication had been discontinued by RI#4's physician on December 13, The following medications were ordered for RI#4 but not administered between January 6, 2014 and January 14, 2014: Provigil 100 mg one time daily (this is a prescription medication to improve wakefulness in adults), Risperdal 0.25 mg twice daily, and Namenda 10 mg twice daily. EI#5, LPN, was hired on January 8, 2014, to administer medications in the facility beginning with the medications ordered for 5:00 PM that evening. EI#5 documented on the back of RI#4's MARs on January 9, 2014, that the noon and 4:00 PM doses of Xanax 0.5 mg and the noon dose of gabapentin 500 mg were not given because EI#5 assessed RI#4 to be "very sleepy." EI#5 also did not administer RI#4's Provigil, Risperdal, and Namenda, but no explanation was documented for not administering these medications. New medication orders were received by the facility for RI#4 on January 10, 2014, for the following medications: hydrochlorothiazide 12.5 mg once a day; ergocalciferol 1000 units once a day; Namenda 10 mg twice a day; megestrol If continuation sheet 23 of 53

24 (X1) PROVER/SUPPLIER/CLIA ENTIFICATION NUMBER: (X3) SURVEY D NAME OF PROVER OR SUPPLIER A 522 Continued From page 23 A 522 acetate 40 mg twice a day and Lortab 5/325 mg every six hours as needed for pain. EI#3 administered the ordered hydrochlorothiazide and a Lortab on January 10, 2014 and administered the hydrochlorothiazide only on January 13, EI#5 documented she administered the same two medications on January 11, 2014, and administered the hydrochlorothiazide only on January 12, On January 13, 2014, at 3:30 PM, Ms. Clarke was asked who would administer medications to the residents at 5:00 PM that day. Ms. Clarke replied it would either be EI#3 or a home health nurse. The surveyor explained to Ms. Clarke that either she provide a licensed person to administer the evening medications or transfer the residents to a location where their needs could be met. On January 13, 2014, at 4:55 PM, during the evening medications pass, EI#5, LPN, told the surveyor she had been called by Ms. Clarke to come in and administer the 5:00 PM medications. EI#5, told the surveyor RI#4's physician had discontinued RI#4's medications on Friday, January 10, 2014 after EI#5 reported that RI#4 had been "very sleepy" on Thursday. EI#5 said that the physician sent new medication orders for RI#4 the same Friday. EI#5 said she was off that day and did not receive the orders until Saturday when she returned to work. EI#5 also stated the only newly ordered medications available to administer on Saturday, Sunday and Monday were the hydrochlorothiazide and Lortab. EI#5 said none of the other medications that had been ordered on Friday were available in the facility at 4:55 PM on Monday, January 13, EI#5 did not administer any medications to RI#4 at 5:00 PM on January 13, Note: This is three days after the orders were given by the physician. If continuation sheet 24 of 53

25 (X1) PROVER/SUPPLIER/CLIA ENTIFICATION NUMBER: (X3) SURVEY D NAME OF PROVER OR SUPPLIER A 522 Continued From page 24 A 522 On January 14, 2014, at 9:50 AM, the surveyor requested that EI#5 provide the surveyor all of RI#4's available medications for inspection. EI#5 provided the surveyor the following medications: gabapentin, hydrochlorothiazide, donezepil, metoprolol, milk of magnesia; sulfa suspension and Lortab 5/325 mg. EI#5 stated the facility did not have the following medications for RI#4: ergocalciferol, Namenda, and megestrol. EI#3 was asked why the facility did not have the medications that had been ordered by RI#4's physician on January 10, EI#3 stated she thought the doctor sent the orders to the pharmacy and then also stated, "I have no clue." The physician's office was not notified the medications were not available and were not administered to RI#4 until after the surveyor questioned EI#3 and EI#5 about the missing medications on January 14, On January 14, 2014, at 12:15 PM, during an interview, EI#13, the home health RN, told the surveyor RI#4 had been very sleepy and lethargic during EI#13's visit on Friday, January 10, RI#4's wound on the sacral area: Record review revealed RI#4 had been admitted to the facility on October 23, On numerous occasions on January 13 and January 14, 2014, while in the facility, the surveyor observed RI#4 attempting to get out of a locked wheelchair positioned against the wall of the dining room with a table pushed up to the wheelchair to prevent RI#4 from getting up. The surveyor observed that RI#4's sacral area was being scrubbed with a friction type motion against her pants and the chair. If continuation sheet 25 of 53

26 (X1) PROVER/SUPPLIER/CLIA ENTIFICATION NUMBER: (X3) SURVEY D NAME OF PROVER OR SUPPLIER A 522 Continued From page 25 A 522 On January 14, 2014, at 8:00 AM, RI#4 was loudly protesting being placed in a wheelchair to be taken to her room for toileting. During toileting, RI#4's sacral area was observed to be very thin with a partially dissolved hydrocolloid gel dressing over a wound. The surveyor observed the center of the wound was black/brown eschar (dead tissue) that measured approximately 4 by 6 centimeters. The eschar and the intact area left of the dressing was surrounded by bright angry red skin approximately 8 to 10 centimeters. Dried grainy stool was observed on RI#4's buttocks and the remaining area of the dressing. When asked how long the wound had been present, EI#3 stated that RI#4 had been admitted to the facility with a small area that had become very big. EI#3 said the home health agency began treating the wound one day last week. As RI#4 stood up from the toilet, the surveyor observed wet bloody discharge on RI#4's buttocks, wound, dressing remnants, and on the back of the toilet seat where RI#4 had scrubbed the wound when sitting down and getting up. On January 14, 2014, at 8:15 AM, during an interview, Ms. Clarke was asked by the surveyor how long RI#4 had the sacral wound. Ms. Clarke replied that RI#4 had come to the facility with the wound and that home health was treating the wound. When the surveyor commented on the large size of the wound, Ms. Clarke stated, "Yes. I have seen it." When asked how long home health had been treating the wound, Ms. Clarke had to refer to EI#3. After reviewing the resident's record and the home health folder, Ms. Clarke and EI#3 could only tell the surveyor that Alacare Home Health agency had started seeing RI#4 on January 10, If continuation sheet 26 of 53

27 (X1) PROVER/SUPPLIER/CLIA ENTIFICATION NUMBER: (X3) SURVEY D NAME OF PROVER OR SUPPLIER A 522 Continued From page 26 A 522 On January 14, 2014, at 10:25 AM, EI#11, an Amedisys Home Health manager, told the surveyor the agency had provided psychiatric nursing services and physical therapy services to RI#4 from October 30, 2013 until December 24, 2013, but had never provided wound care services to RI#4. On January 14, 2014, at 10:35 AM, the surveyor asked EI#3 if any home health agency had treated RI#4's wound before January 10, EI#3 told the surveyor she did not know. On January 14, 2014, at 12:15 PM, during an interview, EI#13, Alacare Home Health RN, stated RI#4's physician did not mention a wound during the referral for home health. EI#13 stated RI#4's family member had told her about the wound on the sacral area during the admission visit on January 10, 2014 and EI#13 then alerted the physician that RI#4 had a wound. EI#13 measured the wound with the eschar measurement of 2.5 by 5 centimeters and the bright red area surrounding the eschar measurement of 8 by 9 centimeters. RI#4 was restrained by the facility staff: The surveyor observed the facility restrain RI#4 by placing RI#4 in a wheelchair, pushing the back of the chair flush against the wall of the dining room, locking the wheels of the chair and then pushing a table up flush to the front of the wheelchair on January 13, 2014, at 4:55 PM. The following observations of RI#4 being restrained by staff were observed on January 14, 2014: At 7:10 AM, RI#4 was observed trying to rock the If continuation sheet 27 of 53

28 (X1) PROVER/SUPPLIER/CLIA ENTIFICATION NUMBER: (X3) SURVEY D NAME OF PROVER OR SUPPLIER A 522 Continued From page 27 A 522 wheelchair back but was unable to move the chair because the chair was locked and positioned again between the wall and a dining table. EI#9 told RI#4 to "Stay right there." RI#4 was angry saying "I can't get out of here!" When asked if RI#4 could get out of the chair or propel it, EI#9 replied, "No. She fell and broke her collar bone, so we lock it." At 7:29 AM, RI#4 was observed to be attempting to stand up from the wheelchair restraint while saying, "I can't get up here. I'll lay this baby down. I wish daddy would come back." RI#4 was eventually able to turn sideways and stand up but was very shaky and unsteady. All three staff members were in the kitchen. The surveyor had to request assistance for RI#4 as none of the staff had responded to RI#4's sounds in the dining room. EI#3 came and guided RI#4 to a very low couch in the living area and instructed RI#4 to sit on the couch for a while. At 7:35 AM, RI#4 stated loudly, "I need to go home and go to bed. This baby is going to have pneumonia after this. Somebody got my cruise mobile!" EI#3 was sitting at a table in the dining room and acknowledged RI#4 by pointing to RI#4's wheelchair stating the cruise mobile was right there. RI#4 was continuously trying to get herself up from the couch. No staff offered to assist RI#4 and RI#4 could not get herself up off of the couch. RI#4 was again observed attempting to stand up from the locked wheelchair at the table at 8:35 AM. EI#5 intervened by getting RI#4 to sit down in the chair and then pushing the dining table back up to the front of the chair. RI#4 complained, "I can't get up!" EI#5 replied, "We will get you up later. You will fall so you stay right there. Don't try to get up." At 8:40 AM, EI#5 was asked why the If continuation sheet 28 of 53

29 (X1) PROVER/SUPPLIER/CLIA ENTIFICATION NUMBER: (X3) SURVEY D NAME OF PROVER OR SUPPLIER A 522 Continued From page 28 A 522 table was being pushed up to RI#4. EI#5 replied RI#4 would try to get up and walk, but would instead get up and fall. EI#5 stated that RI#4 had fallen about two weeks before and had broken her shoulder. EI#5 said that RI#4 would try to slump down and back on her sacral area when sitting and had a sore on that area. EI#5 also explained that she had suggested putting RI#4 into a geriatric chair where the tray could be pushed up to the resident and the chair reclined to keep the resident from getting up. EI#5 administered RI#4's available medication then pushed the wheelchair up against the wall and pushed the table up to the chair. EI#5 then stated, "I know this is a type of restraint, but she moves the table and it is for her own safety." At 8:45 AM, RI#4 was observed loudly saying, "I can't get up!" and attempting to rock the wheelchair back. RI#4 remained restrained by the wheelchair, table, and wall at 9:00 AM, while yelling, "I can't get up!" RI#3 was sitting near RI#4 and told RI#4, "Don't get up, you will fall." EI#5 pushed RI#4 out of the area at 9:05 AM, but returned RI#4 back and positioned the locked wheelchair between the wall and table at 9:08 AM. At 9:10 AM, RI#4 was again yelling, "I can't get out of here! Where is daddy?" At 9:45 AM, RI#4 remained in the wheelchair between the wall and table and was kicking a wooden dining chair beside her while yelling, "I can't get out of here!" RI#4 was observed standing up between the dining table and wheelchair at 10:10 AM. EI#6 walked by and attempted to get RI#4 to sit back down in the wheelchair. EI#6 coaxed RI#4 to sit back down in the locked wheelchair at 10:12 AM. RI#4 yelled out when sitting down, "Oh! That If continuation sheet 29 of 53

30 (X1) PROVER/SUPPLIER/CLIA ENTIFICATION NUMBER: (X3) SURVEY D NAME OF PROVER OR SUPPLIER A 522 Continued From page 29 A 522 hurts!" RI#4 was observed again sitting in the locked wheelchair between the wall and the table in the dining room at 2:10 PM, while in the presence of Ms. Clarke. RI#4 attempted to stand up and EI#5 intervened by telling her to stay there. EI#5 then sat in a chair close to RI#4 for about five minutes and then got up and left the area. RI#7's medications: Record review revealed RI#7 was an 83 year old female with an admission date to the facility of May 16, RI#7 sustained a fall on December 2, 2013, was admitted to the local hospital on December 5, 2013, and was discharged back to the facility on December 12, 2013, with hospice services being resumed that same date. RI#7 expired in the facility on January 7, EI#17, RN for the hospice agency, made a visit on December 13, 2013, to the facility and documented RI#7 had advanced dementia, had difficulty communicating her needs and had become totally dependant on others for all of her care. In fact, EI#17's documentation revealed RI#7 leaned to the left and could not "support herself in an upright position," had difficulty swallowing so her medications were crushed, required two persons to transfer from the bed to the wheelchair, and due to confusion was unable to sign consents for treatment. EI#16, RN for the hospice agency, made a visit on January 2, 2014, and noted RI#7 had increased confusion, could not make her needs known, did not understand to swallow, had diminished chewing skills, would pocket food in her mouth, and had dysphagia. EI#16 also noted If continuation sheet 30 of 53

31 (X1) PROVER/SUPPLIER/CLIA ENTIFICATION NUMBER: (X3) SURVEY D NAME OF PROVER OR SUPPLIER A 522 Continued From page 30 A 522 that RI#7 was bed to wheelchair bound, required 3 people for transfers, must be repositioned by others, and had skin excoriation to her inner buttocks area and groin. EI#16 noted that RI#7 was totally dependent on others for all of her care. EI#16 made a visit back to see RI#7 on January 3, 2014, after the facility reported RI#7 had a temperature above 102 degrees Fahrenheit and was unresponsive. EI#16 documented RI#7 was totally bed bound and totally dependent on others for all care. RI#7's physician ordered an acetaminophen suppository 650 mg to be administered rectally every six hours as needed for elevated temperature or pain and to discontinue medications given by mouth. EI#16 administered a suppository during the visit and instructed EI#3, the unlicensed facility staff member, on how to administer a suppository. Documentation included EI#3 verbalized understanding. Additional documentation included Cipro had previously been ordered by mouth for RI#7 but the facility staff had not obtained the medication from the pharmacy. On January 8, 2014, during a phone interview, Ms. Clarke stated RI#7 had expired in the facility the previous night. The surveyor requested that RI#7's MARs be faxed to the department by Ms. Clarke. A review of RI#7's MARs revealed EI#3, unlicensed staff member, had signed that she had administered the acetaminophen suppository to RI#7 on January 6, 2014 and had also administered RI#7's Exelon 9.5mg topical patch on January 6th and again on January 7, On January 13, 2014, at 12:10 PM, Ms. Clarke and EI#3 were both asked if they were licensed to administer medications in the facility. Ms. Clarke If continuation sheet 31 of 53

32 (X1) PROVER/SUPPLIER/CLIA ENTIFICATION NUMBER: (X3) SURVEY D NAME OF PROVER OR SUPPLIER A 522 Continued From page 31 A 522 and EI#3 both responded, "No." On January 13, 2014, at 1:00 PM, EI#3 told the surveyor that she could not remember administering any acetaminophen suppositories to RI#7. EI#3 was asked to review RI#7's January MARs for the date of the 6th and identify the initials of the person who had administered the suppository. EI#3 reviewed the MARs, then admitted she administered the suppository on that date. When asked what time the suppository had been administered, EI#3 looked at the front and back of the MARs then stated she was not able to determine the time of day she administered the suppository. EI#3 said she did not know she was supposed to document the time medication was administered. EI#3 admitted that RI#7 was not able to speak to request medication or direct her care and also was not able to swallow so only suppositories and patches could be administered. A (3)(g) 18. Records and Reports A 538 All state inspection reports and any resulting corrective action plan from the past 12 months shall be posted in a prominent location. If there has been no inspection in the past 12 months, then the results of the most recent inspection and any resulting corrective action plan, shall be posted. This Rule is not met as evidenced by: Based on observation and interview, Ms. Clarke, failed to post in a prominent location the survey findings and the plan of corrective action for the If continuation sheet 32 of 53