Facility Name: Utopia Care Center Facility ID: 22222 Date: 12/11/11 Surveyor Name: Mr. Ford Resident Name: Mrs. Jones Resident ID: 11 Initial Admission Date: 8-31-11 Interviewable: Yes x No Resident Room: 100 Care Area(s): Use Use this protocol for a sampled resident exhibiting physically or verbally abusive behaviors; socially inappropriate or disruptive behaviors, including resistance to care; psychosocial adjustment difficulties after admission; symptoms of depression; and/or presence of delirium. Procedure Briefly review the assessment, care plan, and orders to identify facility interventions and to guide observations to be made. Corroborate observations by interview and record review. FORM CMS-20067 (11/2010)
Observations (if the resident is still in the facility) FORM CMS 20067 (11/2010) 2
Observe whether staff consistently implements the care plan over time and across various shifts. Staff are expected to assess and provide appropriate care for residents with behavioral, mental status and/or emotional status symptoms from the day of admission. During observations of the interventions, note and/or follow up on deviations from the care plan as well as potential negative outcomes, including but not limited to the following: The quality of staff to resident interactions staff respond to residents who are exhibiting behavioral and/or mental/psychosocial symptoms in a manner that emphasizes the resident s quality of life while ensuring the safety of others; and Specific interventions consistently employed from one staff to another and across shifts. This CE is being completed due to being triggered from the Admission/90 day MDS assessment that indicated the resident had an increase in physical behaviors (pacing/pushing staff) on the 90 day assessment. The resident also has a presence of wandering. The resident was observed on 12/11/11 at 8:00 A.M., in the dining room sitting in a dining room chair with her head bobbing up and down towards her plate of food. Her breakfast was untouched. An interview with the nursing assistant in the dining room said the resident usually ate very well, but recently it s all she can do to keep her awake to eat her breakfast and lately she had to queue her to eat. The nursing assistant said the resident seemed drowsy and the resident told her she was always so sleepy. The nursing assistant attempted to arouse the resident to eat, but she pushed the nursing assistant away. The nursing assistant stated she reported it to the nurse. The resident was observed at 9:30 A.M. and 11:30 A.M. asleep in her bed with music and the lights on. At 12:30 P.M., the daughter came to visit the resident and was observed waking her mother up. The daughter was interviewed and stated she visits everyday for lunch and noticed that her mother was always sleeping. She said her mother told her, I just don t know what is wrong with me sometimes I sleep the day away. On 12/12/11 at 8:10 A.M., a nursing assistant was observed attempting to walk the resident, but she was pushing the nursing assistant s arm away. The nursing assistant said, Some days she is with it and walks by herself and other days I have to hold onto to her if she will let me. If we don t it will be another fall from being drowsy. A second shift nursing assistant was interviewed at 5:00 P.M., and stated the resident is a little confused at times, but the biggest problem is she won t stay in her room at night, I try to get her to go back to bed and she just keeps coming back out into the hallway. The resident paces in the halls and we just keep taking her back. The nurse will give her something and she goes right to sleep. She was not aware of any special interventions that help and did not know where the care plans were kept. She was aware of the DVD player, radio and DVD s in her room, but had never been told that they may decrease her behaviors. FORM CMS 20067 (11/2010) 3
Resident/Representative Interview Interview the resident, family or responsible party to the degree possible to identify: Resident's/Representative's involvement in the development of the care plan including providing insight into why behavioral or mood reactions might occur, defining the approaches and goals, and if interventions reflect choices and preferences; Resident's/Representative's awareness of management programs to address behavioral, mental status or mood symptoms and if interventions are provided according to the care plan; and If interventions are refused, whether counseling on alternatives, consequences, and/or other alternative approaches to address behavioral, mental, and/or emotional symptoms were offered. The daughter was interviewed on 12/12/11 at noon and told the surveyor the resident did wander about the unit, but was harmless. She said her mother was happy and sometimes a little confused. She said she was the person to be contacted for a change in condition and was very involved in her mother s care and attended all her care conferences. She said she attended the most recent care conference. The interventions for the confusion, wandering, falls and her medications were reviewed. The nurse discussed her mother s medications that included Ativan and Zyprexa for her dementia, but she was not aware if they had to give her the Ativan. The daughter discussed with the staff that classical music, old movies that she provided in her room with a DVD player and leaving the lights on in her room seemed to soothe her mother. The staff assured the daughter the interventions were on her mother s care plan and the staff were aware those interventions were to be followed prior to the administration of any medication. The daughter mentioned to the staff nurse that she had noticed when she comes to visit her mother was extremely tired and she couldn t keep her eyes opened and she voiced concerns about her falls. The nurse said she would speak to the physician about her concerns. Staff Interviews Interview staff on various shifts to determine: Knowledge of behavioral management or mental/psychosocial interventions that should be carried out, and how this information is communicated between disciplines and to direct care staff; The process that is in place to review behavior and/or mental/psychosocial symptoms and the roles various disciplines play in the management of behavioral and/or mental/psychosocial symptoms; If nursing assistants know what, when, and to whom to report indications of behavioral, mental and/or emotional status changes; The surveyor interviewed the nurse caring for the resident on 12/12/11 at 1:00 P.M. The nurse said the resident was pleasant and confused at times, but didn t pace on her shift. She said the resident was on Zyprexa and Ativan prn, but she had never had to give the Ativan to the resident. At 4:30 P.M., the second shift nurse who was caring for the resident was interviewed. She stated the resident always paced in the halls on her shift. She said, the staff put her back in her room, but she will never stay in there and go to sleep, she is just back and forth. She said the physician ordered Ativan 2mg IM for her dementia. The nurse verified FORM CMS 20067 (11/2010) 4
Staff Interviews and How staff monitor for the implementation of the care plan, effectiveness of interventions, and any changes in symptoms that have occurred over time. that she had administered the Ativan on 18 times on her shift in the past 30 days, 12 nights towards the end of November and 6 nights the first part of December. The nurse said, It always happens at the same time every night, when I give it she stays in the bed, keeps her from falling and she sleeps like a log. The nurse was not aware of any interventions listed on the care plan and didn t think about looking. The DON was interviewed on 12/12/11 at 5:15 P.M. The DON verified the nursing assistants and nurses should be aware of all interventions on the care plans for the resident. The DON verified the nurse should not have administered the Ativan 2mg IM on 18 nights, 12 nights in November and 6 nights the first week of December without trying the other interventions first. The DON verified if the resident had behaviors that were severe the nurse should have notified the physician. The DON also verified the Consultant Pharmacist came every month and left her monthly reports for the physician s review. The DON provided the copies for the resident s drug regimen. The Consultant Pharmacist documented the use of the Ativan on 12 occasions in November and the six times it was administered in December and recommended the evaluation for the use of the drug. The DON verified that she did not have time to review the reports and had not given them to the physician for review and therefore the recommendations had not been acted upon. Assessment Review the MDS, physician orders, therapy notes, and other progress notes that may have information regarding the assessment of behavior symptoms, assessment of mental and/or psychosocial needs, and resident responsiveness to management programs or interventions. Determine whether the assessment information accurately and comprehensively reflects the status of the resident for: Time, duration, and severity of behaviors and/or mental/psychosocial symptoms (depression, labile or volatile mood, adjustment reactions, delirium) exhibited; The Admission MDS assessment dated 9/12/11 indicated the resident had behavioral symptoms of pacing/pushing. The quarterly MDS assessment dated 12/10/11 indicated the resident had an increase in behavioral symptoms directed towards others of pacing/pushing. There was no evidence of any non-pharmological interventions attempted prior to the use of the Ativan. Further review of the nurses' notes revealed the night shift nurse documented the resident was pacing up and down the hallway and she administered the Ativan on several occasions. The FORM CMS 20067 (11/2010) 5
Assessment Causal, risk, and contributing factors for any behavioral and/or mental/psychosocial symptom(s) that the resident is exhibiting, such as decline in cognitive functioning, confusion, or delirium; and Resident participation in any behavioral management interventions or programs to address mental/psychosocial symptoms (such as symptoms of depression, labile or volatile mood, adjustment reactions). NOTE: If a resident is resisting ADL care, it may be due to a genuine psychological symptom or may be a legitimate defensive reaction to coercive facility practices (such as forcing a resident to endure a shower even while the resident is striking out and protesting). The surveyor should determine whether the facility s practices are the causal factor for the resident s reaction. If so, these constitute deficient practices (Abuse) and not a behavioral symptom. Determine whether there was a "significant change" in the resident's condition and whether the facility conducted a significant change comprehensive assessment within 14 days. A "significant change" is a decline or improvement in a resident's status that: 1. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions, is not "self-limiting;" 2. Impacts more than one area of the resident's health status; and 3. Requires interdisciplinary review and/or revision of the care plan. If there was a "significant change" in the resident's condition and the facility did not conduct a significant change comprehensive assessment within 14 days, initiate F274, Resident Assessment When Required. If a comprehensive assessment was not conducted, also cite F272. 1. If the condition or risks were present at the time of the required comprehensive assessment, did the facility comprehensively assess the resident s physical, mental, and psychosocial needs to identify the risks and/or to determine underlying causes (to the MDS nurse was interviewed on 12/13/11 at 8:00 A.M. and said her coding on the quarterly MDS was gathered from the documentation from the nurse s notes. She stated the resident did have an increase in physical behaviors on her quarterly assessment. She stated staff would be aware of where care plans are located, but was not aware of how the nursing staff was made aware of the interventions. FORM CMS 20067 (11/2010) 6
Assessment extent possible) of the resident s behavioral and/or mental/psychosocial symptoms, and needed adaptations, and the impact upon the resident s function, mood, and cognition? x Yes No F272 NA, condition/risks were identified after completion of the required comprehensive assessment and did not meet the criteria for a significant change MDS NOTE: Although Federal requirements dictate the completion of RAI assessments according to certain time frames, standards of good clinical practice dictate that the assessment process is more fluid and should be ongoing. The comprehensive assessment is not required to be completed until 14 days after admission. For newly admitted residents, before the 14 day assessment is complete, the lack of sufficient assessment and care planning to meet the resident s needs should be addressed under F281, Professional Standards of Quality. Care Planning If the comprehensive assessment was not completed (CE#1 = No), mark CE#2 NA, the comprehensive assessment was not completed. Determine whether the facility developed a care plan that was consistent with the resident s specific conditions, risks, needs, behaviors, and preferences and current standards of practice, and included measurable objectives and timetables, with specific interventions/services for the management and treatment of behavioral, mental and/or emotional symptoms. If the care plan refers to a specific facility treatment protocol that contains details of the treatment regimen, the care plan should refer to that protocol and should clarify any deviations from or revisions to the protocol for this resident. The treatment protocol must be available to the caregivers, and staff should be familiar with the The care plans were reviewed and were dated 11/30/11. The care plans listed the medications, doses and reduction goals, side effects and interventions for the resident s mild confusion, pacing and pushing behaviors. The interventions included: re-direct the resident, classical music, play DVD s of old movies in her room and leave the lights on in her room. Offer warm drinks (hot chocolate or hot tea), sit with resident or one on one. Offer magazines, books or puzzles. Bring the facility s pet cat into room and allow her to pet the cat while she lies in bed. If non-pharmacological interventions were not effective may administer Ativan 2mg IM prn, per physician s order. Evaluate interventions at next review. FORM CMS 20067 (11/2010) 7
Care Planning protocol requirements. If care plan interventions that address aspects of the behavioral management/treatment plan are integrated within the overall care plan, the interventions do not need to be repeated. Review the care plan to determine whether the plan is based upon the goals, needs, and strengths specific to the resident and reflects the comprehensive assessment. Determine whether the plan: Identifies the degree of staff assistance or involvement needed to manage behavior/mental/emotional symptoms; States problems with behavioral and/or mental/psychosocial symptoms in behavioral and/or functional terms as they relate specifically to the individual resident; Identifies specific interventions related to managing the resident s behavioral and/or mental/psychosocial symptoms and related risk or causal factors that reflect the resident s medical/health condition and resident preferences and opinions; Includes baseline and ongoing measurement of the behavior and/or mental/psychosocial symptom(s) and expected response to interventions; and If the resident refuses or is resistant to the behavior management program or mental/psychosocial intervention, the care plan reflects efforts to find alternative means to address the behavior and/or mental/psychosocial symptoms based on causal and contributing factors determined in the assessment process. If care plan concerns are noted, interview staff responsible for care planning as to the rationale for the current plan of care. 2. Did the facility develop a plan of care with measurable goals and interventions to address the care and treatment related to the resident s behavioral and/or mental/psychosocial symptoms, in accordance with the assessment, resident s wishes, and current standards of practice? x Yes No F279 FORM CMS 20067 (11/2010) 8
Care Planning NA, the comprehensive assessment was not completed The comprehensive care plan does not need to be completed until 7 days after the comprehensive assessment (the assessment completed with the RAPS). Lack of sufficient care planning to meet the needs of a newly admitted resident should be addressed under F281, Professional Standards of Quality. Care Plan Implementation by Qualified Persons Observe care and interview staff over several shifts and determine whether: Care is being provided by qualified staff, and/or The care plan is adequately and/or correctly implemented. 3. Did the facility provide or arrange services to be provided by qualified persons in accordance with the resident s written plan of care? Yes x No F282 NA, no provision in the written plan of care for the concern being evaluated Interview with the staff nurse (see above) indicated the non-medical interventions listed on the care plan were not implemented prior to the administration of the Ativan. The DON verified during the interview the nursing staff did not follow the plan of care. The DON provided the policy and procedure on the administration of psychoactive medications and the policy indicated the plan of care should be followed, including the attempts of non-pharmacological interventions prior to the administration of any medications. FORM CMS 20067 (11/2010) 9
Care Plan Revision If the comprehensive assessment was not completed (CE#1 = No), OR, if the care plan was not developed (CE#2 = No), mark CE#4 NA, the comprehensive assessment was not completed OR the care plan was not developed. Determine whether the staff have been monitoring the resident's response to interventions for prevention and/or treatment and have evaluated and revised the care plan based on the resident s response, outcomes, and needs. Review the record and interview staff for information and/or evidence that: If the resident experienced a decline in behavior or mental/psychosocial status or lack of improvement in behavior mental/psychosocial symptoms, the care plan was revised/updated with more appropriate goals or interventions, based on a determination of causal or contributing/risk factors (e.g., unstable condition, acute health problem or change in condition, change in ability to make decisions, change in cognition, a change in medications, sensory problems, environmental disturbances); Staff evaluated outcomes of the plan (the effect of care plan goals and interventions); and The resident and/or the responsible person was involved in the review and revision of the plan. 4. Did the facility reassess the effectiveness of the interventions and review and revise the plan of care (with input from the resident or representative, to the extent possible), if necessary, to meet the needs of the resident? x Yes No F280 NA, the comprehensive assessment was not completed OR the care plan was not developed The care plan was revised as needed. FORM CMS 20067 (11/2010) 10
Provision of Care and Services For the resident who displays mental or psychosocial adjustment difficulties: Determine whether staff have: Recognized and assessed factors affecting the resident s behavioral and/or mental/psychosocial/emotional status; Defined and implemented pertinent interventions consistent with resident condition, goals, and recognized standards of practice to try to: Address factors contributing to psychosocial adjustment difficulties or symptoms such as delirium or behavioral and/or emotional symptoms unrelated to adjustment difficulties; Monitored and evaluated the resident s response to interventions; and Revised the approaches as appropriate. Determine whether there was an avoidable onset of problems or decline in behavioral or mental/psychosocial status, or lack of improvement in behavior or mental/psychosocial status. ` FORM CMS 20067 (11/2010) 11
Provision of Care and Services 5. Based on observation, interviews, and record review, did the facility provide appropriate treatment and services to correct the assessed problem for a resident who displays mental or psychosocial adjustment difficulty? Yes No x NA F319 NA, the resident does not display mental or psychosocial adjustment difficulty The resident did not demonstrate any problems with adjustment to the nursing home placement. The social worker was interviewed on 12/12/11 at 6:00 P.M., and verified the resident was pleasant and had done very well since her placement in the facility. She said the resident paced at times on the evening shift, but was not aware of her ever being a problem. The social worker was aware of interventions on her care plan that helped reduce her behaviors. She said the daughter made sure the facility was aware of what to do when the resident had behaviors because they worked for her when the resident lived with the daughter prior to nursing home placement at home. For the resident whose assessment did not reveal a mental or psychosocial adjustment difficulty: 6. Based on observation, interviews, and record review did the facility ensure that the resident whose assessment did not reveal a mental or psychosocial adjustment difficulty does not display a pattern of decreased social interaction and/or increased withdrawal, anger, or depressive behaviors, unless the resident s clinical condition demonstrates that such a pattern is unavoidable? x Yes No NA F320 NA, the resident s assessment revealed a mental or psychosocial adjustment difficulty `There were no issues with adjustment difficulties. FORM CMS 20067 (11/2010) 12
Provision of Care and Services For the resident who requires care and services to attain or maintain the highest practicable mental or psychosocial well-being: 7. Based on observation, interviews, and record review did the facility provide the necessary care and services to attain or maintain the highest practical physical, mental, and psychosocial well-being in accordance with the comprehensive assessment and plan of care? Yes x No F309 The resident did not receive appropriate care regarding her behaviors. The care plan listed very specific interventions to reduce the resident s behaviors, the night shift staff was not aware of the interventions and did not implement them. The DON verified the care plan interventions should have been used prior to the use of Ativan. The DON verified on days when the resident did not receive the Ativan she was able to feed herself and ambulate with supervision. The DON also verified she failed to review the Consultant Pharmacy Report and provide it to the physician for review and therefore recommendations were not acted upon. FORM CMS 20067 (11/2010) 13
Concerns with Independent but Associated Structure, Process, and/or Outcome Requirements During the investigation of services that address behavioral, mental and/or psychosocial needs, the surveyor may have identified concerns with related outcome, process and/or structure requirements, such as the examples listed below. If an additional concern has been identified, the surveyor should initiate the appropriate care area or F tag and investigate the identified concern. Do not cite any related or associated requirements before first conducting an investigation to determine compliance. Notification of Changes Determine whether staff: Consulted with the physician regarding significant changes in the resident s condition, including the need to alter treatment significantly or failure of the treatment plan; and Notified the resident s representative (if possible) of significant changes in the resident s condition. Abuse Determine whether the facility is engaging in coercive practices to force a resident to endure ADLs or treatments against his/her will. Initiate the Abuse care area for the resident and Abuse Prohibition for the facility if concerns were identified. Dignity Determine whether staff respond to behavioral and/or emotional symptoms in a manner that promotes a sense of dignity and self worth. Social Services Determine whether the facility is providing medically related social services, including Maintaining contact with family; Providing or arranging for provision of needed counseling services; Supporting preferences, customary routines, concerns, and choices; Finding options that most meet the psychosocial and emotional needs of the residents; Providing alternatives to drug therapy or restraints by Consideration of additional citations could be notification of change, dignity, falls and unnecessary medication. FORM CMS 20067 (11/2010) 14
Concerns with Independent but Associated Structure, Process, and/or Outcome Requirements understanding and communicating to staff why residents act as they do, what they are attempting to communicate, and what needs the staff must meet; Teaching staff how to understand and support resident s individual needs; and Promoting actions by staff that maintain or enhance dignity. F271, Admission Orders Determine whether the facility received physician orders for provision of immediate care before conducting the comprehensive assessment and developing an interdisciplinary care plan. F278, Accuracy of Assessments Determine whether staff, that are qualified to assess relevant care areas and are knowledgeable about the resident s status, needs, strengths, and areas of decline, conducted an accurate assessment. F281, Professional Standards Determine whether the services provided or arranged by the facility met professional standards of quality. Professional standards of quality is defined as services that are provided according to accepted standards of clinical practice. Unnecessary Medication Review Determine whether the facility ensures the resident is free from unnecessary medications and that antipsychotic drugs are used appropriately. An unnecessary medication is any medication when used: In excessive dose (including duplicate therapy); or For excessive duration; or Without adequate monitoring; or Without adequate indications for its use; or In the presence of adverse consequences which indicate the dose should be reduced or discontinued; or Any combinations of the reasons above. Antipsychotic medication use based on comprehensive assessment of FORM CMS 20067 (11/2010) 15
Concerns with Independent but Associated Structure, Process, and/or Outcome Requirements the resident: The facility has ensured that residents who have not used antipsychotic medications are not given these medications unless antipsychotic medication therapy is necessary to treat a specific condition as diagnosed and documented in the clinical record; and The facility has ensured that residents who use antipsychotic medications receive gradual dose reductions and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these medications. Sufficient Nursing Staff Determine whether the facility had qualified staff in sufficient numbers to provide necessary care and services, based upon the comprehensive assessment and care plan, to manage and/or treat the resident s behavioral, mental and/or emotional symptoms. F514, Clinical Records Determine whether the clinical records: Accurately and completely document the resident's status, the care and services provided (e.g., to prevent, to the extent possible, or manage the resident s pain) in accordance with current professional standards and practices and the resident s goals; and Provide a basis for determining and managing the resident's progress including response to treatment, change in condition, and changes in treatment. FORM CMS 20067 (11/2010) 16