Aviata At West Palm Beach

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to honor a resident’s full code status and to provide ordered emergency care/CPR when the resident was found unresponsive. The resident was cognitively intact, had a tracheostomy and a feeding tube, required substantial/maximal assistance with activities of daily living, and was receiving hospice services. The resident’s care plan and physician’s orders documented an advanced directive of full code. Despite this, when the resident was found without chest rise and without vital signs, no CPR or emergency services were initiated. On the night of the incident, a CNA working the 11P–7A shift found the resident unresponsive during initial rounds and immediately notified the RN assigned to the resident. The CNA then continued with her rounds. The RN assessed the resident, determined that the resident was not breathing and had no vital signs, but did not check the resident’s chart or electronic record for code status. The RN assumed the resident was a DNR because the resident was on hospice, and therefore did not initiate CPR or call 911. Instead, the RN called the physician, who instructed her to call hospice, and hospice was notified. A hospice nurse was dispatched, and post-mortem care was provided. The RN documented that the resident was found with no chest rising and no vital signs, that hospice was called, and that post-mortem care was provided, but did not document any attempt at CPR. Another RN on the same 7P–7A shift returned from break around 12:30 AM and saw a hospice chaplain at the nurses’ station and the first RN charting. When he inquired, he was told that the resident had died. He observed on the computer screen that the resident was a full code and informed the first RN of this. Despite recognizing that the resident was a full code, he did not report the situation to anyone, continued his shift, and left the facility without notifying administration. The facility’s Regional Nurse Consultant later discovered, during chart audits of discharged residents, that no CPR had been performed on a resident with full code status and notified the Administrator. The Administrator, who also served as Abuse Coordinator, confirmed with the first RN that CPR and 911 had not been initiated. The facility’s abuse and neglect policy defined neglect as failure to provide necessary goods and services to avoid physical harm, pain, mental anguish, or emotional distress, and included failure to report observed or suspected abuse or neglect as an example of neglect. The failure to perform CPR on a full-code resident and the failure of staff to report the incident to administration were identified as neglect. The Immediate Jeopardy began when the resident was found unresponsive and no CPR or emergency services were initiated, despite the resident’s documented full code status. The facility’s own review and interviews established that the RN responsible for the resident did not verify code status and acted on an assumption based solely on the resident’s hospice enrollment. Additionally, the second RN, after learning that the deceased resident was a full code, did not report the occurrence to administration or take further action. These inactions, in the context of the facility’s abuse and neglect policy and the resident’s clearly documented wishes and orders, led to the determination of neglect and Immediate Jeopardy related to failure to provide basic life support according to physician’s orders and advanced directives.

Removal Plan

• Provided individualized training to the involved registered nurse on the Florida Cardiopulmonary Resuscitation Policy, emphasizing steps to take when a resident is unresponsive.
• Suspended the involved registered nurse pending investigation.
• Terminated the involved registered nurse’s employment.
• Verified all current licensed nurses have active BLS/CPR certification cards.
• Conducted code blue drills, education, and post-testing for all licensed nurses.
• Completed an audit of Advanced Directive Discussion forms to ensure resident code status reflects and honors resident wishes.
• Held an ad hoc QAPI Committee meeting to review root cause analysis recommendations.
• Developed and initiated a Performance Improvement Plan based on the root cause analysis identifying failure to follow the Advanced Directive Policy and Procedure.
• Initiated code drills until all current nursing staff participated.
• Provided education to the second nurse who identified the code status regarding the importance of reporting the incident to facility administration.
• Initiated licensed nurse education on CPR policy and procedure, Advanced Directives policy and procedure, Abuse and Neglect, and the requirement to report neglect to administration, with post-testing and participation in code blue drills to validate competency.
• Educated all employees on the Abuse and Neglect policy and procedure, including reporting requirements.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to provide basic life support/CPR in accordance with a resident’s documented full code status and physician orders. Facility policy required that CPR be provided to all residents in cardiac arrest unless there was a fully executed DNR order, and that in the absence of such an order, the nurse must immediately begin CPR and continue until EMS assumed responsibility. The policy also required two nurses to verify resident identification and the presence of a fully executed DNR order in the advanced directive section of the medical record. In this case, the resident had a care plan and a physician’s order specifying full code status, and there was no documentation of a DNR order. Record review showed that the resident was cognitively intact, required substantial/maximal assistance with ADLs, had a tracheostomy and a feeding tube, and was receiving hospice services. The hospice nurse reported that the resident was alert, oriented, and personally chose to be full code, and that hospice honored residents’ decisions to remain full code. Despite this, when the resident was found unresponsive, the required verification of code status and initiation of CPR did not occur. A CNA working the night shift found the resident unresponsive at the start of her shift and immediately notified the RN assigned to the resident, then continued her rounds. The assigned RN stated that upon being notified, she assessed the resident around 11:15 PM, found no breathing and no vital signs, but did not check the chart for code status and did not initiate CPR or call 911. She reported that she assumed the resident was DNR because the resident was on hospice, and instead called the physician, who told her to call hospice, and then she called hospice. A progress note later documented that the resident was found with no chest rise and no vital signs, hospice was called, a hospice nurse was dispatched, and post-mortem care was provided. Another RN on the same shift stated that when he returned from break around 12:30 AM, he saw a hospice chaplain at the nurses’ station and observed the first RN charting; when told the resident had died, he saw on the computer that the resident was full code and informed the first RN of this, but he did not report the situation to anyone and continued his shift. The facility later identified that no CPR or emergency services were initiated for a resident with a full code order, and the resident died. The facility determined that Immediate Jeopardy began when the resident was found unresponsive and no CPR was initiated, and that the noncompliance involved failure to follow the advanced directive and CPR policies and procedures. Interviews with leadership confirmed that the expectation was for licensed nurses to follow facility policy and perform CPR in the absence of DNR orders, and that in this incident, those expectations were not met. The root cause analysis identified failure to follow the Advanced Directive Policy and Procedure as the cause of the noncompliance.

Removal Plan

• Provided individualized training to the involved registered nurse on the Florida Cardiopulmonary Resuscitation (CPR) Policy with emphasis on steps to take when a resident is unresponsive.
• Suspended the involved registered nurse pending investigation.
• Terminated the involved registered nurse’s employment.
• Verified that current licensed nurses have active BLS/CPR certification cards.
• Completed code blue drills, education, and post-testing for licensed nurses to validate understanding and competency.
• Completed an audit of Advanced Directive Discussion forms to ensure resident code status reflects and honors resident wishes.
• Held an ad hoc QAPI Committee meeting to review root cause analysis recommendations (including Medical Director participation) and obtained committee approval of recommendations.
• Developed and initiated a Performance Improvement Plan based on the root cause analysis, identifying failure to follow the Advanced Directive Policy and Procedure.
• Initiated code drills and continued until all current nursing staff participated.
• Provided education to the second nurse who identified the code status regarding the importance of reporting the incident to facility administration.
• Provided licensed nurse education on CPR Policy/Procedure, Advanced Directives Policy/Procedure, and Abuse/Neglect, with post-testing and required passing scores.
• Continued Code Blue Drills on each shift, with results reviewed in QAPI meetings to determine need for further drills and/or education.
• Assigned the Human Resources Generalist to monitor licensed nurses’ CPR cards to ensure active CPR certification and to verify CPR certification for all newly hired licensed nurses.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Facility staff failed to provide necessary care and services for a resident with paraplegia and a history of recurrent urinary tract infections (UTIs), who required monthly catheter changes and prescribed antibiotic therapy. Clinical record review showed that the resident was dependent on staff for personal hygiene, bathing, dressing, and toileting, and had an indwelling urinary catheter. The care plan included approaches to minimize infection risk, such as administering antibiotics as ordered and performing monthly catheter changes. However, review of medication administration records and progress notes revealed no evidence that the resident received the prescribed monthly antibiotic therapy or catheter changes over several months. There was also no documentation indicating that the resident refused these interventions. The resident experienced symptoms including pain on urination, cough, and bladder spasms, and subsequently requested to be seen by a provider. The provider noted a history of recurrent UTI, cloudy urine with sediments, and ordered diagnostic tests. Later that day, the resident was transferred to the hospital, where they were diagnosed with a UTI and suspected urosepsis, and admitted for medical management. Interview with the Director of Nursing confirmed the absence of documentation for both the antibiotic therapy and catheter changes, as well as any resident refusal of care.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain sanitary conditions in the kitchen and food service areas, as observed during a survey. During an initial kitchen tour, a personal cellular device was found on a prep table, and there was an accumulation of food residue on the sharpening stones of a slicer. Additionally, containers of barbecued pork and meatballs were improperly cooled, with temperatures recorded at 49 and 51 degrees Fahrenheit, respectively, from the previous day. The wall near the handwashing sink was damaged, and there was black residue inside the ice machine. In a follow-up kitchen tour, further deficiencies were noted. A dietary aide was observed adjusting glasses, using a personal cellular device, and handling food without performing hand hygiene. Ice from an unknown source was found in the handwashing sink, and another dietary aide was wearing loose-fitting bracelets while preparing food. Additionally, a dietary aide was seen handling portioned drinks with bare hands, directly contacting the lip surface of the cups. These observations indicate a failure to adhere to professional standards for food safety and sanitation.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide timely toenail care for a resident who was admitted with multiple medical conditions, including end-stage renal disease, protein-calorie malnutrition, atrial flutter, bilateral non-pressure wounds of the lower extremities, anemia, hypertension, major depressive disorder, and difficulty walking. The resident, who was cognitively intact, required assistance with activities of daily living such as bathing, dressing, and footwear. Despite having an order for podiatry care upon admission, the resident's toenails were observed to be long and causing discomfort, with one toenail curving into the foot, leading the resident to wear sandals due to pain. Interviews with staff revealed a lack of clarity and follow-through regarding responsibility for toenail care. The MDS Coordinator indicated that the nursing staff was responsible, but there was no documentation of previous podiatry consultations. The resident reported repeatedly asking for nail care over two months without resolution. CNAs stated they would notify a nurse if they were unable to cut a resident's nails, and an LPN confirmed the ability to request a podiatry consult. However, no prior consults were documented, and a new order for podiatry was only written after the surveyor's interview with the resident.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to assess and provide Range of Motion (ROM) exercises as requested by a resident diagnosed with Guillain-Barre Syndrome, Type 2 Diabetes, Osteoarthritis, and Paraplegia. The resident, who had a Brief Interview for Mental Status (BIMS) score of 15, expressed concerns about becoming weaker without ROM exercises. Despite having a physician's order for a physical therapy evaluation and treatment, the resident had not received physical therapy, occupational therapy, or ROM exercises in the last seven days, as indicated in the Minimum Data Set (MDS). The resident communicated her desire for ROM exercises to the MDS Coordinator during meetings and when her family was present, but no action was taken. Interviews with facility staff revealed a lack of communication and follow-through regarding the resident's request for ROM exercises. The Director of Rehabilitation (DOR) was unaware of the resident's request and stated that a restorative aide typically performs ROM exercises. The MDS Coordinator acknowledged the resident's refusal to get out of bed and medication refusal but did not confirm if the resident had refused a rehab screening. The MDS Coordinator did not provide additional documentation to support the resident's care plan or refusal of services by the end of the survey.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain a PICC line in a sanitary manner for a resident, identified as Resident #375, who was admitted with acute osteomyelitis, a pressure ulcer, and a methicillin-resistant Staphylococcus aureus infection. Upon observation, the PICC line dressing was found to be dated prior to the resident's admission, and the resident confirmed that the dressing had not been changed since admission, although it was flushed. The facility's policy required the dressing to be changed 24 hours after insertion and weekly thereafter, or as needed if compromised. The Medication Administration Record (MAR) indicated that the dressing was marked as changed on three separate occasions, but the Director of Nursing (DON) acknowledged that these changes did not occur. This discrepancy between the MAR and the actual care provided highlights a failure in adhering to the facility's policy and physician orders regarding PICC line maintenance, leading to a deficiency in the standard of care provided to the resident.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to adhere to fluid restrictions for a resident who required dialysis care. The resident, who was moderately cognitively impaired, had a care plan that included a fluid restriction of 1000 ml per day due to End Stage Renal Disease (ESRD) and hemodialysis treatment. Despite these restrictions, observations revealed that the resident was frequently provided with fluids exceeding the prescribed limits. On multiple occasions, the resident was found with various beverages on the overbed table, including water, apple juice, coffee, and tea, which collectively surpassed the daily fluid allowance. Interviews with staff members highlighted a lack of consistent adherence to the fluid restriction protocol. Staff members reported that the resident often requested additional fluids and became upset when attempts were made to remove them. The Director of Nursing and other staff acknowledged the resident's non-compliance and the challenges in managing her fluid intake, noting that she would sometimes obtain fluids from the kitchen or vending machines. The Registered Dietitian emphasized the risks associated with fluid overload, including potential cardiac issues, but noted that the resident was previously more oriented and compliant with restrictions. The facility's failure to manage the resident's fluid intake effectively was compounded by communication gaps among staff. The kitchen staff, for instance, provided fluids without being aware of the resident's restrictions. This lack of coordination and oversight contributed to the resident's non-compliance with the prescribed fluid restrictions, posing a risk to her health due to potential fluid overload and related complications.