Trinity Regional Rehab Center

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 protect a resident from neglect by not responding to an exit door alarm and not providing adequate supervision to prevent an elopement. On the day of the incident, a CNA left the resident at the nurse’s station around 1:45 p.m. to go on lunch break. The resident, who had a history of exit-seeking and wandering behaviors, was later discovered missing from his room at approximately 2:15 p.m. A facility-wide missing resident code was initiated, and staff began searching the building and surrounding area. Multiple staff members reported they did not hear any door alarms at the time of the elopement. The resident had been admitted with diagnoses including unspecified sequelae of cerebral infarction, alcohol abuse with alcohol-induced anxiety disorder, unspecified dementia with moderate cognitive impairment, cognitive communication deficit, and syncope and collapse. His most recent MDS showed a BIMS score of 10, indicating moderate cognitive impairment, and he was able to ambulate 150 feet with supervision or touching assistance. The care plan identified him as at risk for elopement due to exit-seeking behavior and ambulating without assistance in hallways, with interventions such as diversional activities, frequent visual checks, and use of an audible monitoring system. Elopement risk evaluations on multiple dates had identified him as an elopement risk, and prior progress notes documented escalating behavioral concerns, repeated attempts to leave through exit doors, agitation, combativeness, and exit-seeking behaviors. Despite this history, the resident did not have an electronic monitoring device in place at the time of the incident, and the prior intervention to use an audible monitoring system had been resolved. The resident exited from a second-floor hallway door near the maintenance office into a stairwell, holding the door handle for approximately 30 seconds to open the delayed egress door, then proceeded down the stairs to a first-floor exit door that had no alarm and could be opened freely from the inside. He then exited through another alarmed door near the business office to the parking lot, but staff reported not hearing any alarms. The resident walked through the parking lot and onto nearby roads, ultimately being found approximately 0.6 miles from the facility by a CNA who left in her car to search for him. Interviews revealed inconsistent staff understanding of which residents were at elopement risk and who should be wearing electronic monitoring devices, with at least one CNA stating she was unsure how to identify elopement-risk residents or whether any such residents were currently in the facility. The facility’s failure to supervise the resident adequately and to ensure effective functioning and response to exit door alarms resulted in an elopement that surveyors determined created a likelihood for serious injury and/or death and was cited at Immediate Jeopardy. Additional interviews highlighted gaps in communication and assessment related to the resident’s elopement risk. The Nursing Home Administrator stated that the resident did not exhibit wandering and exiting behaviors prior to the incident, despite documentation of prior exit-seeking and agitation. The resident’s primary care physician described him as having cognitive decline with variable mentation and stated that if the facility decided to remove the electronic monitoring device, this should have been communicated to him; he also reported he had not been informed of any exit-seeking behaviors. Some staff, including an LPN and CNAs, acknowledged that the resident had shown exit-seeking behaviors in November and December, and one CNA stated that if staff had known more, they might have been more aware of the need to continue monitoring for elopement risk. The combination of the resident’s known elopement risk, removal of monitoring interventions, lack of staff awareness, and failure to respond to or detect door alarms led directly to the resident’s unsupervised departure from the facility.

Removal Plan

• Implemented 1:1 enhanced monitoring for Resident #1 upon return to the facility until discharge
• Updated Resident #1’s care plan
• Completed a PTSD evaluation for Resident #1 with no concerns identified
• Reviewed Resident #1’s elopement risk status; completed an updated elopement evaluation and updated the plan of care as indicated
• Interviewed Resident #1 upon return to the facility; resident described the path taken and what occurred to the NHA/DON
• Evaluated the identified exit door used to leave the unit for proper function and alarm; no issues identified
• Evaluated all facility internal exit doors for proper function; no issues identified
• Completed education on doors and alarms for 100% of staff
• Placed temporary auditory sensor alarms at identified secondary doors that exit the facility
• Held an Ad Hoc QAPI committee meeting to review the concern, approve corrective interventions, and approve a PIP
• Initiated mock elopement drills (every shift for one week, then daily for one week, then every other day ongoing per QAPI recommendations)
• Initiated education on the Missing Resident/Elopement policy/procedure (including elopement books) and Abuse/Neglect/Exploitation; educated all facility staff and contract therapy staff
• Reviewed records of previous daily exit door checks for the past 90 days to validate completion; continued daily door checks per QAPI direction
• Reviewed elopement books to ensure proper information is in place and books are easily accessible
• Verified functioning of the electronic monitoring device check machine
• Evaluated current residents for elopement risk; completed new elopement evaluations and reviewed/updated care plans as indicated
• Reviewed current residents with electronic monitoring devices to verify evaluation accuracy/appropriateness, proper orders, and documentation for placement; updated evaluation/order/care plan as indicated
• Checked the electronic monitoring device system at the front door and confirmed it was functioning
• Held a follow-up Ad Hoc committee meeting to review actions/interventions/outcomes and approve PIP items; Medical Director participated
• Educated direct care licensed nursing staff on completion of elopement evaluations
• Verified proper functioning of exit doors and alarms by the regional maintenance consultant
• Converted locked exit doors to remove delayed egress; exit doors now require key fob/keypad for exiting; educated all facility staff and contract therapy staff
• Educated direct care licensed nursing staff on interventions and notification for residents who refuse/remove wander guard device
• Verified resident photos and resident room name door tags for identification/verification and updated as indicated
• Held an Ad Hoc committee meeting to review steps taken and approve PIP item completion
• Held an Ad Hoc committee meeting; reviewed and updated the elopement drill tracking form/process and updated the location form to ensure all facility areas are assigned
• Initiated ongoing competency testing on resident elopement awareness and prevention (signs/symptoms of exit-seeking behavior, interventions, and notification); completed for facility staff and contract therapy staff
• Provided education to licensed staff regarding identifying elopement risk and locating electronic monitoring device status

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 adequate supervision and prevent elopement for a cognitively impaired resident who had been repeatedly identified as an elopement risk. The resident was admitted with diagnoses including unspecified dementia of unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, as well as cognitive communication deficit and a history of cerebral infarction, alcohol abuse with alcohol-induced anxiety disorder, and syncope and collapse. A quarterly MDS showed a BIMS score of 10, indicating moderate cognitive impairment, and documented that the resident could ambulate 150 feet with supervision or touching assistance. The resident’s care plan included a focus area for risk of elopement, citing exit‑seeking behavior and ambulating without assistance in hallways, with interventions such as diversional activities, frequent visual checks, and use of an audible monitoring system via an electronic monitoring device, which had been initiated and then resolved prior to the incident. Elopement risk evaluations on multiple dates identified the resident as an elopement risk, and a prior physician order for a wander management bracelet had been in place but was discontinued before the elopement. In the months leading up to the incident, facility records documented ongoing concerns about the resident’s wandering and exit‑seeking behaviors. A palliative care note recorded that the resident’s representative was concerned about the resident’s wandering and overall safety. Nursing and psychology notes described escalating behavioral concerns, agitation, combativeness secondary to confusion, not following safety instructions, and repeated attempts to leave the unit through an exit door. Staff documented periods of agitation and exit‑seeking in November and December, with multiple redirection attempts required to return the resident to his room. Despite these documented behaviors and repeated elopement risk evaluations, the resident did not have an electronic monitoring device in place at the time of the elopement, and the resident’s primary care physician stated he had not been informed of exit‑seeking behaviors or of the decision to remove the electronic monitoring device. On the day of the elopement, staff last observed the resident around the nurses’ station and his room shortly before the incident. A CNA reported leaving the resident at the nurses’ station before going on break and, upon returning, was unable to locate him in his room or the building. A missing resident code was initiated, and staff began searching. The resident had exited from the second‑floor hallway near the maintenance office into a stairwell by holding the door handle for approximately 30 seconds, then proceeded down the stairs to a first‑floor door that opened to the outside without an alarm. From there, the resident walked through the parking lot and onto nearby roads, ultimately traveling approximately 0.6 miles away from the facility toward streets with posted speed limits of 30 mph and 55 mph. Multiple staff members reported not hearing any door alarms, and interviews revealed inconsistent staff understanding of how to identify elopement‑risk residents and who should be wearing electronic monitoring devices. The resident was missing for about 10 minutes without staff knowledge before being located off‑site by a CNA and returned to the facility, where he stated he had been going for a walk and that no one saw him leave. This failure to supervise and to ensure effective elopement prevention measures resulted in a determination of Immediate Jeopardy. Additional interviews and record reviews highlighted gaps in staff awareness and communication related to elopement risk and monitoring systems. One CNA stated she was unsure how to identify residents at risk for elopement or who should be wearing an electronic monitoring device and did not know if any residents in the facility were at risk. The maintenance and housekeeping director stated that only the main lobby door was protected by the electronic monitoring device system and that other doors did not use these devices, while the regional nurse confirmed that the electronic monitoring device system only worked on the front door and would not have alerted at other exits. The nursing home administrator acknowledged that the resident had an elopement assessment upon admission and had previously worn an electronic monitoring device, but did not have one at the time of the incident, and that the door used to exit to the outside did not have an alarm. Staff accounts of the incident varied regarding the duration the resident was missing, but consistently indicated that no door alarms were heard and that the resident was found off facility grounds, damp from the rain, after the missing resident code was called. These documented actions and inactions formed the basis for the cited deficiency under the requirement to keep the environment free from accident hazards and to provide adequate supervision to prevent accidents.

Removal Plan

• Implemented 1:1 enhanced monitoring for Resident #1 upon return to the facility until discharge.
• Updated Resident #1's care plan.
• Completed a PTSD evaluation for Resident #1 with no concerns.
• Reviewed Resident #1's elopement risk and completed an updated elopement evaluation with plan of care updates as indicated.
• Interviewed Resident #1 upon return to the facility and evaluated the identified exit door used for proper function/alarm with no issues identified.
• Evaluated all facility internal exit doors for proper function with no issues identified.
• Completed education on doors and alarms for 100% of staff.
• Placed temporary auditory sensor alarms at identified secondary doors that exit the facility.
• Held an Ad Hoc QAPI committee meeting to review the concern, approve corrective interventions, and approve a PIP.
• Initiated mock elopement drills.
• Initiated education on the Missing Resident/Elopement Policy/Procedure (including elopement books) and Abuse/Neglect/Exploitation and completed education for all facility staff and contract therapy staff.
• Reviewed the prior 90 days of daily exit door checks to validate completion and continued daily door checks per QAPI direction.
• Reviewed elopement books to ensure proper information is in place and books are easily accessible.
• Verified functioning of the electronic monitoring device check machine.
• Evaluated current residents for elopement risk and completed new elopement evaluations with plan of care reviews/updates as indicated.
• Reviewed current residents with electronic monitoring devices to verify evaluation accuracy/appropriateness and proper orders/documentation and updated evaluation, order, and plan of care as indicated.
• Checked the electronic monitoring device system at the front door and confirmed it was functioning.
• Held a follow-up Ad Hoc committee meeting to review actions/interventions/outcomes and approve PIP items; Medical Director participated.
• Educated direct care licensed nursing staff on completion of elopement evaluations.
• Verified proper functioning of exit doors and alarms by the regional maintenance consultant.
• Converted locked exit doors to remove delayed egress, implemented keypad/key fob exit function, and educated staff and contract therapy staff.
• Educated direct care licensed nursing staff on interventions and notification for residents who refuse/remove wander guard device.
• Verified resident photos and resident room name door tags for identification/verification and updated as indicated.
• Held an Ad Hoc committee meeting to review steps taken and approve PIP item completion.
• Held an Ad Hoc committee meeting.
• Reviewed and updated the elopement drill tracking form/process to improve organization of the search and updated the location form to ensure all facility areas are assigned.
• Initiated ongoing competency testing related to resident elopement awareness and prevention (signs/symptoms of exit-seeking behavior, interventions, and notification) and completed testing for staff and contract therapy staff.
• Provided education to licensed staff on identifying elopement risk and locating electronic monitoring device status.

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 follow its own resident care policies regarding the labeling of dressings, as required by their written procedures and professional standards of practice. Observations revealed that three residents had dressings or bandages that were not dated, timed, or initialed as specified in the facility's policy. Specifically, one resident was observed with an occlusive dressing on the left side that was not dated, another resident had three undated dressings on the right lower extremity, and a third resident had a dressing on the lower left lateral area with no date, time, or initials. These findings were confirmed through interviews with staff, who acknowledged that the expectation is to label dressings with the date and initials after care is provided. Record reviews showed that all three residents had medical conditions requiring wound care, such as wounds on the lower extremities and other chronic diagnoses. The facility's own policy and staff interviews confirmed that labeling dressings is a required step in the care process. However, the observed failure to consistently label dressings as per policy demonstrated noncompliance with both facility procedures and professional standards of practice.

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

A resident was discharged from the facility while an appeal of her discharge was still pending. The resident had received a 30-day discharge notice due to nonpayment and was informed of her right to appeal. Documentation shows that the resident filed her appeal on what the facility determined was the 11th day after notice, rather than within the 10-day window, and the facility proceeded with the discharge prior to the scheduled hearing date. Both the facility and the resident had received notice of the upcoming hearing, but the discharge was carried out before the appeal was heard. The resident had multiple complex medical conditions, including chronic hepatic failure, COPD, chronic respiratory failure, heart failure, lymphedema, morbid obesity, dysphagia, depression, and anxiety. At the time of discharge, she required significant assistance with transfers, was dependent on a sit-to-stand lift, and used a wheelchair as her primary mode of mobility. Therapy and social services notes indicated that not all necessary equipment, such as the sit-to-stand lift and upright walker, were available at her home at the time of discharge. The resident also reported not having a finalized schedule for home health services and expressed distress about being dependent on a male family member for personal care, which she found undignified and uncomfortable. Facility records and interviews confirm that the discharge was executed despite the pending appeal and without all recommended equipment and services in place. The facility's policy requires a safe, orderly, and planned discharge, including ensuring the resident's needs are met at the discharge location. The resident's care plan and therapy recommendations highlighted the need for specific equipment and support, which were not fully arranged at the time of discharge.

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 ensure that kitchen staff adhered to professional standards for food service safety, as observed during a survey. On the initial tour of the kitchen, a staff member with facial hair was seen stirring a pot without a beard guard, and the Certified Dietary Manager (CDM) was observed without a hairnet. The CDM admitted to forgetting to wear a hairnet after a morning meeting and acknowledged that the staff member should have been wearing a beard guard. Later, another staff member with facial hair was observed without a beard guard while working over a large bowl, and the CDM had to instruct him to put one on, revealing a lack of awareness about the location of beard guards. Further observations revealed a dietary aide handling food without gloves. This staff member was seen opening a loaf of bread with bare hands and placing slices on a table without washing hands or wearing gloves. The Regional Dietitian intervened, instructing the staff member to discard the bread, wash hands, and wear gloves. The staff member admitted to sometimes neglecting to wear gloves due to being busy, despite previous education on the requirement. The facility's policy clearly prohibits contact between food and bare hands and mandates the use of hairnets and beard guards, which were not followed by the staff.

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 ensure prompt efforts were made to resolve grievances related to call light response times, as documented in the Resident Council Meeting Minutes over a period of four months. Concerns were repeatedly raised by the Resident Council regarding the need for more CNAs on the floor during mealtimes, particularly on weekends, and the delay in answering call lights, especially during the 3 p.m. to 11 p.m. shift. Despite these ongoing concerns, the grievance logs from June to November 2024 did not reflect any documented grievances from the Resident Council, indicating a lack of formal acknowledgment and resolution of these issues. Interviews with facility staff revealed inconsistencies in the grievance process. The Activities Director mentioned completing grievance forms for group issues but did not keep copies, while the Social Service Director described a process for logging and resolving grievances that was not effectively tracking recurring issues like call light delays. The Nursing Home Administrator was unaware of specific grievances and did not participate in trending grievances, leaving the Social Service Director to handle this task. The Resident Council President confirmed that the call light concerns remained unresolved, highlighting a disconnect between the facility's grievance policy and its implementation.

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 wound care treatment in accordance with professional standards for four residents. Resident #413, who was cognitively intact, reported that her dressing had not been changed for four days despite orders for it to be changed every other day. The wound care nurse practitioner confirmed the dressing was overdue for a change and noted issues with the dressing not being changed as ordered. Resident #42, also cognitively intact, had undated dressings on both feet that were not changed as per the physician's orders. Observations revealed the dressings were soiled and unchanged over several days, despite being signed off as completed in the Treatment Administration Record. The resident expressed dissatisfaction with the timing of the dressing changes, indicating they were not done daily as required. Resident #263 expressed concerns about her wound treatment, stating that her left heel had been bleeding and the bandage had not been changed since it was applied. Observations confirmed the bandage was dated several days prior, and the Treatment Administration Record showed infrequent dressing changes. Resident #264 had an undated dressing on the left forearm with no corresponding treatment orders, and neither the resident nor the family was aware of the reason for the dressing. The Director of Nursing acknowledged that dressings should be dated and orders followed.

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 ensure proper storage and labeling of medications, as observed in several instances. In one case, a Licensed Practical Nurse (LPN) was found with medication cups containing crushed medication in apple sauce stored in a medication cart drawer, which she intended to administer to residents. The cart also contained loose pills, an unlabeled insulin pen, and non-medical items such as tape and scissors. The LPN admitted to a lack of education regarding the proper storage of medications and was unaware of the need for regular cleaning of the medication carts. In another instance, a resident's room was found with multiple packets of peri-care ointment on the nightstand, without any self-administration assessment or orders for the resident to self-administer medications. Additional observations in other resident rooms revealed various medications and skin protectants left unsecured on nightstands, including wound cleanser, ketoconazole shampoo, and antifungal powder. The Director of Nursing (DON) confirmed that skin protectants should be kept in the treatment cart unless a self-administration assessment is completed. Furthermore, the medication storage room was found with an unlocked refrigerator for narcotics, containing an unsecured syringe of Lorazepam. The LPN/Unit Manager was unaware of the requirement to lock the narcotic box. The facility's policy mandates that all drugs and biologicals be stored in a safe, secure, and orderly manner, with specific guidelines for labeling, storage, and separation of medications, which were not adhered to in these instances.

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 implement safety precautions for a resident who was identified as needing supervision while smoking. The resident, who was moderately cognitively impaired with a BIMS score of 11/15, was observed with cigarettes and a lighter in her possession on multiple occasions. Despite the facility's policy requiring that residents without independent smoking privileges should not keep smoking articles, the resident was allowed to hold her smoking supplies. This was contrary to the smoking assessments and care plan, which indicated that the resident needed supervision and that the facility should store her smoking supplies. Interviews with staff confirmed that the resident was a smoker who required supervision, yet she was still in possession of her smoking materials. The facility's smoking policy, which mandates safe smoking practices and the storage of smoking supplies for residents needing supervision, was not adhered to. The Nursing Home Administrator acknowledged the assessments indicating the need for supervision, yet the resident continued to have access to her smoking supplies, highlighting a lapse in the implementation of the facility's safety protocols.

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 ensure the timely and appropriate change of a central line dressing for a resident, leading to a deficiency in care. Observations revealed that the dressing on the resident's peripherally inserted central catheter (PICC) was dated 10/27/24, despite the requirement for weekly changes. The resident, who was receiving intravenous antibiotics for osteomyelitis, was unable to confirm when the dressing was last changed. Further observations noted remnants of a sticker on the dressing, and a new date of 11/20 was written on it by a staff member without evidence of a proper dressing change. The resident's medical history included orthopedic aftercare following surgical amputation, acute hematogenous osteomyelitis, and atherosclerosis with gangrene. The facility's policy required PICC line dressings to be changed within 24 hours of a new resident's arrival and then every seven days, or as needed if the dressing was soiled or loose. However, the dressing was not changed as per these guidelines, and the staff member involved acknowledged marking the dressing with a new date without confirming a proper change had occurred. This oversight was contrary to the facility's policy aimed at preventing catheter-related infections.

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 accommodate food preferences for two residents, leading to deficiencies in meal service. Resident #90, who has a controlled carbohydrate diet due to end-stage renal disease and type 1 diabetes, was observed receiving meals that did not align with their dietary restrictions. Despite having specific meal preferences documented, such as no rice or potatoes and a preference for double vegetables, Resident #90 was served rice and was not provided with alternative options. This resident expressed frustration over not receiving the correct meals and reported weight loss, relying on protein shakes for nutritional needs. The care plan for Resident #90 included monitoring for signs of malnutrition and serving the diet as ordered, which was not adhered to. Similarly, Resident #263 repeatedly requested meals without gravy but continued to receive food with gravy, which they refused to eat. The Certified Dietary Manager acknowledged the issue, noting that resident choices are documented daily and meetings are held to discuss preferences. However, the dietary staff failed to follow the tray tickets, resulting in non-compliance with resident preferences. The facility's policy on resident food preferences emphasizes assessing and communicating individual preferences upon admission and creating a care plan if the resident is dissatisfied, which was not effectively implemented in these cases.

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 ensure proper infection control practices across two units, as evidenced by several observations and interviews. In one instance, a respiratory mask was left uncovered on a bedside table in the room of a resident with chronic obstructive pulmonary disease and chronic respiratory failure. The resident confirmed that the mask was routinely left uncovered by staff. Additionally, during medication administration, a nurse was observed using a glucometer and glucose test strips without proper labeling or cleaning between residents, despite the facility having enough glucometers for each resident. Further observations revealed an ice scoop left uncovered on a cart in a hallway, which was confirmed by the Director of Nursing (DON) as against facility policy. The DON also acknowledged that respiratory masks should be stored in a bag or box when not in use. The facility's infection prevention and control policies were not adhered to, as evidenced by the improper handling of clean linens and the lack of cleaning of glucometers between uses. Another deficiency was noted in the handling of a resident suspected of having Clostridium Difficile (C-diff). The resident, who had complained of loose stools, was not placed on contact precautions, and no signage was posted on the room door to indicate the need for precautions. The resident was also sharing an IV medication pole with another resident. The facility's policy stated that transmission-based precautions should be initiated when a resident shows signs of a transmissible infection, but this was not followed, as confirmed by the acting Infection Preventionist and the Nursing Home Administrator.