Breckinridge Memorial Nursing Facility

Penalty

Inspection fine: $15,945

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 develop and implement a comprehensive care plan for a resident, identified as R1, who exhibited exit-seeking behaviors. Despite the resident's history of diabetes, aphasia, hemiplegia/hemiparesis, and depression, the facility did not include these behaviors in the resident's care plan. On one occasion, R1 eloped from the skilled nursing facility unit, located in a hospital, via the elevator without staff's knowledge and was found in the lobby attempting to exit through the doors. The facility's policy required comprehensive assessments to be completed within 14 days of admission, quarterly, and when significant changes in the resident's condition occurred. However, the policy did not cover elopement, and the facility did not have a specific policy for Elopement or Wandering Assessments. Interviews with staff revealed that R1 had been exhibiting exit-seeking behaviors prior to the elopement, but these behaviors were not communicated to management or included in the care plan. Staff members reported that R1 had attempted to leave the unit multiple times, but these incidents were not documented or addressed in the care plan. The deficiency was identified as Immediate Jeopardy due to the potential for serious injury, impairment, or death. The facility's failure to have an effective system in place to ensure residents' care plans addressed exit-seeking behaviors was a significant oversight. The lack of communication and documentation regarding R1's behaviors contributed to the failure to implement appropriate interventions to prevent the elopement.

Removal Plan

• The facility took immediate action to remove the IJ by returning R1 to the facility without any injury/harm sustained, as determined by an assessment performed by the RN on duty.
• Per MD order, a wander guard was placed on R1's person to ensure staff would be alerted if she tried to enter the elevator/exit the 2nd floor facility again.
• R1's family was notified, and they agreed with the plan in place.
• Staff continued to complete a weekly elopement risk assessment, per the facility's assessments policy.
• Additional policy has been created to ensure a consistent plan following an elopement.
• Education on wandering and exit-seeking behavior was provided to all staff of the nursing facility by the ADON.
• The education was added to the orientation check list for new hires of the facility by the ADON.
• The MDS Coordinator completed audits to ensure the wander guard transmitter was in place for R1 and elopement assessments were completed on the resident as per policy.
• The ADON will conduct random interviews with staff to ensure understanding of the education provided. A minimum of 2 interviews will be conducted at least once weekly for six months.
• The ADON will monitor resident charts weekly to ensure completion of elopement risk assessment.
• Assessments policy was revised to change the wording from wander risk assessment to Elopement Risk Assessment by ADON.
• A new policy titled, Elopement was created to address steps to be completed upon an elopement occurring.
• Per policy, care plans are updated immediately following a change in care by the nurse on duty. R1's care plan was updated after her elopement by the RN on duty.

Penalty

Inspection fine: $15,945

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 resident safety for one of the sampled residents, who exhibited exit-seeking behaviors. On a specific date, the resident eloped from the skilled nursing facility unit without staff knowledge and was found in the first-floor lobby of the acute care hospital where the facility was located, attempting to exit the building. The facility's policies did not adequately address elopement, and there was no specific policy for Elopement or Wandering Assessments. The resident's comprehensive care plan was not updated to reflect wandering or exit-seeking behaviors until after the elopement occurred. Interviews with staff revealed inconsistencies in the awareness and reporting of the resident's exit-seeking behaviors. Some staff members reported observing exit-seeking behaviors and attempts to leave the unit, while others did not witness such behaviors or were not informed of them. The facility's Assistant Director of Nursing (ADON) and other staff members were not aware of any exit-seeking behaviors prior to the elopement, and the facility's assessment policy did not identify the resident as an elopement risk. The facility's failure to have an effective system in place to ensure resident safety was identified as likely to cause serious injury, impairment, or death if immediate action was not taken. The deficiency was identified under 42 CFR 483.25 Quality of Care, F689, and Substandard Quality of Care (SQC) at 42 CFR 483.25. The facility's lack of a comprehensive policy and staff awareness contributed to the resident's ability to elope from the facility.

Removal Plan

• The facility took immediate action to remove the IJ. The resident was returned to the facility without any injury/harm sustained, as determined by an assessment performed by the RN on duty.
• Per MD order, a wander guard was placed on R1's person to ensure staff would be alerted if she tried to enter the elevator/exit the facility again.
• Her family was notified, and they agreed with the plan in place.
• R1 was able to continue to self-propel in her wheelchair throughout the facility while she worked on her crossword puzzles, as she normally did.
• Staff continued to complete a weekly elopement risk assessment, per the facility's assessments policy.
• Additional policy has been created to ensure a consistent plan following an elopement.
• All residents are assessed weekly per assessments policy. No other residents were considered to be an elopement risk.
• Education on wandering and exit-seeking behavior was provided to all staff of the nursing facility by the ADON.
• The education was added to the orientation check list for new hires of the facility by the ADON.
• The training was an in-person verbal educational format in which employees received a copy of the material presented. It described wandering and exit-seeking behaviors, and the steps that were to be taken should those behaviors occur within the facility.
• The MDS Coordinator completed audits to ensure the wander guard transmitter was in place for R1 and elopement assessments were completed on the resident as per policy.
• The ADON will conduct random interviews with staff to ensure understanding of the education provided. A minimum of 2 interviews will be conducted at least once weekly. If staff give any indication they were unclear of education provided, they will be reeducated immediately.
• The ADON will monitor resident charts weekly to ensure completion of elopement risk assessment. Information from all audits and interviews will be taken to quarterly QAPI meetings.
• Assessments policy was revised to change the wording from wander risk assessment to Elopement Risk Assessment by ADON.
• A new policy titled, Elopement was created to address steps to be completed upon an elopement occurring. Input for the policy was provided by QAPI members: CEO, DON, ADON, Safety Office, and Quality Officer. The new policy was provided to all Nurses.
• Per policy, care plans are updated immediately following a change in care by the nurse on duty. R1's care plan was updated after her elopement by the RN on duty.
• All staff received education on reporting behaviors. Care plans continue to be updated immediately by the nurse on duty and reviewed quarterly by the MDS Coordinator.

Penalty

Inspection fine: $15,945

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 residents had reasonable access to and privacy in their use of communication methods, specifically regarding the receipt of mail on weekends. The facility's policy on Resident Rights and Responsibilities, last revised in 2001, stated that residents should be able to send and receive mail without hindrance. However, interviews with staff revealed that there was no policy or procedure in place to handle mail delivery on Saturdays, resulting in residents not receiving their mail until the following Monday. Interviews with the Director of Nursing (DON), Administrator, and Assistant Director of Nursing (ADON) confirmed the absence of a weekend mail policy. The Activities Director (AD) and other staff members explained that the Business Office, responsible for sorting and delivering mail, was closed on weekends. Consequently, mail delivered on Saturdays was not picked up until Monday, delaying residents' access to their correspondence. This affected three cognitively intact residents, who were unaware of their right to receive mail on Saturdays. The deficiency was highlighted during a State Survey Agency Recertification Survey, prompting the ADON to acknowledge the need for a policy to ensure residents' rights to receive mail on weekends. Despite the facility's recognition of the issue, no immediate corrective actions were mentioned in the report. The lack of a weekend mail policy potentially affected all residents in the facility, as mail delivery was delayed due to the Business Office's weekend closure.

Penalty

Inspection fine: $15,945

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 residents were free from abuse, as evidenced by an incident involving two residents. On October 10, 2024, a staff member witnessed one resident strike another resident three times on the leg with a rolled-up newspaper. The incident occurred when the aggressor, who was self-propelling in her wheelchair, approached her roommate, who was lying on the bed. The facility's policy on abuse, neglect, and misappropriation mandates protection from abuse and outlines procedures for managing suspected abuse, but the incident still occurred. The aggressor had a history of behavioral issues, including refusing medications and displaying fits of anger. Her medical history included diabetes, aphasia, hemiplegia, hypertension, hyperlipidemia, and depression. The facility's care plan for her included interventions to manage her behavior, such as anticipating her needs and providing positive interactions. However, the care plan did not specifically address potential aggression towards other residents, as she had not exhibited such behavior before. The facility assessed her mental status as impaired, and she had been experiencing increased agitation and frustration due to communication difficulties following a stroke. The victim, who was unable to communicate effectively due to Alzheimer's disease and other conditions, was moved to a different room following the incident. The facility's response included notifying relevant parties and making changes to the aggressor's care plan and medications. However, the initial failure to prevent the incident and the lack of specific interventions in the care plan for potential aggression towards other residents contributed to the deficiency.

Penalty

Inspection fine: $15,945

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 properly label and store resident-specific medications, leading to a deficiency in medication management for two residents. During an observation, eight vials of antibiotics and sixty cups of Valproic Acid were found unlabeled in the medication room. The facility's policy requires medications to be labeled with resident information, but this was not adhered to, increasing the risk of medication errors. Resident 10, who was receiving intravenous antibiotics, and Resident 12, who was prescribed Valproic Acid, were directly affected by this deficiency. The antibiotics and Valproic Acid were stored without proper labeling, and staff relied on informal knowledge of the residents' medication needs rather than adhering to labeling protocols. This practice was acknowledged by the Registered Nurse and Pharmacy Director as potentially leading to medication errors. Interviews with facility staff, including the Pharmacy Director, Registered Nurses, and the Director of Nursing, revealed a lack of consistent adherence to labeling protocols. While some staff believed that barcode scanning and the five rights of medication administration could mitigate the risk of errors, the absence of resident labels on medications was recognized as a significant oversight. The Pharmacy Director admitted to occasionally delivering unlabeled medications, particularly on weekends, with the intention of labeling them later, which contributed to the deficiency.