Pender Memorial Hosp Snf

Penalty

Inspection fine: $56,989

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

Nurse Aide (NA) #1 failed to immediately report an incident of abuse when Resident #2 threatened Resident #1 with a knife. The administration was not made aware of the incident until two days later when Resident #1 reported it to Nurse #1, who then informed the administration. This delay in reporting resulted in the knife remaining in Resident #2's possession, and no protective measures were implemented immediately, placing all residents at risk of harm from further abuse by Resident #2. The facility also failed to notify the state agency of the abuse within the required timeframe and did not report the abuse to Adult Protective Services (APS). The administration only contacted the state agency on 4/18/24, a week after becoming aware of the incident. This delay in reporting and failure to follow proper procedures contributed to the severity of the deficiency. Interviews with staff and residents revealed that NA #1 did not take the threat seriously and did not want to be involved, which led to her inaction. The Director of Nursing (DON) and the facility Administrator were unaware of the need to report the incident to APS and were unsure if the incident was reportable to the state agency. This lack of knowledge and failure to follow established policies and procedures resulted in a significant lapse in resident safety and regulatory compliance.

Removal Plan

• Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance.
• NA #1 did not follow the abuse policy by immediately reporting to leadership or law enforcement.
• The Director of Nursing (DON) notified company police that there was a resident in possession of a knife, which posed a security threat.
• The DON called the local police department for assistance with confiscating the knife.
• The DON cleared the Skilled Nursing Unit (SNU) hallways of residents and staff.
• Residents were escorted to their rooms and room doors were shut by staff.
• Staff were relocated to the day room.
• The DON instructed the local police to search Resident #2's room for any additional contraband.
• The DON and local police asked Resident #2 if he had any concerns about his safety and he responded no.
• After the knife was confiscated, the DON announced via a unit overhead page that staff and residents were free to move about the unit.
• The Social Worker reported to the unit and was briefed on the situation by the DON.
• The DON directed the Social Worker to round first on Resident #1.
• The Social Worker provided emotional support and offered resources such as Chaplain services, counseling, physician consultation etc. to Resident #1.
• The DON rounded on residents and implemented a two-team member approach to providing care to Resident #2, or when entering his room.
• The DON debriefed with the oncoming nursing supervisor who then instructed the security officer to complete extra rounding on the SNU.
• The DON consulted the Medical Director and a Behavioral Health consult was ordered for Resident #2.
• The DON debriefed the team and instructed the team to place this patient on close supervision and call the local police department immediately at the onset of any threatening behaviors from Resident #2.
• The Minimum Data Set (MDS) Coordinator modified Resident #2's care plan to include interventions to reduce or eliminate inappropriate or threatening behaviors.
• The DON notified the dietary services to place Resident #2 on a safe tray that utilizes plastic utensils, Styrofoam tray and no plastic bags.
• The DON investigated the incident by interviewing team members and the alert and oriented residents to assess for other incidents.
• The DON facilitated a leadership meeting with legal department, case management, risk management, company police and manager of Clinical Outcomes to establish next steps, including the clinical appropriateness of resident discharge and associated CMS regulations.
• The DON completed the Nursing Home Notice of Transfer/Discharge that was signed by the facility President/Administrator and given to Resident #2.
• The attending provider completed a discharge summary and wrote a discharge order for Resident #2.
• The DON discussed the context of Resident #2's discharge, including the facility policy, CMS guidelines, and importance of resident and staff safety with SNU staff via a staff meeting.
• The DON self-reported the resident abuse safety incident to the NC Department of Health and Human Services via fax.
• The DON told Resident #1 that Resident #2 was discharged and reassessed Resident #1 for mental suffering.
• The Administrator and the DON reviewed the one other abuse allegation since September of 2022.
• The DON reviewed the annual training transcripts for all SNU team members to ensure they completed required resident abuse/neglect education.
• The SNU Clinical Coordinator provided education to SNU clinical team members present on-site via on-site in-person training.
• The Nursing Supervisor educated team members in the following disciplines of the above educational topics via in-person, face-to-face huddles.
• The DON facilitated a SNU team meeting and in-service and completed education regarding the same topics outlined above.
• The Manager of Clinical Outcomes facilitated another in person, face-to-face in-service on the abuse topic as outlined above.
• Education regarding the same topics as above will be ongoing by unit leaders until 100% compliance is achieved and prior to staff working on the floor.
• The Resident Council was provided education to residents on how to report safety concerns.
• Company police provided an in-person, face-to-face in-service to SNU staff about abuse.
• As part of onboarding new staff, standard, facility-wide orientation facilitated by the Human Resources Department includes education regarding timely abuse reporting.
• A computer-based learning module created by the facility's Professional Development Department about resident abuse and neglect remains a part of the SNU staff's annual education requirements.
• The DON will be responsible for ensuring completion of a unit-specific orientation checklist that includes each new hire's verification of understanding the abuse policy.

Penalty

Inspection fine: $56,989

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 protect a resident's right to be free from mental and verbal abuse perpetrated by another resident. On 4/09/24, Resident #2 entered Resident #1's room and threatened her with a knife, stating 'I'm gonna get you with it.' Resident #1 reported that Resident #2 popped the switchblade open and waved the 4-inch blade in front of her face, causing her to fear for her life. This incident was witnessed by Nurse Aide #1, who turned her head and walked away, failing to intervene or report the situation immediately. Resident #1 remained in her room, afraid to leave due to the threat from Resident #2. Resident #2 had a history of behavioral issues, including a previous incident on 2/27/24 where he attempted to strike Resident #1. Despite this, his care plan did not include interventions for behavioral issues. On 4/11/24, the Director of Nursing (DON) was informed of the knife incident and took steps to secure the facility, including contacting the local police to confiscate the knife. However, Resident #2 was not immediately removed from the facility, and Resident #1 continued to feel unsafe. The police discovered that Resident #2 had two outstanding felony warrants, and he was eventually discharged to the local jail on 4/18/24. The facility's failure to protect Resident #1 from abuse and the delayed response to the incident resulted in immediate jeopardy. The DON and staff did not take immediate and effective action to ensure the safety of Resident #1 and other residents. The facility's lack of a comprehensive care plan for Resident #2's behavioral issues and the inadequate response from staff, including Nurse Aide #1's failure to act, contributed to the severity of the situation. Immediate jeopardy was removed on 5/3/24 after the facility implemented a credible allegation of immediate jeopardy removal, but the facility remained out of compliance at a lower scope and severity level to ensure education and monitoring systems were effective.

Penalty

Inspection fine: $56,989

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 an individualized person-centered care plan for a resident with multiple medical conditions, including GERD, hypertension, diabetes mellitus, falls, incontinence, pain, opioid pain medication, mood, and depression. The resident's care plan, last updated on 2/21/23, included focus areas for these conditions but lacked corresponding interventions. Additionally, the focus area for falls had no identified goal or interventions. The resident was cognitively intact and experienced symptoms of depression, incontinence, and chronic pain, for which she received routine and PRN pain medications and antidepressant medication. Interviews with the MDS Nurse and the Director of Nursing revealed that the facility had been experiencing staffing challenges following the resignation of the previous MDS coordinator in December 2023. The new MDS Nurse, hired within the last month, acknowledged that the care plans should have been completed with interventions and goals for each focus area. The Director of Nursing confirmed that while the MDS assessments had been completed, the care plans had not been updated timely. The Administrator was also aware of the delay in completing the care plans due to the staffing issues.

Penalty

Inspection fine: $56,989

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's Quality Assessment and Assurance Committee failed to maintain implemented procedures and monitor interventions that were previously put in place following the recertification survey. This failure was evident in a repeat deficiency related to developing and implementing comprehensive care plans (F656). Specifically, the facility did not have an individualized person-centered care plan for a resident in areas such as GERD, hypertension, diabetes mellitus, falls, incontinence, pain, opioid pain medication, mood, and depression. During the recertification survey, the facility was cited for not having a care plan related to antidepressant medication for a resident who was receiving such medication. The Director of Nursing reported that turnover in the role of Minimum Data Set Coordinator may have contributed to the repeat citation.