Ramseur Rehabilitation And Healthcare Center

Penalty

Inspection fine: $18,000

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 immediately notify the resident, the resident's physician, and a family member about situations that affected the resident, such as injury, decline, or changes in room assignment. This lack of timely communication was observed and documented by surveyors during the review of facility practices and records. The deficiency centers on the facility's failure to ensure that all required parties were promptly informed when significant events impacting the resident occurred, as required by regulation.

Penalty

Inspection fine: $18,000

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 a failure to provide appropriate treatment and care according to physician orders, as well as the resident’s preferences and goals. The report indicates that care was not delivered in alignment with the established plan or the expressed wishes and objectives of the resident, as required by regulations. This lapse resulted in the resident not receiving the individualized care and treatment that had been ordered and preferred, as documented in their care plan.

Penalty

Inspection fine: $18,000

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 accurately code Minimum Data Set (MDS) assessments for two residents. For one resident with schizoaffective disorder, bipolar type, physician orders indicated a monthly intramuscular injection of Haloperidol, an antipsychotic medication, which was administered as ordered in June and July. However, the quarterly MDS assessment did not reflect the use of antipsychotic medications during the look-back period. For another resident with obesity, physician orders specified weekly subcutaneous injections of semaglutide for weight loss, which were administered as ordered. The quarterly MDS assessment for this resident incorrectly documented the administration of insulin, despite no physician orders or evidence of insulin administration. Interviews with the MDS coordinator confirmed the inaccuracies in the MDS assessments for both residents. The assessments in question were completed by another MDS nurse, who was unavailable for interview. The facility administrator was unaware of the reasons for the incorrect coding and stated an expectation for all MDS assessments to be accurate.

Penalty

Inspection fine: $90,957

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 of sexual abuse. A moderately cognitively impaired male resident was found beside a severely cognitively impaired female resident's bed with his hand moving under the covers around her groin area. The female resident's brief was open, and there was stool on the outside of her brief and on her sheets, while the male resident had stool on his hands. The male resident admitted to inappropriate touching, stating he was 'playing around' with the female resident 'down there.' The female resident did not have the cognition to express or understand consent for physical sexual advances. The male resident had a history of dementia and stroke, and his care plan indicated episodes of verbally aggressive behaviors. The incident was observed by a nurse aide who reported the male resident's actions and the condition of the female resident. The male resident was interviewed by the social worker and admitted to the inappropriate behavior, acknowledging that he knew it was wrong. The police were notified, and the male resident was charged with sexual battery. The facility's investigation revealed that the male resident had no prior history of sexual aggression. The female resident's responsible party was notified, and the female resident was transferred to another room for her protection. The medical director evaluated both residents and determined that neither had the cognitive ability to give or withhold informed consent. The male resident was placed on every 15-minute observations following the incident, but he continued to wander the facility between these checks.

Removal Plan

• Social Worker talked with Resident #39 about the incident that occurred and explained to resident #39 what he had done wrong.
• The physician changed resident #39's medication to add Zoloft 25mg tablet daily by mouth for aggression.
• Resident #39 has been placed on 1 on 1 observation.
• MDS Nurse updated resident #39's care plan to reflect new behavior of sexual aggression and interventions for managing behavior.
• MDS Nurse updated care guide for resident #39 and staff notified of changes through care guide.
• MDS Nurse will continue to update interventions as needed.
• The Staff Development Coordinator educated 100% of facility staff on the facility abuse policy to include residents right to be free from abuse to include sexual, physical, mental, verbal and misappropriation of property as well as signs of abuse and reporting of abuse or potential abuse.
• Staff development Coordinator will provide education for abuse training to new hires during orientation.
• 1:1 supervision will be documented and reported to the facility Administrator and Director of Nursing to ensure monitoring of resident.
• The Director of Nursing will ensure the 1:1 staff member is provided each shift with the staffing coordinator.
• All CNA's will be educated by the Director of Nursing/Staff Development Coordinator on supervision of resident during 1:1 duty.
• Education will include a goal of 1:1 in protecting other residents from any sexual aggression by resident #39 and ensuring resident #39 does not encounter resident #7 and documenting of any aggression during shift.
• The facility completed Ad Hoc QAPI to review investigation and current action plan to ensure all components were done and followed.
• The facility administrator and Director of Nursing are responsible for continued compliance.

Penalty

Inspection fine: $90,957

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 several components of its abuse policy, leading to a deficiency in handling an allegation of sexual abuse. Specifically, the facility did not immediately report the allegation of sexual abuse of a severely cognitively impaired female resident by a moderately cognitively impaired male resident to the Administrator. Additionally, the facility did not provide a physical examination of the alleged victim by a trained/licensed professional for signs of sexual abuse. The facility also failed to protect the alleged victim and other residents by not placing the alleged perpetrator on one-to-one observation immediately after the incident was reported. Furthermore, the facility did not assess all other residents for signs of sexual abuse when the allegation was reported, and it failed to report the allegation to Adult Protective Services in a timely manner. The incident involved a severely cognitively impaired female resident who was found by a nurse aide with a male resident's hand under her bed covers. The male resident had stool on his fingers, and the female resident's brief was open with stool on the sheets. The nurse aide reported the incident to a medication aide, who delayed reporting it to the unit supervisor by 30 minutes. The unit supervisor then reported the incident to the Director of Nursing, who initiated an investigation and called the police. However, the facility did not conduct an immediate physical assessment of the female resident, and the male resident was not placed under one-to-one observation until several hours later. Interviews with staff revealed that there was confusion and delay in reporting the incident, and the facility's policies were not followed. The Director of Nursing and the previous Administrator were unaware of the delays in reporting and the lack of immediate assessment and protection for the residents. The facility's failure to follow its abuse prevention, intervention, reporting, and investigation policies resulted in a deficiency that had the potential to affect other vulnerable residents in the facility.

Removal Plan

• The Regional Director of Operations and Regional Clinical Nurse educated the Director of Nursing, Administrator, Medical and Staff Development Coordinator on abuse policy to include residents' right to be free from abuse, signs of abuse, and reporting of abuse or potential abuse.
• Education included the process and action to protect residents if any type of abuse occurs according to facility policy and procedure on abuse, including assessment of all residents involved, immediate protection for all residents, immediate reporting to Management, state agencies, Ombudsman, APS, families, physician, and law enforcement.
• Staff Development Coordinator and/or Director of Nursing educated all nursing staff on proper procedures for reporting any suspected abuse and immediate reporting to the Administrator and Director of Nursing for direction.
• Education included direction for resident assessment immediately following an incident, physician notification by Nurse for direction of care for resident, and need to send out to hospital for further examination.
• Social Worker talked with Resident #39 about the incident and explained what he had done wrong.
• The physician changed Resident #39's medication to add Zoloft 25mg tablet daily by mouth for aggression.
• Resident #39 has been placed on one-to-one observation.
• The facility completed AdHoc QAPI to review investigation and current action plan to ensure all components were done and followed.
• The facility provided documentation of the in-service education that was provided to all staff which included the review of the facility's Abuse Policy and included immediate reporting of any allegations of abuse to the Administrator immediately, provide a physical examination by a trained/licensed professional for any signs of sexual abuse, provide protection for the resident that is the victim of abuse, provide protection for all other residents when an allegation of abuse is reported, and report any allegations of abuse to the proper authorities.
• The Staff Development Coordinator ensured all staff are educated regarding the reporting of abuse allegations to the administrator immediately, provide a physical examination by the physician or if the physician is not available send the resident to the emergency department for evaluation if there is an allegation of sexual abuse, provide protection for the abused individual and all other residents, and reporting of allegations of abuse to the proper authorities.
• Observations of Resident #39 were made and the facility was providing one-to-one observation of the resident.
• Facility staff (sampled from all disciplines) were able to verbalize the types of abuse, what steps they should take to assess and protect the resident of an alleged abuse, and what authorities should be notified of allegations of abuse.
• The facility provided skin assessments that were completed on residents with a Brief Interview for Mental Status (BIMS) of less than 9 and interview forms that were completed on all residents with a BIMS of 9 or above.
• The facility notified Adult Protective Services of the allegation of sexual abuse for Resident #7.
• The facility provided minutes of their Quality Assurance Performance Improvement (QAPI) meeting.

Penalty

Inspection fine: $90,957

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 residents from the misappropriation of narcotic medication, specifically Oxycodone, prescribed to treat pain for three residents. Resident #16 had an order for Oxycodone 10 mg every 6 hours as needed for pain. The Narcotic Count Sheet indicated discrepancies where Nurse #12 documented wasting the medication without proper verification. Despite the resident reporting no concerns about her pain management, the records showed that Nurse #12 had a history of addiction and tested positive for Oxycodone on 2/28/24, suggesting potential misappropriation of the medication. Resident #75 had an order for Oxycodone 5 mg every 4 hours as needed for pain. The Narcotic Count Sheet for February 2024 documented that Nurse #12 wasted a tablet, allegedly witnessed by Nurse #6. However, Nurse #6 later stated that she did not waste the medication with Nurse #12, indicating falsification of records. Drug testing for Nurse #6 was negative, further pointing to Nurse #12's involvement in the misappropriation. Resident #239 had an order for Oxycodone 10 mg every four hours as needed for pain. The Narcotic Count Sheet showed that Nurse #12 signed out the medication multiple times on 2/28/24, despite the resident's pain assessments indicating no need for the medication. The resident confirmed that she only requested Oxycodone once on 2/27/24, further highlighting the discrepancies in medication administration by Nurse #12.

Penalty

Inspection fine: $90,957

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 individualized and comprehensive care plans for four residents, leading to deficiencies in their care. Resident #2, who was admitted with a displaced subtrochanteric fracture of the right femur and diabetes mellitus with diabetic polyneuropathy, was occasionally incontinent of bladder and always incontinent of bowel. Despite this, there was no care plan related to incontinence care. Both the Director of Nursing (DON) and the Minimum Data Set (MDS) Nurse acknowledged the oversight. Resident #85, who had severe cognitive impairment and dysphagia, did not have a care plan addressing dysphagia or aspiration precautions, which was also confirmed as an oversight by the DON and MDS Nurse. Resident #66, admitted with an infection and inflammatory reaction due to an internal right knee prosthesis requiring intravenous (IV) antibiotics, lacked a care plan for IV antibiotic use. This was similarly acknowledged as an oversight by the DON and MDS Nurse. Resident #78, who had severe cognitive impairment and was on Ciprofloxacin for a polymicrobial bacterial infection for at least a year, did not have a care plan for the indefinite use of antibiotics. The MDS Coordinator and the DON both confirmed this was an oversight. These deficiencies indicate a failure to provide person-centered care plans tailored to the specific needs of the residents.

Penalty

Inspection fine: $90,957

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 a fall mat was in place for Resident #31 according to the care planned fall safety interventions. Resident #31, who was admitted with diagnoses including dementia and lack of coordination, had a documented fall on 1/27/23, after which a fall mat was placed beside her bed as a safety measure. However, during observations on 4/30/24 and 5/1/24, the fall mat was not present beside the bed, in the room, or in the bathroom. Interviews with nursing staff and nurse aides revealed that they were unaware of the requirement for a fall mat for Resident #31, and the Director of Nursing confirmed that the fall mat had been present during an audit in March 2024 but was unaware of its current absence. The care plan for Resident #31, last reviewed on 4/22/24, included the use of a fall mat as an intervention for her risk of falls due to impaired balance, history of falls, dementia, and psychotropic medication use. Despite this, the fall mat was not in place during the survey, indicating a failure to implement the planned safety intervention. This deficiency was identified through record review, observations, and staff interviews, highlighting a lapse in the facility's adherence to the care plan designed to prevent accidents for Resident #31.

Penalty

Inspection fine: $90,957

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 clarify a consultation note and discontinue an order for PICC line care for Resident #78. The resident was readmitted from the hospital with a diagnosis of polymicrobial bacterial infection and had a PICC line present. An order was placed for PICC line dressing changes every seven days. However, an Infectious Disease progress note indicated that the PICC line was to be removed on 4/5/24. Despite this, the order for dressing changes remained active in the Medication Administration Record (MAR) from 4/5/24 to 4/30/24. On 5/1/24, during an observation of personal care, it was noted that Resident #78 no longer had a PICC line. The Unit Supervisor reviewed the progress note and acknowledged that the order should have been discontinued but was not, attributing it to an oversight. The Director of Nursing confirmed that a clarification order should have been obtained to discontinue the PICC line dressing change order when the PICC line was removed.

Penalty

Inspection fine: $90,957

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 Assurance and Performance Improvement (QAPI) committee failed to maintain implemented procedures and monitor interventions following an annual recertification and complaint survey. This resulted in repeated deficiencies in the areas of Accuracy of Assessments and Free of Accident Hazards/Supervision/Devices. Specifically, the facility failed to complete a Minimum Data Set (MDS) discharge assessment within the required time frame for one resident and failed to accurately code the MDS in the area of medication for another resident. These issues were attributed to MDS Nurse turnover, as stated by the Administrator during an interview. Additionally, the facility failed to review and revise care plans in critical areas such as antibiotic use and JP drain management for one resident. There were also failures in ensuring fall safety interventions, such as the placement of a fall mat, and providing adequate supervision to prevent resident-to-resident altercations and safe transfers for high-risk residents. These repeated deficiencies across multiple surveys indicate a pattern of the facility's inability to sustain an effective Quality Assessment and Assurance Program, which the Administrator attributed to leadership turnover.

Penalty

Inspection fine: $90,957

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 complete a Minimum Data Set (MDS) discharge assessment within the required time frame for one resident. Resident #58 was admitted and had an admission MDS assessment completed. Nursing documentation noted that the resident was discharged home, but no discharge MDS assessment was found in the resident's record. The MDS Coordinator explained that she usually opens the MDS assessment when aware of a pending discharge but noticed the discharge assessment for this resident had not been transmitted. The corporate Nurse Consultant confirmed that MDS assessments are expected to be transmitted within the required timeframe.

Penalty

Inspection fine: $90,957

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 accurately code the Minimum Data Set (MDS) for a resident in the area of medication. Resident #24, who had been readmitted with diagnoses including Stroke and coronary artery disease, had a Significant Change in Status MDS assessment that incorrectly noted the resident had received anticoagulant medication. A review of the resident's February 2024 Medication Administration Record (MAR) revealed that the resident had not received anticoagulant medication but had received antiplatelet medication. During an interview, the MDS Coordinator confirmed that she checked the MAR when completing MDS assessments and acknowledged that anticoagulant medication should not have been coded. The Corporate Nurse Consultant also stated that she would expect MDS assessments to be accurate.

Penalty

Inspection fine: $90,957

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 review and revise the care plans for a resident in the areas of antibiotic use and JP drain management. The resident was admitted with diagnoses including a urinary tract infection, an abscess to the left kidney requiring a JP drain, and a right foot diabetic ulcer. Despite the removal of the JP drain and PICC line on 03/25/24, the resident's care plan, dated 04/04/24, still indicated the presence of these devices and the need for IV antibiotics. Interviews with the MDS Nurse and the Director of Nursing confirmed that these care plan areas should have been updated and removed, but this was overlooked.

Penalty

Inspection fine: $90,957

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 written notification to residents and/or their representatives regarding hospital transfers and a facility-initiated discharge. For Resident #78, there was no documentation of a written notice of transfer provided to the resident or their representative for hospital transfers on two separate occasions. Interviews with the wound nurse, Social Worker, and Director of Nursing revealed that while the resident's representative was notified via phone, no written notice was sent. The Administrator was unaware of this lapse in protocol and expected the regulation to be followed. Similarly, Resident #86 was transferred to the hospital without written notice being provided to the resident or their representative. The Social Worker and Director of Nursing confirmed that they did not send written notifications for hospital transfers. Additionally, Resident #64 received a 30-day discharge notice, but the facility failed to send a copy of this notice to the Ombudsman. The Social Worker admitted to not notifying the Ombudsman due to waiting for documentation from the Business Office Manager, who clarified that such documentation was not necessary for notifying the Ombudsman. The Administrator confirmed that the Social Worker should have notified the Ombudsman when the discharge notice was issued.