Solon Pointe At Emerald Ridge

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 keep comprehensive person-centered care plans updated to reflect residents’ current medical and psychological status and to involve resident representatives in choosing care and treatment interventions during care plan development. For one resident with schizoaffective disorder, bipolar type, dementia with psychotic disturbance, and a cognitive communication deficit, the most recent MDS showed the resident was cognitively intact, required hands-on assistance for ADLs, and had no documented behaviors. However, the resident’s care plan, dated several months earlier, continued to list multiple behavior problems, including traveling to vending machines regardless of diet, smearing feces, preferring women’s clothing and painted nails, refusing organization of personal items and housekeeping, hanging soiled clothing in various places, and embellishing stories about money and credit cards. Physician orders required behavior monitoring every shift, and the MAR showed zero documented behaviors for at least three consecutive months, yet the care plan was not revised. The inaction in updating this resident’s care plan was confirmed by the Social Service Director, who acknowledged that the care plan had not been updated to reflect the resident’s current behavioral status. This failure occurred despite a facility policy on comprehensive person-centered care plans that states assessments are ongoing and care plans are revised as information about residents and their conditions change. The discrepancy between the absence of documented behaviors over several months and the continued listing of extensive behavioral concerns on the care plan demonstrates that the resident’s plan of care was not reassessed or modified in accordance with current information. For a second resident with anoxic brain damage, intracranial injury, post-traumatic seizures, and spastic quadriplegic cerebral palsy, the MDS showed severe cognitive impairment (BIMS score of 00) and total dependence on staff for ADLs. Hospital admission paperwork documented a history of traumatic brain injury from a gunshot wound, right hemicraniectomy with cranioplasty, wheelchair dependence, seizure disorder, and a need for a bed alarm due to fall risk. Facility fall risk assessments identified the resident as high risk for falls, and an admission care conference noted poor safety awareness and dependence for all care. The care plan identified increased fall risk and an actual fall related to brain injury, with interventions such as ensuring a safe environment, anticipating needs, keeping the call light within reach, using handrails, and keeping the bed in the lowest position at night, but did not include floor mats. The resident experienced an unwitnessed fall from bed, was found with his head down off the side of the bed, and required hospital evaluation, where he was diagnosed with a fall with head injury. Post-fall documentation identified contributing factors including poor bed mobility, decreased safety, epilepsy, loss of trunk control, impaired posture stability, decreased safety awareness, sliding out of bed, and inability to self-correct or recognize the need for assistance. A fall follow-up assessment listed fall mats as a new intervention and stated they were effective, and a post-fall investigation noted extended bed and extended air mattress as current interventions, but there was no documentation of prior or subsequent implementation of floor mats. Multiple observations on different days and times showed the resident in bed without fall mats in place. Staff interviews further demonstrated that the care plan and interventions were not aligned with the resident’s identified risks or with the representative’s requests. An LPN stated the resident was fully dependent, a fall risk, checked every two hours, and had never had fall mats in place, despite the POA asking about them; the LPN stated fall mats were not needed because the resident could not move on his own. A CNA confirmed the resident was a fall risk, used a special high-back wheelchair to reduce falls when out of bed, did not have floor mats, and that the bed was in the highest position during the day. The MD acknowledged the resident was at high risk for falls due to a history of rolling out of bed and that floor mats are typically an option for high-risk residents. The DON stated the resident was identified as a fall risk based on diagnoses and that information from other sources was considered, but confirmed there were no fall mats before the fall and that she did not put floor mats in place because she felt they were not needed. The POA reported the resident was completely dependent, had a history of sliding out of bed and seizures, had informed staff of these issues, and had requested fall mats as a safety precaution due to his brain injury and prior falls, but facility staff refused to put fall mats in place. This pattern shows the facility did not revise the care plan to incorporate the representative’s requests or the resident’s ongoing fall risk, contrary to the facility’s policy that the interdisciplinary team, in conjunction with the resident and/or representative, develops and revises the care plan and that residents and representatives have the right to participate and request revisions.

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 implement and consistently maintain appropriate fall interventions for a resident with severe cognitive and physical impairments and a known high risk for falls. The resident was admitted with anoxic brain damage, intracranial injury, post-traumatic seizures, and spastic quadriplegic cerebral palsy, and was wheelchair-bound with weakness in all extremities. An MDS assessment showed a BIMS score of 00, indicating severe cognitive impairment, and documented that the resident was dependent on staff for ADLs and had poor safety awareness. The care plan identified increased fall risk and an actual fall related to brain injury, with interventions such as ensuring a safe environment, anticipating needs, keeping the call light within reach, using handrails, and keeping the bed in the lowest position at night. Hospital admission paperwork and fall risk assessments identified the resident as a high fall risk who required a bed alarm and had a history of falls. On one occasion, the resident experienced an unwitnessed fall around 12:30 A.M., when an RN heard a sound and found the resident with his head down on the right side of the bed and legs still in bed. The resident was repositioned and placed back on the ventilator, and shortly afterward had projectile vomiting and was sent to the hospital due to his history of intracranial surgery and presenting symptoms. Hospital documentation diagnosed a fall with head injury and again identified the resident as high risk for falling. A post-fall investigation noted contributing factors including poor bed mobility, decreased safety, epilepsy, history of seizure activity, loss of trunk control, impaired posture stability, decreased safety awareness, and sliding out of bed with inability to self-correct or recognize the need for assistance. The investigation document referenced prior interventions and current interventions such as repositioning, neurological checks, and use of an extended bed and extended air mattress, but did not show prior or subsequent implementation of floor mats. Subsequent observations by surveyors on multiple occasions showed the resident in bed without fall mats in place, despite his inability to voluntarily control his body and only being able to follow with his eyes and slightly move his head. Staff interviews confirmed that the resident was fully dependent for ADLs, was a fall risk, and required checks every two hours, but that floor mats were not used as a fall intervention. A CNA reported that the resident used a special high-back wheelchair to decrease fall risk when out of bed, that the bed was kept in the highest position during the day, and that she had never seen it in the lowest position. The DON acknowledged that the resident was identified as a fall risk based on his diagnoses and that there were no fall mats in place prior to the fall, and stated that she did not implement floor mats because she felt they were not needed based on her assessment. The facility’s fall management policy required staff to identify interventions related to specific risks and causes and to monitor and document residents’ responses to interventions intended to reduce falls or fall risk, but the resident’s identified risks and documented fall history were not consistently addressed with appropriate and sustained fall interventions.

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 prevent the elopement of a cognitively impaired resident with a history of attempted elopement. The resident, who was assessed to be at risk for elopement, left the facility through an alarmed elevator that did not sound an alarm. The resident was found 1.4 miles away from the facility by a tenant at a previous residence. The facility's failure to ensure the proper functioning of the alarm system and the lack of staff awareness led to the resident's unsupervised departure and subsequent discovery far from the facility. Additionally, the facility did not ensure that other residents at risk for elopement had functioning electronic monitoring bracelets. One resident was observed without an electronic monitoring bracelet despite a physician's order, and another resident had a bracelet that did not function properly due to being expired. The facility's failure to maintain and check the functionality of these monitoring devices put residents at risk for elopement. The facility also failed to implement appropriate fall interventions for two cognitively impaired residents who were assessed to be at risk for falls. The care plans for these residents did not have the necessary fall interventions in place, further indicating a lack of adequate supervision and preventive measures. These deficiencies affected multiple residents and highlighted significant lapses in the facility's safety protocols and monitoring systems.

Removal Plan

• A resident head count was completed by facility staff to ensure that all current residents were accounted for. All residents were accounted for.
• Resident #70 was returned by the Police department and daughter.
• Resident #70 had a head-to-toe assessment completed by Licensed Practical Nurse (LPN) #672, including visual assessment and physical assessment, and including but not limited to heat related issues. All results were unremarkable for significant negative effects.
• Assessments were completed on residents at risk for elopement by DON and Licensed Practical Nurse (LPN) #615. At risk residents were determined by the most recently completed wander assessment.
• Resident #70 was immediately placed on a 1:1 supervision by State tested Nursing Assistant (STNA) #678 upon return to the facility, at which point the one on one was discontinued by the DON and STNA #678 was reassigned at the elevator to ensure safety for all residents at risk for wandering.
• The facility implemented a plan for a designated staff member to remain in place at elevator door 24 hours/7 days per week, to ensure residents at risk of wandering did not exit. This would remain in place until root cause of functioning concern is identified and corrected.
• Resident #70's physician was notified of Resident #70's return to the facility and assessment findings by ADON #343.
• All staff members present were interviewed by ADON #343.
• All stairwell and exit door alarms were checked for functioning by DON. The facility indicated there were no concerns noted.
• All residents with an order for a monitoring device (wander guards bracelets) were assessed to ensure placement of the wander guard and proper functioning of wander guard by DON and ADON #343.
• The facility indicated any wander guard that was not functioning properly was replaced by DON/designee.
• Resident #70's previous wander guard was removed, and a new wander guard was placed on Resident #70 by the DON.
• Elopement drills for staff were conducted by the DON.
• An elopement drill was conducted for all staff by DON.
• An elopement drill for all staff was conducted by Registered Nurse (RN) #563.
• All staff in-service related to elopement protocols began by the DON and/or designee, including but not limited to ensuring that wander guards are in place and functioning as ordered, how to engage wander guard bracelets prior to applying, how to check for functioning of the wander guard bracelet and wander guard system, wandering residents' policy, elopement policy, pictures to be obtained and uploaded to EHR upon admission to the facility, the elopement binder, and notification protocols by the Administrative Team. No staff who are absent or PRN (pro re nata) is permitted to return to the floor and resident care until this in-servicing /education is completed.
• All nursing staff in service on correct input of wander guard orders by the DON and/or designee (check placement and check function every shift) upon placement of wander guard by DON/designee. No staff who are absent or PRN (pro re nata) is permitted to return to the floor and resident care until this in-servicing /education is completed.
• All nursing staff was to begin ensuring an order is in place to check wander guard placement and function every shift daily, ongoing.
• All wandering device orders were to be transcribed into point click care (PCC) the day of implementation by nursing audit began by the DON/designee daily for 2 weeks then weekly at RISK for 3 month and present to Quality Assurance Performance Improvement (QAPI).
• The profile pictures of all residents at risk for wandering were audited for accurate profile pictures in the electronic health record (EHR) by Medical Records/Central Supply #524. DON /designee began to audit profile pictures for all new admissions, five residents a week for two weeks then weekly for three months. Results would be presented to the facility Quality Assessment and Performance Improvement (QAPI).
• Resident #70's profile picture was uploaded to the EHR and was placed in the wander guard book by Medical Records/Central Supply #524.
• The elopement binder was audited for accuracy by Medical Records/Central Supply #524. No other discrepancies were identified. The elopement binder is to be audited for accuracy by DON/ designee five times a week for 2 weeks then weekly for 3 months. Results will be presented to QAPI.
• The DON and Administrator met with Alta Contractor (electronic monitoring company) regarding wander guard alert system to ensure the system was functioning per manufacturer's guidelines. No concerns were identified.
• All residents with wander guard bracelet orders were clarified to ensure an order to check placement and check function is placed in the HER and care planned by DON and LPN Supervisor #455.
• Wandering risk assessments were completed on all census active residents by DON and LPN Supervisor #455. All residents identified at risk for wandering were given a wander guard placed on their person, an order written for wander guard and the Provider/resident representative was notified. Additionally, the care plan was updated.
• Resident #14 was identified to be at risk of wandering. Her physician was notified, and an order was given for a wander guard. A wander guard was placed on her, checked for placement/function, and her care plan was updated by Registered Nurse (RN) #443.
• All new employees hired by the facility would receive education on residents at risk for wandering policy by the DON /designee.
• The Minimum Data Set (MDS) nurse was educated by the DON, on ensuring that all residents who have an order for wander guard have a care plan in place for the wander guard. The education included ensuring that an intervention for checking the function and checking the placement of the wander guard are in the plan of care by DON/designee.
• All staffing agencies utilized by the facility were provided education for their employees by the DON and a copy of this training was placed in the agency education binder by the Administrator.
• All activities department and front desk staff were in serviced on PCC profile picture uploading upon admission by Administrator/ designee. Staff who were absent or PRN (pro re nata) would not be permitted to return to the floor and resident care until this in-servicing /education was completed.
• All receptionists were in service on the elopement binder review and updating the binder weekly and with any new admission by the Administrative Team. Staff who were absent or PRN (pro re nata) would not be permitted to return to the floor and resident care until this in-servicing /education was completed.
• The Admissions Director was in serviced on posting new admissions room number and expected date of admission by time clock daily (which is a secured area), by Administrator/designee. No staff who are absent or PRN (pro re nata) is permitted to return to the floor and resident care until this in-servicing /education is completed.

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 a resident's call light was accessible to request assistance as needed. Resident #28, who was cognitively intact and required assistance with activities of daily living, was observed with her call light wrapped around a lamp above her head, out of reach. Despite her preference for the call light to be within reach, it was placed out of reach by a State tested Nursing Assistant (STNA). This was verified by both Resident #28 and a Licensed Practical Nurse (LPN), who confirmed that the resident frequently used her call light.

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 timely implement measures to promote the mobility of a resident who required a specialized wheelchair. Resident #28, who had diagnoses including chronic respiratory failure, hemiplegia, morbid obesity, and dependence on a respirator, was admitted to the facility and remained bedfast for about a year due to the lack of an appropriate wheelchair. Despite being cognitively intact and expressing a desire to get out of bed, the resident did not receive a suitable wheelchair until a loaner chair was obtained by the occupational therapist in late April 2024. The delay in providing the necessary equipment resulted in the resident not being able to participate in mobility activities or therapy services aimed at improving her condition and quality of life. Interviews with the resident, her son, and facility staff revealed that the resident had previously been mobile and engaged in activities when she lived in Florida. However, upon transferring to the current facility, she was not provided with a suitable wheelchair, which hindered her ability to get out of bed and participate in daily activities. The occupational therapist confirmed that the resident was not evaluated for a wheelchair until January 2024, nine months after her admission, and that the facility did not have a chair available for her to use. The therapist eventually obtained a loaner chair from a community vendor, allowing the resident to begin participating in therapy and mobility activities. The facility's failure to provide timely and appropriate equipment for Resident #28 was attributed to a lack of communication and approval from the administration. The administrator claimed that the resident never expressed a desire to get out of bed until recently, and no one had requested a chair for her. The therapy department also did not screen the resident for a wheelchair or range of motion services until January 2024, despite her being bedfast and dependent on staff for all activities of daily living. This deficiency highlights the need for better coordination and communication within the facility to ensure residents receive the necessary equipment and services to maintain and improve their mobility and overall well-being.

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 oxygen orders were obtained and documented for a resident with chronic obstructive pulmonary disease and unspecified glaucoma. The resident, who was moderately cognitively impaired, received oxygen therapy but lacked specific physician orders detailing the liters to be administered and the frequency of administration. The medical record review revealed gaps in the documentation of oxygen therapy orders from 02/27/24 through 03/03/24, and incomplete orders from 03/03/24 through 03/19/24. Additionally, there was no documentation on the Medication Administration Record (MAR) indicating that the resident's oxygen saturation was assessed or that oxygen was administered as per the orders during this period. Interviews with the respiratory therapist confirmed the absence of specific orders and the reliance on the resident's existing oxygen levels without proper physician directives. The deficiency was further highlighted by the respiratory therapy notes and nursing notes, which showed inconsistencies in the oxygen therapy provided to the resident. Despite the resident being on continuous oxygen at two liters per nasal cannula, there were no corresponding physician orders or documentation to support this treatment. The respiratory therapist admitted to being unaware of the specific physician orders and confirmed that the orders were not complete with the required liter amount. This lack of proper documentation and adherence to physician orders represents a significant lapse in the facility's respiratory care for 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 monitor a resident's blood pressure prior to the administration of medication as per physician orders. This deficiency affected one resident who had diagnoses including COPD, CHF, and hypertension. The physician's order required the resident's blood pressure to be checked before administering sacubitril valsartan and to hold the medication if the blood pressure was less than 120/60. However, the blood pressure readings were not documented in the Medication Administration Record (MAR) or any other part of the medical record before administering the medication. Interviews with nursing staff and the Director of Nursing (DON) confirmed that the blood pressure was not consistently checked and documented as required by the physician's order. The DON and the resident's primary care physician verified that the order to check the blood pressure was in place, but the nurses did not document the results, leading to a failure in compliance with the physician's order and facility policy. The report also highlighted that the electronic medical record system did not prompt the nurses to check the blood pressure before administering the medication, which contributed to the oversight. The DON and the primary care physician confirmed that the blood pressure readings were not documented, and the DON acknowledged that the nurses should have documented the blood pressure results as per the physician's order. The facility's policy on administering medications requires that any results achieved from administering medications be recorded in the resident's medical record, which was not followed in this case.

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 complete documentation in the medical record of Resident #85, who had severe cognitive impairment and multiple complex medical conditions, including cerebral palsy, chronic respiratory failure, and a tracheostomy. The care plan for Resident #85 included specific interventions for tracheostomy care and monitoring, which were not consistently documented as completed. For instance, trach care orders and trach assessments were not documented for several shifts, and oral care was also not recorded as completed for specific time periods. Additionally, there was no documentation of the time of transport to the hospital in the resident's medical record. On 04/09/24, Resident #85 self-decannulated her trach, and despite multiple attempts by the respiratory therapist to reinsert the trach, the resident remained stable on room air. The resident was eventually sent to the emergency room for further evaluation. However, the transport timeline revealed a significant delay between the call to the ambulance company and the actual arrival of the ambulance at the facility. The Director of Nursing was unable to provide an explanation for the missing documentation in the Therapy Administration Record. The facility's policy on charting and documentation emphasized the importance of documenting all services provided to the resident and any changes in their condition. However, the review of Resident #85's medical record revealed multiple instances of incomplete documentation, which hindered effective communication between the interdisciplinary team regarding the resident's condition and response to care. This deficiency was investigated under Complaint Number OH00153124.

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 timely repair the wall in a resident's room, which had several large visible holes, dents, and scrape markings. This deficiency was observed in the room of Resident #28, who had a BIMS score of 15 out of 15, indicating cognitive intactness. Despite the resident's inability to see the wall from her position in bed, the damage was clearly visible during visits. The resident's medical record indicated multiple serious health conditions, including chronic respiratory failure, hemiplegia, morbid obesity, major depressive disorder, anxiety, tracheostomy, and dependence on a respirator. Staff interviews and observations confirmed the presence of the wall damage. An LPN, several respiratory therapists, and a housekeeper all acknowledged the condition of the wall, with the housekeeper stating that she had reported the issue to the Maintenance Director weeks ago. The Maintenance Director confirmed awareness of the damage but had not initiated any repairs. The deficiency was investigated under Complaint Number OH00153124.