Brushy Creek Post Acute

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 necessary care and services to a resident who was admitted with multiple diagnoses, including hypertensive crisis, likely acute intracranial hemorrhage, left PCA occlusion, dementia with word-finding difficulties, and ambulatory dysfunction. Upon admission, the resident's blood pressure was recorded at 192/103, which exceeded the threshold for intervention as outlined in the facility's policy and the physician's order for as-needed antihypertensive medication. Despite this, documentation did not show that the ordered medication was administered following the elevated blood pressure reading. The resident's care plan indicated the need for antihypertensive medication and required staff to observe for side effects and promptly notify the physician if any were observed. However, there was a lack of communication and follow-through among staff regarding the resident's abnormal vital signs. The CNA who took the vital signs did not report the elevated blood pressure to the LPN, and the LPN was unaware of the abnormal reading. The resident was not entered into the electronic medical record system, which contributed to the lack of documentation and follow-up. The resident was later found unresponsive and pronounced deceased. Interviews with staff revealed confusion about reporting protocols and a lack of clarity regarding responsibilities for monitoring and responding to abnormal vital signs. The facility's failure to monitor and provide medications as ordered by the physician resulted in neglect of the resident's care needs, as evidenced by the lack of timely intervention for the hypertensive crisis.

Removal Plan

• Administrator notified the Medical Director of the Immediate Jeopardy.
• Director of Nursing and/or designee initiated education for all staff on Abuse/Neglect policies and procedures.
• All staff (including any agency assigned staff) that have not completed education will not be permitted to work until education is completed.
• Director of Nursing and/or designee initiated education to all nursing staff on procedure for follow up on abnormal vital signs.
• Director of Nursing and/or designee initiated education to all CNAs related to reporting abnormal vital signs.
• Director of Nursing and/or designee initiated an audit on all residents' Medication Administration Records (MARs) with anti-hypertensive and/or cardiovascular medications to ensure medications were given as ordered.
• 10 residents receiving cardiac medications will be audited weekly for 4 weeks and monthly for 2 months to ensure medications are given as ordered.
• Director of Nursing and/or designee initiated education with CNAs on facility policy and procedure for following checklist for taking resident vital signs.
• Director of Nursing and/or designee initiated education with all licensed nurses on what medications are available in Omnicell and how to pull medications from the Omnicell.
• Director of Nursing and/or designee initiated education for all licensed nurses on entering residents into PCC (PointClickCare) timely upon admission.

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 initiate cardiopulmonary resuscitation (CPR) for a resident in accordance with physician orders and the resident’s code status. The resident was admitted with multiple diagnoses, including hypertensive crisis, likely acute intracranial hemorrhage, left PCA occlusion, dementia with word-finding difficulties, and ambulatory dysfunction. Documentation revealed that the resident’s Medication Administration Record (MAR) indicated a full code status, but this was not reflected on the face sheet or care plan. When the resident was found unresponsive, staff did not initiate CPR, and the nurse documented that a Do Not Resuscitate (DNR) order was confirmed, despite the absence of such documentation in the medical record. Interviews with facility staff revealed confusion and inconsistency regarding the resident’s code status. The Director of Nursing (DON) and other staff members indicated reliance on information from the hospital and verbal statements from the resident’s daughter, but there was no documented discussion or signed DNR in the facility’s records. The nurse practitioner and other staff described challenges with entering code status into the electronic medical record and uncertainty about the process for confirming and documenting code status upon admission. The social services director also confirmed that there was no opportunity to speak with the resident or family about advance directives prior to the incident. The lack of clear documentation and communication regarding the resident’s code status led to the failure to provide basic life support as required by physician orders. The facility’s policies required that advance directives be respected and documented, but these procedures were not followed, resulting in the omission of CPR for a resident who was, according to available orders, a full code. This deficiency was determined by the survey team to constitute substandard quality of care and was cited under 42 CFR 483.24 – Quality of Life.

Removal Plan

• Administrator notified the Medical Director of Immediate Jeopardy.
• Social Service Director initiated an audit on Code Status for all new admissions.
• All code binders in all cottages audited to ensure they match orders in PCC.
• Social Service Director initiated an audit on Code Status for all other residents and audited code binders in all cottages to ensure they match orders in PCC.
• New admission's code status and code books will be audited.
• Social Service Director initiated an audit on Advanced Directive to determine if conversations with resident and/or responsible representative held at time of admissions for all new admissions.
• New admissions will be audited to ensure education offered on Advance Directives and code status honored.
• Education provided by the Assistant Regional Director of Clinical Services and Regional President of Operations to Administrator, Director of Nursing, Assistant Director of Nursing, and Social Service Director on conversations with resident and/or responsible representative for Advanced Directives upon admission.
• Education conducted as a review of facility policy and procedure in regard to Advanced Directives with resident and/or responsible representative upon admission.
• Education initiated by Director of Nursing and/or designee to all licensed nurses related to education resident and/or responsible representative on Advanced Directive and code status upon admission.
• All staff (including any agency-assigned staff) that have not completed education will not be permitted to work until education is completed.
• Director of Nursing and/or designee-initiated education for all nursing staff on Code Blue policy and procedures.
• Director of Nursing initiated an audit on Code Status accuracy and Advanced Directives on all resident Care Plans.
• Care plans will be audited to ensure code status is accurate.

Penalty

Inspection fine: $30,665

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 were free from unnecessary psychotropic medications and did not follow established protocols for medication monitoring and documentation. For one resident with a history of dementia, psychotic disturbance, and schizoaffective disorder, an antipsychotic medication (aripiprazole) was administered without documented evidence of behaviors or symptoms justifying its continued use. Multiple staff interviews confirmed the absence of hallucinations, delusions, or paranoia, and the resident herself denied current symptoms. Despite this, the medication remained active, and the interdisciplinary team had not documented a recent evaluation supporting its necessity. Another resident with Alzheimer's disease and agitation, who was on hospice care, had an active PRN order for lorazepam (an antianxiety medication) without a required stop date. The DON was unaware of the need for stop dates on hospice-prescribed medications. Additionally, a third resident with PTSD, major depressive disorder, and ADHD had two PRN orders for Adderall (a CNS stimulant) without end dates, and the medication had not been administered since being ordered. The DON did not recognize Adderall as a psychotropic medication and believed that unused orders would be discontinued after 30 days, but the orders remained active. Review of facility policy indicated that psychotropic medications should not be used unless clinically indicated and that PRN orders for such medications must have a documented rationale and duration, especially if extended beyond 14 days. The facility's failure to ensure adequate monitoring, documentation, and adherence to stop-date requirements for psychotropic and CNS stimulant medications resulted in deficiencies for three residents reviewed.

Penalty

Inspection fine: $30,665

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 administer medications and implement Enhanced Barrier Precautions (EBP) in accordance with its own infection prevention and control policies. During a medication pass, a registered nurse was observed using her fingers to obtain medications from bottles and medication cards without performing hand hygiene, and placed an insulin pen on a resident's bed linens before and after administration. The nurse acknowledged that these actions were improper and could lead to cross-contamination. The Director of Nursing confirmed that these practices should not have occurred. Additionally, staff did not consistently implement EBP for residents requiring such precautions. One resident with a history of sepsis due to MRSA received IV medication from a nurse who did not wear a gown, despite EBP signage indicating this requirement. Another resident with open wounds and on EBP was provided incontinent care by an LPN who did not wear a gown, stating she did not see the sign. There was confusion among staff regarding when gowns were required, with conflicting statements from the Staff Development Coordinator and the Infection Preventionist, despite clear signage outlining the need for gowns and gloves during personal care for residents on EBP.

Penalty

Inspection fine: $30,665

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 assess and document a resident's ability to self-administer medications, as required by its own policy. One resident, who had a history of left leg fracture, respiratory failure, a tracheostomy (without ventilator), and required a PEG tube for nutrition and medication administration, was observed self-administering all of his medications. Although the care plan indicated that the resident preferred and was capable of self-administering medications as determined by the interdisciplinary team, the facility's documentation and oversight were inconsistent. The Medication Administration Record (MAR) did not consistently indicate which doses were self-administered, and the Director of Nursing was unaware that the resident was self-administering all medications, being only aware of nebulizer treatments. Observations and interviews revealed that the resident was seen crushing and administering medications via PEG tube, with the nurse providing visual oversight only most of the time. The nurse confirmed that she documented medication administration in the MAR as with any other medication, regardless of whether it was self-administered. The facility's policy required an assessment of the resident's ability to self-administer medications and clear documentation in the MAR, but these steps were not consistently followed, leading to a deficiency in ensuring safe medication management for the resident.

Penalty

Inspection fine: $30,665

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 physician-ordered adaptive feeding equipment for one resident, despite clear documentation in the resident's care plan and physician orders. The resident, who had diagnoses including encephalopathy, dysphagia, and dementia, was admitted with a need for adaptive utensils to aid in self-feeding. Observations showed that the resident's meal tray did not include the required adaptive equipment, and the meal ticket did not indicate the need for such equipment. Interviews with staff confirmed that the dietary department was not aware of the order for adaptive utensils, and the process for communicating such orders was not followed. Review of the resident's records revealed that the care plan and physician orders specified the use of adaptive utensils during all meals, and the nutritional assessment noted the resident's use of adaptive feeding equipment. However, the dietary manager confirmed that the meal ticket lacked this information, and the dietary staff did not have access to physician orders. The rehabilitation director stated that changes to diets or adaptive equipment were typically hand-delivered to dietary, but in this case, the order was missed and not communicated, resulting in the resident not receiving the necessary adaptive equipment.

Penalty

Inspection fine: $30,665

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 the Daily Staff Posting included all required information, such as the facility name, the actual hours worked by nurses in each cottage, and whether the nurse on duty was an RN or LPN. Observations revealed that the staff posting in Dogwood Cottage did not display the facility name and lacked details about the nurse's credentials. The posting listed one nurse and one CNA for both day and night shifts, but did not specify if the nurse was an RN or LPN. Interviews with an LPN indicated that nurses were responsible for multiple cottages during their shifts, and the posted information did not accurately reflect their presence in each cottage. The facility also did not have a written policy for staff posting. The DON acknowledged that the current postings did not meet regulatory requirements.

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 two residents, R93 and R107, were free from the use of physical restraints, as required by their policy. Both residents were observed seated in Broda chairs with chair alarms and had bed alarms in place. There was no documentation indicating that less restrictive methods were attempted before resorting to these alarms, which are considered restraints. The facility's policy mandates that restraints should only be used to treat medical symptoms and not for fall prevention, discipline, or staff convenience. Resident R93 was admitted with diagnoses including dementia, muscle weakness, and a history of falls. The resident was assessed as severely cognitively impaired and had physician orders for bed and chair alarms. Observations confirmed the use of these alarms, and interviews with staff revealed that the alarms were used due to the resident's impulsivity and fall history. However, there was no documentation of monitoring or assessment of the alarms, nor any evidence of attempts to use less restrictive interventions. Resident R107, also severely cognitively impaired, was admitted with conditions such as Parkinson's disease and dementia. The resident required substantial assistance for mobility and had orders for bed and chair alarms. Staff interviews indicated that the alarms were used due to the resident's impulsivity and fall risk. Similar to R93, there was no documentation of monitoring or assessment of the alarms, and the Director of Nursing confirmed that fall prevention was not a valid reason for their use. The lack of documentation and failure to attempt less restrictive methods contributed to the deficiency.

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 revise the Preadmission Screening and Resident Review (PASARR) Level I for a resident when a new diagnosis of schizoaffective disorder was made. The resident was initially admitted with diagnoses of major depressive disorder and generalized anxiety disorder, and later, a new diagnosis of schizoaffective disorder was added. Despite this significant change in the resident's mental health status, the facility did not update the PASARR Level I screening to reflect the new diagnosis, which is necessary to determine the need for specialized or rehabilitative services. The oversight was identified during a review of the resident's electronic medical record, which showed the addition of antipsychotic medication for the new diagnosis. Interviews with facility staff, including the MDS Coordinator and the Social Services Director, revealed a lack of communication and follow-through in updating the PASARR screening. The Director of Nursing also confirmed the expectation for a new PASARR Level I to be completed with such a diagnosis change. The facility's training materials indicated that a new PASARR Level I should be conducted for serious mental illness diagnoses, but this was not adhered to 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 proper monitoring of a resident's antipsychotic medication, leading to a deficiency in the safe administration and dosing of the medication. The resident, identified as R93, was admitted with diagnoses including anxiety disorder, Parkinson's disease with dyskinesia, and dementia. The resident had a physician's order for Quetiapine Fumarate, an antipsychotic medication, to be administered at bedtime for Parkinson's psychosis. However, the facility did not monitor the resident for behaviors, side effects, or the efficacy of the medication as required by their policy. The facility's policy on antipsychotic medication use mandates that staff observe, document, and report the effectiveness of interventions, including antipsychotic medications, and monitor for side effects. Despite this, a review of the resident's medication administration records revealed no documentation of such monitoring. Interviews with the nursing staff and the Director of Nursing confirmed the absence of necessary documentation and monitoring, which should have been flagged during chart audits. This oversight indicates a failure to adhere to the facility's policy, compromising the safe administration of the antipsychotic medication.

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 maintain a safe, hazard-free environment for a resident, resulting in an accident. The resident, who was severely cognitively impaired and wheelchair-bound, was dependent on staff for all activities of daily living. The resident had a history of falls and was assessed as a high fall risk. Despite these known risks, a wooden chair was left next to the resident's bed, which the resident allegedly pulled onto herself, causing a laceration to her forehead that required sutures. The chair was used by staff to feed the resident while she was in bed, but it was not recognized as a potential hazard. On the day of the incident, the resident was found with blood on her face, clothing, and sheets. Staff interviews revealed that the chair was used for feeding the resident, and there was a small amount of blood on the chair's arm. The Director of Nursing conducted an investigation and concluded that the chair was the cause of the injury. The incident highlights a failure to ensure the resident's environment was free from accident hazards, despite the resident's high fall risk and cognitive impairment.

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 report an allegation of sexual abuse involving two residents to the state agency. According to the facility's policy, any resident-to-resident altercations involving sexual contact must be reported immediately, but no later than two hours, especially when one resident's capacity to consent is unknown. Resident 1 (R1) was severely cognitively impaired with a BIMS score of 6 out of 15, while Resident 2 (R2) was cognitively intact with a BIMS score of 13 out of 15. On the night of the incident, a CNA found both residents disrobed and standing beside the bed in R1's room. R1 was upset and crying, stating she did not mean to do it. R2 claimed that R1 had invited him into her room. Despite the incident, the Director of Nursing (DON) did not report it to the state agency, believing it was consensual based on R1's statements. Interviews with various staff members, including a CNA, RN, NP, ADON, and DON, revealed that R1 initially denied the allegation but later admitted to initiating the contact and expressed that R2 did not do anything wrong. R2 was sent to the ER after becoming upset and non-compliant when told he could not return to R1's room. The police were called but did not file a report because R1 expressed that the incident was consensual. Despite these findings, the facility did not follow its policy to report the incident to the state agency, leading to a deficiency in handling and reporting suspected abuse or neglect.

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 report an allegation of sexual abuse involving two residents to the state agency. According to the facility's policy, such incidents should be reported immediately but no later than two hours. The incident involved Resident 1, who was severely cognitively impaired with a BIMS score of 6, and Resident 2, who was cognitively intact with a BIMS score of 13. The incident was discovered by a Registered Nurse who found both residents disrobed from the waist down. Resident 2 claimed that Resident 1 had invited him into the room, and Resident 1 confirmed this, stating that Resident 2 did not do anything wrong. Despite this, the facility's policy mandates reporting any sexual activity where one resident's capacity to consent is unknown, which was the case with Resident 1 due to her severe cognitive impairment. The Assistant Director of Nursing and the Director of Nursing both confirmed that the incident was not reported to the state agency. The ADON mentioned that the police were called but did not file a report because Resident 1 expressed that the interaction was consensual. The DON stated that the incident was not reported to the state agency because it was deemed consensual. This failure to report the incident constitutes a violation of the facility's policy and regulatory requirements for reporting allegations of abuse.