Johns Island 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 ensure that a resident, identified as R1, was free from neglect, which resulted in the resident's death. R1, who had a history of adult failure to thrive, protein calorie malnutrition, dementia, and dysphagia, was on a therapeutic diet requiring pureed food and thickened liquids. On the day of the incident, R1 was left unattended in a common area where a meal tray with regular food was left on a dining room table. R1, who was known to wander and had moderate cognitive impairment, consumed food from the tray that was not suitable for his dietary needs. The staff, including two CNAs and an LPN, were at the nurse's station and did not notice R1 eating the food or later slumping over on the couch. The LPN discovered R1 slumped over with a bluish face when she returned from the nourishment kitchen with R1's bolus tube feeding. Despite attempts to perform the Heimlich maneuver and suctioning, R1 was pronounced dead by EMS shortly after. The facility's failure to monitor R1 and ensure he received the appropriate diet directly contributed to the incident. The facility's policy on recognizing signs and symptoms of abuse and neglect was not adhered to, as R1 was left unattended and consumed food that was not part of his prescribed diet. The incident highlights a significant lapse in supervision and adherence to dietary orders, which are critical for residents with specific dietary needs due to medical conditions like dysphagia. The staff's inaction in monitoring R1 and ensuring the removal of inappropriate food trays led to the tragic outcome.

Removal Plan

• Statements were written by all staff on duty.
• Nurse on duty was interviewed via phone by RDCS and DON. She stated she noted him slumped over and bluish color to face and observed what she felt to be a possible obstruction to his airway, so she initiated the Heimlich and attempted to suction his airway until EMS arrived.
• Camera footage was observed by Administrator and DON to establish a timeline and confirm he had eaten food from a tray sitting in the common area.
• Education was initiated with all staff regarding picking up all trays timely and not leaving any food trays unattended on a unit.
• Audits were initiated of all residents who wander or have behaviors to ensure all are care planned for wandering and staff are aware of this behavior and risk for getting food that is not theirs.
• An audit was initiated for all residents on a mechanically altered diet to ensure orders are correct and tray cards and care plans also reflect correct diets as ordered.
• Standup/stand down imitated to track progress of the abatement plan.
• Audits initiated for all residents on a mechanically altered diet to ensure that orders are correct and correlate with tray cards and care plans to reflect current orders.
• Audits initiated for all residents who have behaviors of wandering and would be at risk to take food from other residents or areas that is not their ordered diet to ensure care plan is reflective of the behavior.
• Education initiated immediately for all staff to ensure understanding of timely removal of trays from the unit and not left unattended. All newly hired staff and or agency staff will receive the education prior to first shift worked.
• Educations was sent to all staff via CORV. Wet signatures will be obtained as staff report for duty on next scheduled shift.
• Education provided to all staff related to neglect.
• All newly hired staff and or agency staff will receive the education prior to their first shift worked.
• Administrative staff will be conducting audits of all units during meal times to ensure monitoring of all residents for safety during mealtime and to ensure that at the end of the meal or assisting residents with eating that the trays are removed timely and not left unattended and are returned to the tray cart and to the kitchen.
• Audits will be completed for every meal for the first 72 hours, then three times per week, then weekly, then monthly, then random thereafter.
• All audits and data will be reported to the QA committee for review, recommendation, and follow-up.

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 adequate supervision and safety for a resident, leading to a fatal incident. The resident, who had a therapeutic diet due to dysphagia and other medical conditions, consumed food from another resident's meal tray left unattended in the dining area. This occurred while the resident was unsupervised in the common area, and staff were occupied at the nurse's station. The resident, who had a history of wandering and cognitive impairment, was able to access and consume the food, which was not suitable for their dietary needs. The resident's medical history included diagnoses such as adult failure to thrive, protein calorie malnutrition, dementia, and dysphagia, among others. The resident was on a regular pureed diet with nectar thick liquids and received enteral feeding through a gastrostomy tube. Despite these dietary restrictions, the resident was able to access and consume a regular diet meal, which included solid foods that posed a choking hazard. The incident was captured on video footage, showing the resident eating from the tray and later slumping over on the couch, unnoticed by the staff until it was too late. The staff's inaction and lack of supervision contributed to the resident's death. The meal tray was left unattended in a common area, and the staff failed to monitor the resident, who was known to wander and had a history of putting things in their mouth. The staff at the nurse's station did not notice the resident's actions or their subsequent distress until after the resident had already consumed the food and was in distress. The nurse attempted the Heimlich maneuver and suctioning, but the resident was pronounced dead by EMS shortly after.

Removal Plan

• Statements were written by all staff on duty.
• Nurse on duty was interviewed via phone by RDCS and DON. She stated she noted him slumped over and bluish color to face and observed what she felt to be a possible obstruction to his airway, so she initiated the Heimlich and attempted to suction his airway until EMS arrived.
• Camera footage was observed by Administrator and DON to establish a timeline and confirm he had eaten food from a tray sitting in the common area.
• Education was initiated with all staff regarding picking up all trays timely and not leaving any food trays unattended on a unit.
• Audits were initiated of all residents who wander or have behaviors to ensure all are care planned for wandering and staff are aware of this behavior and risk for getting food that is not theirs.
• An audit was initiated for all residents on a mechanically altered diet to ensure orders are correct and tray cards and care plans also reflect correct diets as ordered.
• Standup/stand down initiated to track progress of the abatement plan.
• Audits initiated for all residents on a mechanically altered diet to ensure that orders are correct and correlate with tray cards and care plans to reflect current orders.
• Audits initiated for all residents who have behaviors of wandering and would be at risk to take food from other residents or areas that is not their ordered diet to ensure care plan is reflective of the behavior.
• Education initiated immediately for all staff to ensure understanding of timely removal of trays from the unit and not left unattended. All newly hired staff and or agency staff will receive the education prior to first shift worked.
• Education was sent to all staff via CORV. Wet signatures will be obtained as staff report for duty on next scheduled shift.
• Education provided to all staff related to neglect.
• All newly hired staff and or agency staff will receive the education prior to their first shift worked.
• Administrative staff will be conducting audits of all units during meal times to ensure monitoring of all residents for safety during mealtime and to ensure that at the end of the meal or assisting residents with eating that the trays are removed timely and not left unattended and are returned to the tray cart and to the kitchen.
• Audits will be completed for every meal for the first 72 hours, then three times per week, then weekly, then monthly, then random thereafter.
• All audits and data will be reported to the QA committee for review, recommendation, and follow-up.

Penalty

Inspection fine: $15,646

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 timely written notifications of emergent hospital transfers to residents, their representatives, and the Ombudsman for eight out of nine residents reviewed. This deficiency was identified through a review of records, interviews, and policy analysis. The facility's policy requires that residents and their representatives be notified of transfers, including the reason and location, and that the Ombudsman be informed when practicable. However, the facility did not adhere to these requirements, as evidenced by the lack of documentation in the residents' records and the absence of notifications to the Ombudsman. Several residents, including those with severe cognitive impairments and significant medical conditions, were transferred to the hospital without receiving the required written notifications. For instance, one resident with metabolic encephalopathy and severe cognitive impairment was transferred multiple times without proper documentation or notification to the Ombudsman. Another resident with a history of falls and severe cognitive impairment was also transferred without the necessary notifications. These omissions were confirmed through interviews with the Social Services Director and other staff members, who acknowledged the failure to notify the Ombudsman and provide written notifications to residents and their representatives. The facility's failure to provide written notifications was further highlighted by the lack of clarity regarding staff responsibilities for sending out transfer notifications. Interviews with the Administrator, Director of Nursing, and Medical Records staff revealed confusion about who was responsible for issuing these notifications. The Administrator believed that verbal communication with residents' representatives was sufficient, while the Medical Records staff was unsure of their role in the notification process. This lack of clarity and adherence to policy resulted in the deficiency identified by the surveyors.

Penalty

Inspection fine: $15,646

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 an accurate Minimum Data Set (MDS) assessment for one resident, identified as Resident 13, out of 28 sampled residents. This deficiency was identified through a review of records, staff interviews, and the Resident Assessment Instrument (RAI) Manual. The issue arose when the facility did not correctly code the MDS, which could lead to inaccurate assessment and care planning. Specifically, the resident's quarterly MDS indicated one fall with minor injury, but the subsequent annual MDS incorrectly showed no falls since the last assessment. This discrepancy was discovered during a review of the resident's electronic medical record (EMR), which documented a fall on 07/28/24, contradicting the annual MDS coding. Resident 13 had a medical history that included type II diabetes, dementia with agitation, degenerative disease of the nervous system, polyneuropathy, osteoporosis, anxiety disorder, and insomnia. The resident experienced a fall on 07/28/24, as noted in the EMR Progress Notes, where the resident was found on the floor due to cognitive impairment. During an interview, the MDS Coordinator acknowledged the incorrect coding of the annual MDS and confirmed that the facility uses the RAI Manual for MDS accuracy. The facility administrator expressed an expectation for accurate MDS assessments.

Penalty

Inspection fine: $15,646

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 update the care plan regarding resuscitation status for a resident, identified as R111, which could affect the appropriateness of care in the event of a respiratory or cardiac arrest. The resident's electronic medical record (EMR) indicated a Do Not Resuscitate (DNR) status, confirmed by a signed DNR order from the resident's representative and a physician's order. However, the care plan in the EMR inaccurately reflected a 'Full Code' status, indicating that the resident would receive cardiopulmonary resuscitation (CPR) if their heart or breathing stopped. The discrepancy was identified during a review of the resident's significant change of status assessment, which showed the resident had a terminal diagnosis and was receiving hospice services. Despite these updates, the care plan was not revised to reflect the resident's DNR status. The Director of Nursing (DON) acknowledged the inconsistency upon reviewing the EMR and stated that the care plan should have been updated to align with the resident's current resuscitation preferences.

Penalty

Inspection fine: $15,646

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 restorative nursing services to a resident, identified as R112, who was reviewed for such services. R112 had a history of acute osteomyelitis of the right tibia and fibula, generalized muscle weakness, abnormal posture, and multiple contractures, among other conditions. Despite these needs, the facility did not have a policy for restorative nursing, and there were no orders for range of motion (ROM) assistance in R112's clinical physician orders. The resident's care plan indicated a decline in activities of daily living and mobility, requiring assistance due to multiple fractures and contractures, but did not include specific interventions for ROM exercises. Interviews with staff revealed that the facility lacked a restorative nursing program, and there was no documentation of training or in-services provided to nursing staff for active or passive range of motion (AROM/PROM) exercises. The Director of Rehabilitation and other staff members confirmed that while therapy services had been provided to R112, there were no follow-up orders or documented training for nursing staff to continue ROM exercises after therapy discharge. The Director of Nursing acknowledged the absence of a restorative nursing program and the lack of communication between therapy and nursing departments regarding the continuation of ROM exercises. Observations and interviews with R112 indicated that the resident was not receiving the necessary ROM exercises, which were only performed during wound care or when repositioning was required. R112 expressed that his joints felt stiffer since the completion of therapy, and staff did not offer PROM. The lack of a structured restorative nursing program and the absence of documented orders or training for staff to provide ROM exercises contributed to the deficiency in care for R112, potentially leading to increased contractures and decreased mobility.

Penalty

Inspection fine: $15,646

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 recognize and thoroughly investigate an injury of unknown origin for a resident, identified as R52, which had the potential to place residents at risk of abuse. The facility's policy required all reports of resident abuse, including injuries of unknown origin, to be thoroughly investigated. However, the investigation into R52's injury was not conducted as an injury of unknown origin, despite the resident's severe cognitive impairment and inability to communicate effectively. R52 was admitted with medical diagnoses including a traumatic rupture of a ligament in the left wrist and was severely cognitively impaired, with a BIMS score of 00 out of 15. Progress notes indicated that R52 exhibited signs of pain and agitation, particularly in the right arm, which was later found to have a fracture. Despite these symptoms, the facility's investigation did not consider the possibility of an injury of unknown origin, and the investigation was limited to the resident's combative behavior and the assumption that the pain was related to this behavior. Interviews with staff, including the Administrator, revealed that the investigation was not as thorough as required for an injury of unknown origin. The Administrator admitted that the investigation did not involve the facility's physiatrist or the interdisciplinary team and was not conducted with the depth necessary for an abuse investigation. The facility's failure to conduct a comprehensive investigation into the fracture as an injury of unknown origin represents a deficiency in their handling of potential abuse cases.