Health inspection·May 16, 2019

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interview and policy review, the facility failed to apply hand splints as ordered for one (Resident #9) of one residents reviewed for positioning. The facility census was 70. Findings include: Review of the medical record of Resident #9 revealed an admission date of 01/18/16 with diagnoses including persistent vegetative state and contracture of the right and left hand. Review of the quarterly minimum data set assessment dated [DATE] revealed the resident was never or rarely understood and was totally dependent of staff for all activities of daily living. The assessment further revealed impairment of upper extremities, assistance with splints occurred three days of the look back period of 02/02/19 to 02/08/19. Observations on 05/13/19 and 05/14/19 until 1:30 P.M. revealed no splints had been applied to bilateral hands of Resident #9. Observation on 05/14/19 at 1:30 P.M. with Licensed Practical Nurse (LPN) #200 revealed no splints were applied to Resident #9's bilateral hands. LPN #200 located the splints in the bottom drawer of the bedside table and applied the splints. Interview on 05/14/19 at 1:30 P.M. with LPN #200 provided verification of the missing splints. When questioned as to the need of any splints for Resident #9, LPN #200 replied he was unaware of any need. When review of the treatment administration record for 05/19 revealed the order for bilateral hand splints to be applied from 7:00 A.M. to 7:00 P.M., LPN #200 replied I don't consider them splints. Interview on 05/14/19 at 1:35 P.M. with State Tested Nursing Assistant #210 revealed a Resident Care form is in each room to identify the devices each resident has been ordered to be wearing or using. STNA #210 reviewed the form for Resident #9 and confirmed bilateral hand splints should be applied from 7:00 A.M. to 7:00 P.M. She then verified the braces had not been applied at 7:00 A.M. as ordered. Review of the facility policy tilted Contractures and Splinting undated, revealed the device should be applied according to the resident's care plan. Page 1 of 4 366189 366189 05/16/2019 Vancrest of Delphos 1425 East Fifth Street Delphos, OH 45833

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and review of a facility policy, the facility failed to complete a thorough investigation to determine the root cause of a fall. This affected one (Resident #41) of three residents reviewed for accidents. The facility census was 70. Findings include: Review of Resident #41's medical record revealed an admission dated of 05/16/03. Medical diagnoses included cerebral palsy, diabetes mellitus, mild intellectual disability, major depressive disorder, epilepsy, restlessness and agitation, generalized muscle weakness, spinal stenosis, chronic ischemic heart disease, and age related osteoporosis. Review of the resident's care plan originally dated 02/19/14 revealed she had difficulty with ambulation related to an unsteady gait. Interventions included use a gait belt at all times, unless contraindicated. Review of the resident's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a brief interview for mental status (BIMS) score of 13, indicating mild cognitive impairment. She required extensive assistance with one staff for bed mobility, transfers, walking, dressing, toilet use, and personal hygiene. She used a walker and/or wheelchair for locomotion. She had one fall since her prior assessment with no injuries. Review of the resident's nursing note from Licensed Practical Nurse (LPN) #240 dated 05/10/19 at 5:03 A.M. revealed the resident was ambulating to the bathroom with a State Tested Nursing Assistant (STNA) when she urinated on floor and slipped and fell onto her buttocks. The resident complained of pain in the left leg. Review of the resident's fall investigation dated 05/10/19 created by LPN #240 and completed by the Director of Nursing (DON) revealed the resident was ambulated to the bathroom with STNA and urinated while walking and slipped and fell on her buttocks. Resident #41 was assessed and no injuries were noted. The resident was oriented to person and situation. All interventions in place at time was checked. Predisposing environmental factor was wet floor. Predisposing physical factors were listed as incontinence and gait imbalance. Predisposing situation factors were ambulating with assistance, recent room change, and using a walker. No witness statements were included. Under the section titled Witnesses was written no witnesses found. Continued review of the resident's medical record revealed the resident was sent to the emergency room on [DATE] at 7:23 A.M. for further evaluation. Review of the resident's hospital documentation dated 05/10/19 revealed the resident presented for evaluation following a fall. The resident tripped over her walker while ambulating to the bathroom and fell. Results of a computed tomography (CT) of the resident's left hip revealed a sacral fracture. Review of a fall follow up events note dated 05/13/19 from the DON revealed the resident was educated to alert staff when she was urinating. Staff was to utilize a wheelchair if the resident had 366189 Page 2 of 4 366189 05/16/2019 Vancrest of Delphos 1425 East Fifth Street Delphos, OH 45833

F 0689 already been incontinent when in route to the bathroom. Level of Harm - Minimal harm or potential for actual harm Interview with the DON on 05/15/19 at 2:34 P.M., revealed the STNA assisting Resident #41 on 05/10/19 was STNA #270. She stated she interviewed STNA #270 and the resident had her gait belt on when she fell. She stated she did not have her write a witness statement. Residents Affected - Few Interview with LPN #280 on 05/15/19 at 2:40 P.M. revealed STNA #270 was not assisting the resident during the fall. She stated it was STNA #250. Interview with STNA #250 via telephone on 05/15/19 at 2:56 P.M., revealed he was assisting Resident #41 to the bathroom on 05/10/19 when she fell. He stated he assisted her with a gait belt. She stated her leg hurt and as she was walking to the bathroom, her leg gave out. She urinated on the floor. He stated he did not notice she urinated until after she fell. Interview with LPN #240 via telephone on 05/15/19 at 3:39 P.M. revealed she was called to check Resident #41 after she fell on [DATE]. She stated when she got to the resident's room, she was sitting on the floor in front of her bed. There was urine on the floor. She stated the resident did not have her gait belt on and she told STNA #250 to put the gait belt on the resident so they could assist her to stand. She stated she had not been interviewed about the fall. Interview with the DON on 05/15/19 at 4:21 P.M. verified she did not interview STNA #250 or LPN #240 regarding the resident's fall interventions. She verified she did not obtain a witness statement from STNA #250 regarding the fall. Further interview with STNA #250 on 05/15/19 at 5:35 P.M. revealed he took the resident's gait belt off after she fell. He stated he noticed it was a little loose. He stated no one had interviewed him or asked him to write a statement about the fall. Review of an undated facility policy titled Incident/Accident Reporting revealed an incident is an unexpected occurrence which is not consistent with the routine operation of the facility or the routine care of a particular resident. It may be an accident or an unusual occurrence which may or may not result in an injury. Procedures included post fall investigation and plan of care changes for falls should be completed soon after the fall to ensure appropriate follow through. Immediate intervention to prevent reoccurrence must be instituted for all falls. The administrator, DON, and/or nursing designee will review and investigate as appropriate. 366189 Page 3 of 4 366189 05/16/2019 Vancrest of Delphos 1425 East Fifth Street Delphos, OH 45833

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, staff interview and facility policy review, the facility failed to properly store tuberculin purified protein derivative and the control solution for the blood glucose monitoring system. This affected one (D Hall) of three medication storage rooms observed and five residents (#10, #22, #33, #45 and #47) who have their blood glucose monitored in the C Hall. The facility census was 70. Findings include: Observation on 05/16/19 at 12:45 P.M. of the C Hall medication cart revealed a box of control solution for blood glucose monitoring system which contained a small bottle of control solution labeled Level 1 and a second small bottle labeled Level 2. The box was dated 11/23/18. Observation of the medication storage room in the D Hall revealed an opened vial of tuberculin purified protein derivative undated. Review of the box of control solution revealed to discard after three month from opening date. Interview on 05/16/19 12:52 P.M. with Licensed Practical Nurse (LPN) #230 provided verification of the outdated control solution and the undated tuberculin purified protein derivative. Review of the facility policy titled Medication Storage in the Facility dated 10/22/07, revealed outdated medications should be removed and disposed of according to procedure. 366189 Page 4 of 4