Health inspection·May 19, 2021

§72311, Nursing Services – General (a)Nursing service shall include, but not be limited to, the following: (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan § 72523. Patient Care Policies and Procedures. (a)Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. F-689 §483.25(d) Accidents. The facility must ensure that - §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2) Each resident receives adequate supervision and assistance devices to prevent accidents. On 2/18/2021, an unannounced visit was made to the facility to investigate a complaint related to quality of care. The facility failed to ensure Resident 1, who was at risk for falls and needed supervision and assistance with walking, did not fall sustaining injury when walking alone, by: 1. Not evaluating increased fall risk when Resident 1 was prescribed increased doses of psychotropic medications (prescribed to treat a variety of mental health issues when those issues cause significant impairment to healthy functioning. These drugs exert an effect on the chemical makeup of the brain and nervous system). 2. Not providing supervision and assistance when Resident 1 was going to use the toilet. 3. Not implementing the plan of care developed on 2/10/2021 for Seroquel and Zoloft increased doses. Seroquel was increased to 25 milligrams (mg) every morning and 50 milligrams at night. Zoloft was increased from 25 mg at bedtime to 50 mg in the morning. The intervention included monitoring vital signs for 72 hours every shift. 4. Not implementing the plan of care developed on 2/12/2021 for Ativan (for anxiety [feeling of fear, dread, and uneasiness]) which indicated to take Resident 1’s vital signs (a group of the four to six most important medical signs that indicate the status of the body’s vital functions, including body temperature, respiratory and heart rate and blood pressure) every shift for 72 hours. As a result, on 2/13/2021 at 11:40 p.m. Resident 1 sustained a fall, required transfer to General Acute Care Hospital 1 (GACH 1), where she was found to have a commuted right radial fracture (broken forearm at the wrist into multiple pieces). A review of Resident 1’s Admission Record indicated an admission dated 11/12/2020 with diagnoses including schizoaffective disorder (mental disorder characterized by abnormal thought processes and unstable mood) and dementia (a group of thinking and social symptoms that interferes with daily functioning). A review of Resident 1’s Physician's Order dated 11/12/2020, indicated to administer the resident sertraline (Zoloft) 25 milligram (mg), one tablet by mouth at bedtime, for depression. According to the manufacturer, the side effects of Zoloft include dizziness, sleepiness, and low blood pressure related to position changes (from lying to sitting or standing). A review of Resident 1’s Physician's Order dated 11/12/2020, indicated to administer the resident quetiapine (Seroquel) 25 mg, one tablet by mouth at bedtime, for schizoaffective disorder. According to the manufacturer, the side effects of Seroquel include dizziness, sleepiness A review of Resident 1’s Fall Risk Assessment dated 11/14/2020, indicated Resident 1 had a high fall risk. A review of Resident 1’s he Care Plan for fall, dated 11/14/2020, indicated Resident 1 had limited mobility, needed assistance from staff, and had memory problems. The goal was the resident fall risk to be minimized. The interventions included monitoring side effects of medications and reminding resident to use the call light and reporting medication side effects to the physician. A review of Resident 1’s Minimum Data Set (MDS, standardized care and screening tool) dated 11/19/2020, indicated Resident 1 was totally dependent with one-person assist for transfers and toilet use. Resident 1 was not steady while moving from seated to standing position or while walking. A review of Resident 1’s Psychiatrist's Patient Visit Information Notes, dated 2/9/2021, indicated Resident 1 reported feeling "very anxious," not sleeping at night, and "very restless in bed." Resident 1 complained of feeling sad about recent physical health decline. The psychiatrist increased sertraline from 25 mg to 50 mg orally daily. The psychiatrist ordered quetiapine 25 mg in the morning and 50 mg at night orally as mood stabilizer for bipolar disorder (a person's mood changes from a depressed or low feeling to a high manic feeling or vice versa). A review of the Care Plan dated 2/10/2021 indicated Resident 1's Seroquel and Zoloft had a dosage increase. The care plan goal indicated Resident 1 will have no complications and will minimize risk for further decline in condition. The care plan interventions included to assess Resident 1 for pain every shift, monitor vital signs every shift for 72 hours, notify the physician and family representative of changes as appropriate. A review of Resident 1's Care Plan for lorazepam (Ativan - antianxiety medication) dated 2/12/2021, indicated Resident 1 had a new order for Ativan one mg, one tablet as needed for 14 days by mouth at bedtime for anxiety. The care plan interventions included monitoring for vital signs every shift for 72 hours. According to the manufacturer, the side effects of Ativan include dizziness, sleepiness, drowsiness, weakness, and unsteadiness (unsteady walk). A review of the Medication Administration Record (MAR) for 2/2021, indicated Resident 1 was given: - Seroquel 25 mg at 9 a.m. and 50 mg at 9 p.m., on 2/10/2021, 2/11/2021, 2/12/2021 and 2/13/2021 - Zoloft 50 mg every morning from 2/10/2021 - 2/13/2021 and, - Ativan one mg on 2/12/2021. A review of the Progress Notes, dated 2/13/2021 at 9:57 p.m., indicated Resident 1 was noted with drowsiness, and sleeping more than usual and Resident 1's psychiatrist was notified and awaiting return call. A review of the Progress Notes dated 2/14/2021 at 2:18 a.m., indicated on 2/13/2021 at 11:30 p.m., Resident 1 was observed to be asleep. At 11:40 p.m., Resident 1 was overheard screaming for help and was found on the floor, prone position (body position in which the person lies flat with the chest down and the back up) with legs bent and right arm positioned in her back. Resident 1 stated she was in a hurry to get up to go to the bathroom. Resident 1 stated she lost her balance and fell. Resident 1 complained of pain on the right wrist with pain rated at a score of eight out of 10 (using a scale of zero to 10, zero indicating no pain and 10 indicating the worst possible pain). Resident 1's primary physician was notified and gave an order to transfer Resident 1 to GACH 1. A review of the GACH 1 Emergency Room Report, dated 2/14/2021, indicated Resident 1's right upper arm had deformity and swelling to the distal forearm (wrist area) with tenderness to right elbow, forearm, wrist and hand. The x-ray report indicated Resident 1 sustained comminuted (bone was broken into more than two pieces), impacted distal right radial fracture (break in the bone that occurs near the wrist) with intra articular extension of the right arm (fracture of the wrist joint). Closed reduction (set a broken bone without surgery) was performed and a splint (a medical device that heals the fractured bones by keeping the broken ends together and in alignment) was applied. During an interview on 3/2/2021 at 9:50 a.m., Resident 1 stated she had a fall and broke her arm. Resident 1 stated she was right-handed, unable to use her right arm, and suffered occasional pain. During a telephone interview and concurrent record review, on 3/31/2021 at 12:20 pm, Resident 1's Progress Notes were reviewed. Licensed Vocational Nurse 1 (LVN 1) stated Resident 1's vital signs were not obtained on 2/10, 2/11, and 2/12/2021 during the night shift (11 p.m. to 7 a.m.) and on 2/13/21 during the morning (7 a.m. to 3 p.m.) and afternoon (3 p.m. to 11 p.m.) shifts. LVN 1 stated the vital signs should have been done for 72 hours, per Resident 1's Care Plan for Seroquel and Zoloft dated 2/10/2021 and Ativan care plan dated 2/12/2021. During a telephone interview on 4/2/2021 at 4:14 p.m., the facility’s Pharmacist stated the most common side effects of Zoloft and Seroquel were dizziness and hypotension. Taking Resident 1's vital signs would help determine the side effects of the medications. During a telephone interview on 4/5/2021 at 2:26 p.m., the interim DON stated there was no monitoring for the side effects of Ativan, such as drowsiness and change in cognition. On 4/7/2021 at 7:37 a.m., during a telephone interview, the interim DON stated the vital signs should be taken because the Seroquel, Zoloft, and the Ativan can change cognition (mental action of acquiring understanding), cause dizziness, low blood pressure, and can lower the heart rate. During an interview on 4/16/2021 at 1:30 p.m., Resident 1's Care Plan for fall, dated 11/14/2020 was reviewed with the director of staff development (DSD). The Care Plan indicated Resident 1 was at risk for fall related to limitation in functional mobility needing assistance from staff, advancing age. The DSD stated Resident 1's use of psychotropic medications should be included as one of the risk factors for fall. A review of the facility's policy titled, "Fall Management Program," revised 8/21/2020, indicated the purpose was to provide residents a safe environment that minimizes complications associated with falls. The facility will implement a fall program that supports providing an environment free from fall hazards. A review of the facility’s policy titled, "Behavior/Psychoactive Drug Management," revised 11/2018 indicated it was the policy of the facility to provide person-centered, comprehensive and interdisciplinary care that reflects best practice standard of care, that reflects and provide a therapeutic (relating to the healing of disease) environment that supports residents to obtain or maintain the highest physical, mental and psychosocial well-being. The policy indicated the resident should be observed for side effects and adverse consequences that would include: 1. General/anticholinergic (drugs used to treat a variety of medical conditions that affect the contraction and relaxation of muscles): constipation, blurred vision, dry mouth, urinary retention, sedation, 2. Cardiovascular side effects (relating to the heart) including orthostatic hypotension (when a blood pressure suddenly drops when standing up or sitting down), arrhythmia (heart beats with an irregular or abnormal rhythm) A review of the facility’s policy titled, "Comprehensive Person-Centered Care Planning," revised 11/2018, indicated the facility would provide a person-centered, comprehensive and interdisciplinary care that reflects best practice standards for meeting health, safety, psychosocial, behavioral, and environmental needs of residents in order to obtain or maintain the highest physical, mental and psychosocial well-being. The facility failed to ensure Resident 1, who was at risk for falls and needed supervision and assistance with walking, did not fall sustaining injury when walking alone, by: 1. Not evaluating increased fall risk when Resident 1 was prescribed increased doses of psychotropic medications. 2. Not providing supervision and assistance when Resident 1 was going to use the toilet. 3. Not implementing the plan of care developed on 2/10/2021 for Seroquel and Zoloft increased doses. Seroquel was increased to 25 mg every morning and 50 milligrams at night. Zoloft was increased from 25 mg at bedtime to 50 mg. The intervention included monitoring vital signs for 72 hours every shift. 4. Not implementing the plan of care developed on 2/12/2021 for Ativan for anxiety which indicated to take Resident 1’s vital signs every shift for 72 hours. As a result, on 2/13/2021 at 11:40 p.m. Resident 1 sustained a fall, required transfer to GACH 1, where she was found to have a commuted right radial fracture. The above violations, jointly or separately, presented either an imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result to Resident 1.