Health inspection·December 16, 2021

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. F840 §483.70(g) Use of outside resources. §483.70(g)(1) If the facility does not employ a qualified professional person to furnish a specific service to be provided by the facility, the facility must have that service furnished to residents by a person or agency outside the facility under an arrangement described in section 1861(w) of the Act or an agreement described in paragraph (g)(2) of this section. §483.70(g)(2) Arrangements as described in section 1861(w) of the Act or agreements pertaining to services furnished by outside resources must specify in writing that the facility assumes responsibility for- (i) Obtaining services that meet professional standards and principles that apply to professionals providing services in such a facility; and (ii) The timeliness of the services. §72511. Use of Outside Resources. (a) If a facility does not employ qualified personnel to render a specific service to be provided by the facility, there shall be arrangements through a written agreement with outside resources which shall meet the standards and requirements of these regulations. (b) Copies of affiliation agreements, contracts or written arrangements for advice, consultation, services, training, or transportation, with other facilities, organizations, or individuals, public or private agencies, shall be on file in the facility's administrative office. These shall be readily available for inspection and review by the Department. (c) The affiliation agreement, contracts and written arrangements shall include, but not be limited to: (1) Description of the services to be provided. § 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. On 9/15/2021, the Department of Public Health made an unannounced visit to the facility to investigate an entity related incident related to quality of care/treatment-Resident safety. The facility failed to ensure adequate supervision to prevent fall and injuries and follow a contract agreement with an outside resource resulting on Resident 1 sustaining an avoidable injury. On 9/4/2021, Resident 1, who was at risk of elopement (a patient who leaves the healthcare facility unnoticed and doing so may present an imminent threat to the patient's health or safety because the patient has been deemed too ill or impaired to make a reasoned decision to leave), was dropped off unaccompanied (not escorted by a responsible adult) by Driver 1 from Transportation Company 1 (TC 1) at a Dialysis Center (DC – an outside treatment center, for residents who require dialysis - a procedure for removal of accumulated waste from the blood). Resident 1 fell and sustained a right shoulder fracture (broken bone) and a decline on his physical condition. A review of Resident 1's Admission Record indicated the facility admitted the resident, a 73-year-old male, on 5/18/2019 to the Dementia Unit (a secure unit [doors need a specific code to open] of the facility for resident with exit-seeking behavior and at risk for elopement). Resident 1’s diagnoses included Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), end stage renal disease (ESRD, total loss of kidney function) and dependence on renal hemodialysis (a procedure to remove fluid and waste products from the blood and to correct electrolyte imbalances with a dialysis machine [an artificial kidney] or a dialyzer. To get the blood into the dialyzer, the doctor needs to make an access, or entrance, into the blood vessels), and hypertension (high blood pressure). A review of Resident 1’s Minimum Data Set (MDS, a standardized assessment and care-screening tool), dated 8/26/2021, indicated the resident had a severely impaired cognition (the person has a very hard time remembering things, making decisions, concentrating, or learning. Severe levels of impairment can lead to losing the ability to understand the meaning or importance of something and the ability to talk or write, resulting in the inability to live independently). Resident 1 was independent with bed mobility, transfers, walking in the room, dressing, and eating. Resident 1 required supervision with walking in the corridor, toilet use, and personal hygiene. A review of Resident 1’s Care Plan, developed on 4/18/2020, for the resident’s risk of decreased ability to perform activities of daily living (ADLs, such as toilet use, bathing, grooming, personal hygiene, and dressing), included in the interventions monitoring of decline in ADLs function and providing cueing for safety and sequencing to maximize current level of functioning. A review of Resident 1’s Care Plan, developed on 4/18/2020, for the resident’s fall risk due to cognitive loss and lack of safety awareness related to Alzheimer's disease and hypertension, included in the interventions providing verbal cues for safety and sequencing when needed and assessing resident for changes in medical, pain and mental status. A review of Resident 1’s Physician’s Orders, dated 5/28/2020, indicated for the resident to have dialysis treatment at DC three times a week on Tuesdays, Thursdays, and Saturdays and transportation to pick up Resident 1 each dialysis day between 12:15 p.m. and 12:45 p.m. A review of Resident 1’s Change in Condition Evaluation, dated 11/21/2020, indicated Resident 1 had an actual incident of leaving the facility unattended. During this incident, the Police Department was contacted and helped look for the resident. Resident 1 was found and accompanied by the police back to the facility. A review of Resident 1’s Care Plan, developed on 11/21/2020, for the resident’s risk of elopement due to cognitive loss and impulsive behavior related to his Alzheimer's disease, included in the interventions monitoring the resident’s location with visual checks at least every hour and as needed. A review of Resident 1’s Elopement Evaluation form, dated 7/5/2021, indicated Resident 1 had a history of wandering and was at a significant risk of getting to a potentially dangerous place such as stairs or outside of the facility. A review of Resident 1’s Care Plan, developed on 8/30/2021, indicated Resident 1 had a decline in cognitive function or impaired thought process related to Alzheimer's disease. The interventions included providing consistent, trusted caregiver, and structured daily routine, when possible. A review of Resident 1’s Progress Notes, dated 9/4/2021, indicated Resident 1 was in stable condition and was picked up by Driver 1 at 12:20 p.m. to go to dialysis treatment. Resident 1 was ambulatory (walking) with steady gait.  A review of Resident 1’s Progress Notes, dated 9/4/2021, indicated at 1:35 p.m., DC staff called to inform Resident 1 did not arrive to his dialysis appointment.  The MDS Nurse called TC 1 and found out Driver 1 was new and got lost but was already on his way to DC. At 2:59 p.m., paramedics (or emergency medical services [EMS] are health professionals certified to perform advanced life support procedures who respond to 911 calls and treat and transport people in health crisis) called to inform Resident 1 was wandering in downtown, had fallen, and was taken to General Acute Care Hospital 1 (GACH 1) for evaluation.   A review of Resident 1’s History and Physical exam from GACH 1, with an admission date of 9/4/2021, indicated Resident 1 arrived with right arm pain. A review of Resident 1’s Diagnostic Radiology Consultation Report from GACH 1, dated 9/4/2021, indicated x-rays (type of radiation called electromagnetic waves. X-ray imaging creates pictures of the inside of the body) of the right shoulder and humerus (long bone of the arm) showed an acute comminuted fracture (a break of the bone into more than two fragments) through the surgical neck of the right humerus (the neck lies just below the head of the humerus, it is called the surgical neck because this is the location of many fractures that require surgery). A review of Resident 1’s Discharge Summary from GACH 1, dated 9/8/2021, indicated Resident 1 received orthopedic (relating to the branch of medicine dealing with the correction of deformities of bones or muscles) consultation and was placed in a coaptation splint (a short splint or plastic bandage designed to shoulder and elbow) with coaptation splint (a short splint or plastic bandage) with an arm sling (a device that helps immobilize the arm and shoulder). A review of Resident 1’s Admission Record indicated the facility re-admitted the resident on 9/8/2021 with a new diagnosis of comminuted fracture of the right humerus. A review of Resident 1’s Nursing Admission Assessment, dated 9/9/2021, indicated Resident 1 came with bruising and swelling of the right arm and face. A review of Resident 1’s Admission Skin Check Assessment, dated 9/9/2021, indicated Resident 1 came from GACH 1 with multiple abrasions and discoloration on his back and right arm swelling with a removable cast / immobilizer. A review of Resident 1’s MDS dated 9/13/2021 indicated the resident’s physical condition had deteriorated after readmission. After re-admission, Resident 1 needed limited assistance with walking in the room and eating and required extensive assistance with bed mobility, transfers, walking in the corridor, dressing, toilet use, and personal hygiene. On 9/15/2021 at 12:01 p.m., during an interview, Licensed Vocational Nurse 1 (LVN 1) stated on 9/4/2021 she was in charge of the resident. LVN 1 stated Certified Nursing Assistant 2 (CNA 2) accompanied Resident 1 to the facility's lobby to meet Driver 1.  LVN 1 stated she did not know if CNA 2 informed Driver 1 of the safety precautions needed with Resident 1 due to his wandering and elopement behaviors.  On 9/15/2021 at 12:47 p.m., during an interview, CNA 2 stated on 9/4/2021, she took the resident to the lobby to meet with Driver 1 and did not inform him of safety precautions needed with Resident 1. On 9/15/2021 at 2:13 p.m., during an interview, Registered Nurse 1 (RN 1) stated on 9/4/2021, she called TC 1 after paramedics informed them Resident 1 was found wandering in the street of downtown. RN 1 stated she was informed Driver 1 was new to the company. RN 1 stated the expectation was for drivers to drop off the resident inside DC and leave him with a dialysis staff. On 9/15/2021 at 2:30 p.m., during an interview, Director of Nursing (DON) confirmed Resident 1 was an elopement risk and was at fall risk. On 9/15/2021 at 3:08 p.m., during an interview, Administrator (ADM) stated TC 1 did not follow a door-to-door transportation (transportation of a person from the door of the initial location through the door of the end location). ADM stated Driver 1 should have accompanied Resident 1 into DC. On 10/14/2021 at 10:39 a.m., during a telephone interview, Dispatch Manager (DM) at TC 1 stated the facility did not communicate to Driver 1 Resident 1's elopement and wandering risks and Driver 1 did not know he needed to escort Resident 1 into DC. On 10/20/2021 at 12 p.m., during a telephone interview, Driver 1 stated he dropped off Resident 1 in front of DC and did not escort the resident into the building because he did not know Resident 1 was confused or was at risk of going elsewhere. On 10/21/2021 at 1:07 p.m., during a telephone interview with ADM and concurrent review of a document titled, "Business Associate Agreement" between the facility and TC 1, dated 5/18/2019, did not include a door-to-door transportation agreement. The ADM verified and stated, door-to-door transportation agreement was not included in the agreement. The ADM further stated door-to-door was an expected service from TC 1 when providing private transportation.  A review of the facility's policy and procedures titled, "Dementia: Care of Patient," revised on 6/1/2021, indicated practice standards included monitoring residents for elopement risk and safety to self and/or others. Communicate care plan changes to patient, family, patient representative, and staff. A review of the facility's policy and procedures titled, "Elopement of Patient," revised on 2/28/2021, indicated residents determined to be at risk will receive appropriate interventions to reduce risk and minimize injury. A review of the facility’s policy and procedures titled, “Falls Management,” revised on 6/1/2021, indicated residents determine to be at risk will receive appropriate interventions to reduce risk and minimize injury. The policy further indicated that it is the facility’s practice standard to communicate patient’s fall risk status to caregivers. A review of the facility's policy and procedures titled, "Dialysis: Hemodialysis (HD) Provided by a Certified Dialysis Facility," revised on 11/1/2019, indicated, “The facility's staff must assist the patient in making arrangements for safe transportation to and from the dialysis facility." A review of the facility's document titled, "Nursing Home Dialysis Transfer Agreement," signed on 2/18/2010, between the facility and DC, indicated "Facility shall have the responsibility for arranging suitable transportation of the designated resident to and from center, including the selection of the mode of transportation, qualified personnel to accompany the designated resident and transportation equipment usually associated with this type of transfer including the use of appropriate life support measures in accordance with the applicable federal and state laws and regulations. Facility shall be responsible for ensuring that the designated resident is medically stable to undergo such transportation, shall be responsible for the designated resident during transfer to and from center, including medical and non-medical emergencies, and shall be responsible for all costs of transportation associated with the transfer of the designated resident to and from center and facility. Facility shall be responsible for, and shall provide the necessary personnel for, assisting the designated resident in entering into and exiting from center." A review of the facility’s document titled, "Business Associate Agreement" between the facility and the transportation company, dated 5/18/2019, did not include a door-to-door transportation agreement. The facility failed to ensure adequate supervision to prevent fall and injuries and follow a contract agreement with an outside resource resulting on Resident 1 sustaining an avoidable injury. On 9/4/2021, Resident 1, who was at risk of elopement (a patient who leaves the healthcare facility unnoticed and doing so may present an imminent threat to the patient's health or safety because the patient has been deemed too ill or impaired to make a reasoned decision to leave), was dropped off unaccompanied by Driver 1 from TC 1 at a DC. Resident 1 did not go inside DC and wandered away. Resident 1 fell and a sustained a right shoulder fracture and a decline on his physical condition. 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.