Advanced Healthcare Of Mesa

Based on clinical record review, staff interview, the Resident Assessment Instrument (RAI) manual, and facility failed to properly complete a Discharge Minimum Data Set (MDS) assessment for Resident #31. The deficient practice could result in delayed identification of potential risks and care needs of the residents.

Findings include:

Resident #31 was admitted into the facility on July 05, 2024 with a diagnosis of surgical wound infections, peritoneal abscess, elevated white blood cell count, chronic obstructive pulmonary disease, and epigastric pain.

MDS revealed that the resident had been discharged to a short-term general hospital.

Progress notes for resident #31 revealed that residents had been discharged home with Home Health services with discharge summary, and medication review on July 19, 2024.

Resident #31 was discharged on July 05, 2024; however, MDS and progress notes there was a discrepancy between progress notes, and MDS.

An interview was conducted on October 17, 2024 at 1:19PM with RN/MDS Coordinator (Registered Nurse & Minimum Data Set) (Staff #9) review with progress notes and states that resident #31 was discharged to home health and that the resident never went to the hospital. RN MDS (Staff # 9) had reviewed resident MDS and stated that on the MDS it is revealed that resident has been discharged to a short term hospital. RN MDS Coordinator ( staff # 9) stated that the MDS was inaccurate and that this is not part of the facility expectation.

Based on record review, and staff interview, the facility failed to develop and maintain an emergency preparedness communication plan that complies with Federal, State, and local laws and must include contact information related to staff, entities providing services under arrangement, next of kin, guardian or custodian, other facilities and volunteers be reviewed and updated at least annually. Failure to have an emergency preparedness communication plan that includes specific information could lead to harm to both patients and staff.

Findings include:

Based on record review, and staff interview on October 23, 2024, revealed a communication plan that did not include contact information related to staff, physicians, volunteers, next of kin, or entities providing services under agreement. The Emergency Plan did not include an emergency preparedness communication plan that included contact information related to entities providing services under arrangement, and other facilities.

Management confirmed during the review process and exit conference on October 23, 2024, that the facility did not have the necessary contact information for staff, physicians, volunteers, next of kin, and entities providing services in their Emergency Plan.

Based on record review and staff interview, the facility failed to participate in drills as required. Failure to participate in drills may lead to untrained staff in an emergency and may result in harm to the residents during an emergency.

Findings include:

Based on record review and staff interview on October 23, 2024, revealed the facility was missing documents proving participation in a full-scale exercise (FSE) that was community-based or based exercise or tabletop drills within the last year.

Management confirmed during the exit conference on October 23, 2024, that the facility could not provide proof of participation in a full-scale exercise that was community-based within the last year.

Based on observation and staff interview, the facility failed to ensure the electrical breaker for the fire alarm system has visual markings to distinguish it from other breakers. Failure to properly identify/mark the fire alarm system could lead to the harm of residents and staff in an emergency.

NFPA 101 - 2012 Edition, Section 18.3.4.5.1, Detection systems, where required, shall be in accordance with 9.6.1.3 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code,. unless it is an approved existing installation, which shall be permitted to be continued in use, and NFPA 72, National Fire Alarm and Signaling Code, unless it is an approved existing installation, which shall be permitted to be continued in use.

NFPA 72-2010 Edition, Section 10.5.5.2. For fire alarm systems the circuit disconnecting means shall be identified as "FIRE ALARM CIRCUIT." Section 10.5.5.3. For the fire alarm system, the circuit disconnecting means shall have a red marking.

Findings include:

Observations made in the electrical room on October 23, 2024, revealed the electrical panel and electrical circuit breaker for the fire alarm system did not have visual markings to distinguish it from other breakers.

The management team confirmed during the facility tour and exit conference on October 23, 2024, that the electrical panel and electrical circuit breaker for the fire alarm system did not have visual markings to distinguish it from other breakers.

Based on observation the facility failed to provide a fire extinguisher near the generator. Failing to have an available fire extinguisher during an emergency could result in harm to the patients and/or staff.

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.5.12 "Portable fire extinguishers shall be provided in all health care occupancies in accordance with 9.7.4.1" Section 9.7.4.1 "Where required by the provisions of another section of this Code, portable fire extinguishers shall be installed, inspected, and maintained in accordance with NFPA 10, Standard for portable Fire Extinguishers." 9.7.4 Manual Extinguishing Equipment. 9.7.4.1 Where required by the provisions of another section of this Code, portable fire extinguishers shall be selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers. NFPA 10 2010 Edition 6.3.1.1 Minimum sizes of fire extinguishers for the listed grades of hazard shall be provided in accordance with Table 6.3.1.1, 6.3.1.2 Fire extinguishers shall be located so that the maximum travel distances do not exceed those specified in Table 6.3.1.1.

Findings include:

Observations made while on tour on October 23, 2024, revealed the facility failed to have a fire extenguish installed within 50 feet of the generator.

The management team confirmed during the facility tour and exit conference on October 23, 2024, that the facility did not have a fire extinguisher within 50 feet of the generator.

Based on facility documentation, the facility failed to ensure two residents (#86, #26) were notified were made aware of the bed-hold policy upon transfer to the hospital.

Findings include:

Resident #86 was admitted to the facility on November 10, 2023 with diagnoses that included periprosthetic fracture around internal prosthetic left knee joint, acute and chronic respiratory failure with hypoxia, and chronic pain syndrome.

The minimum data set (MDS) dated November 14, 2022 included a brief interview for mental status score of 13 indicating the resident was cognitively intact.

A progress note dated November 14, 2021 at 4:17 PM revealed that the resident had a rapid Covid test and tested positive earlier today. The resident complained of shortness of breath, with wet cough. The physician was notified and the resident was transferred to the emergency department (ER) via ambulance for further medical management. The family was notified about the hospital transfer and the resident's belongings were sent along with her.

A progress note dated November 14, 2021 at 10:08 PM revealed that the resident's daughter called the facility to report on the resident regarding the ER admission and discharge. The daughter was notified about the facility Covid-19 positive patient protocol. Despite being educated, the concerned family member was audibly upset due to the fact the resident cannot be readmitted into this facility with a positive Covid-19 status.

Review of the clinical record did not reveal a bed-hold policy signed and dated by the resident or a family member.

-Resident #26 was admitted to the facility on with diagnoses that included benign prostatic hyperplasia without lower urinary tract symptoms, hypertensive heart disease with heart failure, and an anxiety disorder.

The minimum data set (MDS) dated August 29, 2023 included a brief interview for mental status score of 12 indicating the resident had a mild cognitive impairment.

A progress note dated September 10, 2023 revealed that the resident was transported to the hospital as per physician's orders for possible sepsis at approximately 6:40 a.m. The vital signs were taken prior to transport and were as follows: 112/57 blood pressure, 121 heart rate, 72% oxygen on 1 liter., 102.7 temperature, and 22 respiratory rate. There was an attempt to contact the resident's daughter, but there was no answer. The nurse sent the face sheet and orders to transport.

Review of the clinical record did not reveal a bed-hold policy.

During an interview conducted on November 6, 2023 at 9:24 AM with resident #26, he stated that he did not receive a written statement regarding the reason for going to the hospital or a bed hold policy when he was transferred to the hospital.

An interview was conducted on November 8, 2023 at 8:27 AM with the Director of Nursing (DON/staff #81), who stated that the the resident is given a bed-hold policy when he/she is transported to the hospital if it is feasible. If the situation is emergent, the bed hold policy is discussed with a family member, who would decide if he/she wanted to pay the rate required. She stated that she was not sure if the conversation regarding the bed hold policy with the family member is documented in a progress note. She also, stated that if the bed-hold form was used, she would expect that it was signed and dated by the resident or family member.

During an interview conducted on November 8, 2023 at 9:12 AM with the Administrator (staff #90), she stated that resident #86 would not have been given the resident a bed-hold policy because the facility wasn't going to accept the resident back due to being Covid positive.

The facility's policy "Admission, Transfer, Discharge Rights (F-Tag)" states that before a patient is transferred to a hospital or goes on therapeutic leave, the facility will provide written information to the patient, a family member or resident representative specifying the duration of the bed-hold policy during which the patient is permitted to return and resume temporary residence in the facility.

Based on clinical review, staff interviews and the facility policy and procedures, the facility failed to ensure one resident (#86) was permitted to return to the facility after a hospitalization.

Findings include:

Resident #86 was admitted to the facility on November 10, 2023 with diagnoses that included periprosthetic fracture around internal prosthetic left knee joint, acute and chronic respiratory failure with hypoxia, and chronic pain syndrome.

The minimum data set (MDS) dated November 14, 2022 included a brief interview for mental status score of 13 indicating the resident was cognitively intact.

Review of a Covid-19 test dated November 14, 2023 revealed a positive result.

A progress note dated November 14, 2021 at 4:17 PM revealed that the resident had a rapid Covid test and tested positive earlier today. The resident complained of shortness of breath, with wet cough. The physician was notified and the resident was transferred to the emergency department (ER) via ambulance for further medical management. The family was notified about the hospital transfer and the resident's belongings were sent along with her.

A progress note dated November 14, 2021 at 10:08 PM revealed that the resident's daughter called the facility to report on the resident regarding the ER admission and discharge. The daughter was notified about the facility Covid-19 positive patient protocol. Despite being educated, the concerned family member was audibly upset due to the fact the resident cannot be readmitted into this facility with a positive Covid-19 status.

Review of the clinical record did not reveal a bed-hold policy signed and dated by the resident or a family member.

An interview was conducted on November 8, 2023 at 8:27 AM with the Director of Nursing (DON/staff #81), who stated that the the resident was transferred to the hospital because she tested positive for Covid, was symptomatic, and the physician wanted her transferred to the hospital. She stated that the facility did not keep residents who tested positive for Covid and would transfer them to the hospital or another facility. She stated that if the resident would have passed the quarantine period, she would have been able to come back to the facility. Then she reviewed the progress notes and stated that the daughter was told on November 14, 2021, that the resident could not return to the facility, which is the same day that the resident was transferred to the hospital. She acknowledged that on November 14, 2023, she did not know how long the hospital was going to keep the resident or if the resident was being admitted, but knew that the resident was in the incubation period, so was not admitted back to the facility. She stated that the facility was able to isolate residents with Covid-19 by room, but did not have staff to care for the residents. She wouldn't have hired registry staff to provide one to one care for residents with Covid-19 because it is not practical for financial reasons, but doesn't have any documentation of trying to find additional staff or telling AZDHS that this was not feasible.

An interview was conducted on November 8, 2023 at 9:04 AM with a Registered Nurse/Critical Nurse Manager (RN/staff #25), who stated that she was responsible for discharge planning and any family concerns. She stated that if a resident was Covid-19 positive in 2021 and symptomatic, the resident was transferred to the hospital if ordered by the physician. During the interview, she reviewed facility documentation and stated that she didn't have any notes regarding the resident's discharge. She stated that it was her understanding that the facility did not have a Covid unit and she followed facility protocol, which was to transfer the Covid-19 positive residents to the hospital or another facility.

During an interview conducted on November 8, 2023 at 9:12 AM with the Administrator (staff #90), she stated that resident #86 would not have been given the resident a bed-hold policy because the facility wasn't going to accept the resident back due to being Covid-19 positive.

An interview was conducted on November 8, 2023 at 10:20 AM with the Administrator (staff #90) and the Director of Nursing (DON/staff #81). Both staff stated that they developed a plan for Covid positive residents, but didn't implement the plan. Staff #90 stated that they were a Covid-19 free facility and wanted to remain that way.

The facility's "Covid-19 Emergency Plan, Location of Confirmed Patients with SARS-CoV-2" states to identify space in the facility that could be dedicated to care for residents with confirmed Covid-19. This could be a dedicated floor, unit, or wing in the facility or a group of rooms at the end of the unit that will be used to cohort residents with Covid-19. Determine the location of the Covid-19 care unit and create a staffing plan before residents or HCP with Covid-19 are identified in the facility.

Based on facility documentation, the facility failed to ensure two residents (#86, #26) were notified in writing regarding the reason for transfer and a copy was sent to the ombudsman.

Findings include:

Resident #86 was admitted to the facility on November 10, 2023 with diagnoses that included periprosthetic fracture around internal prosthetic left knee joint, acute and chronic respiratory failure with hypoxia, and chronic pain syndrome.

The minimum data set (MDS) dated November 14, 2022 included a brief interview for mental status score of 13 indicating the resident was cognitively intact.

A progress note dated November 14, 2021 at 4:17 PM revealed that the resident had a rapid Covid test and tested positive earlier today. The resident complained of shortness of breath, with wet cough. The physician was notified and the resident was transferred to the emergency department (ER) via ambulance for further medical management. The family was notified about the hospital transfer and the resident's belongings were sent along with her.

A progress note dated November 14, 2021 at 10:08 PM revealed that the resident's daughter called the facility to report on the resident regarding the ER admission and discharge. The daughter was notified about the facility Covid-19 positive patient protocol. Despite being educated, the concerned family member was audibly upset due to the fact the resident cannot be readmitted into this facility with a positive Covid-19 status.

-Resident #26 was admitted to the facility on with diagnoses that included benign prostatic hyperplasia without lower urinary tract symptoms, hypertensive heart disease with heart failure, and an anxiety disorder.

The minimum data set (MDS) dated August 29, 2023 included a brief interview for mental status score of 12 indicating the resident had a mild cognitive impairment.

During an interview conducted on November 6, 2023 at 9:24 AM with resident #26, he stated that he did not receive a written statement regarding the reason for going to the hospital or a bed hold policy when he was transferred to the hospital.

An interview was conducted on November 8, 2023 at 8:27 AM with the Director of Nursing (DON/staff #81), who stated that the nurse/charge nurse informs the resident and family verbally regarding the reason for transport to the hospital. She also stated that the ombudsman is notified of the transfer at the end of the month, but the reason for discharge is not included.

An interview was conducted on November 8, 2023 at 10:20 AM with the Administrator (staff #90) and the (DON/staff #81). , Interview with 1. Administrator and 2. DON, Staff #81 stated that the facility did not give the residents a written reason for being transferred to the hospital, so the ombudsman did not receive a copy. She stated that the facility has never been provided the resident with a reason for transfer in writing and is currently looking at how to develop a process. Staff #90 stated that when she was at a conference, she heard other facilities talking about notifying the ombudsman about the reason for the transfer, but didn't know what they were talking about.

The facility's policy "Admission, Transfer, Discharge Rights (F-Tag)" states that before a facility transfers or discharges a patient, the facility will notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. Subject to the resident's agreement, the facility must send a copy of the notice to a
representative of the Office of the State Long Term Care Ombudsman.

Based on facility documentation, the facility failed to ensure two residents (#86, #26) were notified were made aware of the bed-hold policy upon transfer to the hospital.

Findings include:

Resident #86 was admitted to the facility on November 10, 2023 with diagnoses that included periprosthetic fracture around internal prosthetic left knee joint, acute and chronic respiratory failure with hypoxia, and chronic pain syndrome.

The minimum data set (MDS) dated November 14, 2022 included a brief interview for mental status score of 13 indicating the resident was cognitively intact.

A progress note dated November 14, 2021 at 4:17 PM revealed that the resident had a rapid Covid test and tested positive earlier today. The resident complained of shortness of breath, with wet cough. The physician was notified and the resident was transferred to the emergency department (ER) via ambulance for further medical management. The family was notified about the hospital transfer and the resident's belongings were sent along with her.

A progress note dated November 14, 2021 at 10:08 PM revealed that the resident's daughter called the facility to report on the resident regarding the ER admission and discharge. The daughter was notified about the facility Covid-19 positive patient protocol. Despite being educated, the concerned family member was audibly upset due to the fact the resident cannot be readmitted into this facility with a positive Covid-19 status.

Review of the clinical record did not reveal a bed-hold policy signed and dated by the resident or a family member.

-Resident #26 was admitted to the facility on with diagnoses that included benign prostatic hyperplasia without lower urinary tract symptoms, hypertensive heart disease with heart failure, and an anxiety disorder.

The minimum data set (MDS) dated August 29, 2023 included a brief interview for mental status score of 12 indicating the resident had a mild cognitive impairment.

A progress note dated September 10, 2023 revealed that the resident was transported to the hospital as per physician's orders for possible sepsis at approximately 6:40 a.m. The vital signs were taken prior to transport and were as follows: 112/57 blood pressure, 121 heart rate, 72% oxygen on 1 liter., 102.7 temperature, and 22 respiratory rate. There was an attempt to contact the resident's daughter, but there was no answer. The nurse sent the face sheet and orders to transport.

Review of the clinical record did not reveal a bed-hold policy.

During an interview conducted on November 6, 2023 at 9:24 AM with resident #26, he stated that he did not receive a written statement regarding the reason for going to the hospital or a bed hold policy when he was transferred to the hospital.

An interview was conducted on November 8, 2023 at 8:27 AM with the Director of Nursing (DON/staff #81), who stated that the the resident is given a bed-hold policy when he/she is transported to the hospital if it is feasible. If the situation is emergent, the bed hold policy is discussed with a family member, who would decide if he/she wanted to pay the rate required. She stated that she was not sure if the conversation regarding the bed hold policy with the family member is documented in a progress note. She also, stated that if the bed-hold form was used, she would expect that it was signed and dated by the resident or family member.

During an interview conducted on November 8, 2023 at 9:12 AM with the Administrator (staff #90), she stated that resident #86 would not have been given the resident a bed-hold policy because the facility wasn't going to accept the resident back due to being Covid positive.

The facility's policy "Admission, Transfer, Discharge Rights (F-Tag)" states that before a patient is transferred to a hospital or goes on therapeutic leave, the facility will provide written information to the patient, a family member or resident representative specifying the duration of the bed-hold policy during which the patient is permitted to return and resume temporary residence in the facility.

Based on personnel file review, staff interviews, and facility documentation, the facility failed to ensure that documentation of compliance with the fingerprint clearance for two staff (#72 and #88).

Findings include:

-Regarding staff #72

Review of the personnel record revealed staff #72 had a hire date of May 19, 2022. Further review of staff #72 personnel record revealed Registered Nurse license status of Unencumbered and active with an expiration date of April 1, 2028 and has a compact status of multistate.

However, there was no evidence found that staff #72 had fingerprint clearance since the date of hire or had an Application for Fingerprint Clearance Card submitted during any period of employment.

-Regarding staff #88

The personnel record revealed that staff #88 had a hire date of June 8, 2023. Further review of staff #88 personnel record revealed an Application for Fingerprint Clearance Card was completed on September 29, 2023 with the hand-written statement "in-process" at the top of the form.

However, there was no evidence found that staff #88 had fingerprint clearance following the completed date of application for fingerprint clearance.

An interview with the Administrator (staff #90) and the Director of Nursing (staff #81) conducted on November 9, 2023 at 9:29 AM. The Administrator stated the reason for the staff #72 did not have a fingerprint card on file was that the State Board of Nursing cleared his license for him to be eligible to work in multiple states. The Administrator stated for the reason staff #88 did not have a fingerprint card on file was that the fingerprint investigation process is still pending and the application was submitted on September 29, 2023.

Based on clinical review, staff interviews and the facility policy and procedures, the facility failed to ensure one resident (#86) was permitted to return to the facility after a hospitalization.

Findings include:

Resident #86 was admitted to the facility on November 10, 2023 with diagnoses that included periprosthetic fracture around internal prosthetic left knee joint, acute and chronic respiratory failure with hypoxia, and chronic pain syndrome.

The minimum data set (MDS) dated November 14, 2022 included a brief interview for mental status score of 13 indicating the resident was cognitively intact.

Review of a Covid-19 test dated November 14, 2023 revealed a positive result.

A progress note dated November 14, 2021 at 4:17 PM revealed that the resident had a rapid Covid test and tested positive earlier today. The resident complained of shortness of breath, with wet cough. The physician was notified and the resident was transferred to the emergency department (ER) via ambulance for further medical management. The family was notified about the hospital transfer and the resident's belongings were sent along with her.

A progress note dated November 14, 2021 at 10:08 PM revealed that the resident's daughter called the facility to report on the resident regarding the ER admission and discharge. The daughter was notified about the facility Covid-19 positive patient protocol. Despite being educated, the concerned family member was audibly upset due to the fact the resident cannot be readmitted into this facility with a positive Covid-19 status.

Review of the clinical record did not reveal a bed-hold policy signed and dated by the resident or a family member.

An interview was conducted on November 8, 2023 at 8:27 AM with the Director of Nursing (DON/staff #81), who stated that the the resident was transferred to the hospital because she tested positive for Covid, was symptomatic, and the physician wanted her transferred to the hospital. She stated that the facility did not keep residents who tested positive for Covid and would transfer them to the hospital or another facility. She stated that if the resident would have passed the quarantine period, she would have been able to come back to the facility. Then she reviewed the progress notes and stated that the daughter was told on November 14, 2021, that the resident could not return to the facility, which is the same day that the resident was transferred to the hospital. She acknowledged that on November 14, 2023, she did not know how long the hospital was going to keep the resident or if the resident was being admitted, but knew that the resident was in the incubation period, so was not admitted back to the facility. She stated that the facility was able to isolate residents with Covid-19 by room, but did not have staff to care for the residents. She wouldn't have hired registry staff to provide one to one care for residents with Covid-19 because it is not practical for financial reasons, but doesn't have any documentation of trying to find additional staff or telling AZDHS that this was not feasible.

An interview was conducted on November 8, 2023 at 9:04 AM with a Registered Nurse/Critical Nurse Manager (RN/staff #25), who stated that she was responsible for discharge planning and any family concerns. She stated that if a resident was Covid-19 positive in 2021 and symptomatic, the resident was transferred to the hospital if ordered by the physician. During the interview, she reviewed facility documentation and stated that she didn't have any notes regarding the resident's discharge. She stated that it was her understanding that the facility did not have a Covid unit and she followed facility protocol, which was to transfer the Covid-19 positive residents to the hospital or another facility.

During an interview conducted on November 8, 2023 at 9:12 AM with the Administrator (staff #90), she stated that resident #86 would not have been given the resident a bed-hold policy because the facility wasn't going to accept the resident back due to being Covid-19 positive.

An interview was conducted on November 8, 2023 at 10:20 AM with the Administrator (staff #90) and the Director of Nursing (DON/staff #81). Both staff stated that they developed a plan for Covid positive residents, but didn't implement the plan. Staff #90 stated that they were a Covid-19 free facility and wanted to remain that way.

The facility's "Covid-19 Emergency Plan, Location of Confirmed Patients with SARS-CoV-2" states to identify space in the facility that could be dedicated to care for residents with confirmed Covid-19. This could be a dedicated floor, unit, or wing in the facility or a group of rooms at the end of the unit that will be used to cohort residents with Covid-19. Determine the location of the Covid-19 care unit and create a staffing plan before residents or HCP with Covid-19 are identified in the facility.

Based on facility documentation, the facility failed to ensure two residents (#86, #26) were notified in writing regarding the reason for transfer and a copy was sent to the ombudsman.

Findings include:

Resident #86 was admitted to the facility on November 10, 2023 with diagnoses that included periprosthetic fracture around internal prosthetic left knee joint, acute and chronic respiratory failure with hypoxia, and chronic pain syndrome.

The minimum data set (MDS) dated November 14, 2022 included a brief interview for mental status score of 13 indicating the resident was cognitively intact.

A progress note dated November 14, 2021 at 4:17 PM revealed that the resident had a rapid Covid test and tested positive earlier today. The resident complained of shortness of breath, with wet cough. The physician was notified and the resident was transferred to the emergency department (ER) via ambulance for further medical management. The family was notified about the hospital transfer and the resident's belongings were sent along with her.

A progress note dated November 14, 2021 at 10:08 PM revealed that the resident's daughter called the facility to report on the resident regarding the ER admission and discharge. The daughter was notified about the facility Covid-19 positive patient protocol. Despite being educated, the concerned family member was audibly upset due to the fact the resident cannot be readmitted into this facility with a positive Covid-19 status.

-Resident #26 was admitted to the facility on with diagnoses that included benign prostatic hyperplasia without lower urinary tract symptoms, hypertensive heart disease with heart failure, and an anxiety disorder.

The minimum data set (MDS) dated August 29, 2023 included a brief interview for mental status score of 12 indicating the resident had a mild cognitive impairment.

During an interview conducted on November 6, 2023 at 9:24 AM with resident #26, he stated that he did not receive a written statement regarding the reason for going to the hospital or a bed hold policy when he was transferred to the hospital.

An interview was conducted on November 8, 2023 at 8:27 AM with the Director of Nursing (DON/staff #81), who stated that the nurse/charge nurse informs the resident and family verbally regarding the reason for transport to the hospital. She also stated that the ombudsman is notified of the transfer at the end of the month, but the reason for discharge is not included.

An interview was conducted on November 8, 2023 at 10:20 AM with the Administrator (staff #90) and the (DON/staff #81). , Interview with 1. Administrator and 2. DON, Staff #81 stated that the facility did not give the residents a written reason for being transferred to the hospital, so the ombudsman did not receive a copy. She stated that the facility has never been provided the resident with a reason for transfer in writing and is currently looking at how to develop a process. Staff #90 stated that when she was at a conference, she heard other facilities talking about notifying the ombudsman about the reason for the transfer, but didn't know what they were talking about.

The facility's policy "Admission, Transfer, Discharge Rights (F-Tag)" states that before a facility transfers or discharges a patient, the facility will notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. Subject to the resident's agreement, the facility must send a copy of the notice to a representative of the Office of the State Long Term Care Ombudsman.

Based on observation, clinical record, staff interviews and the facility policy and procedures, the facility failed to use appropriate hand hygiene practices and PPE when providing wound care for one resident (#18). The deficient practice could result in infection.

Findings include:

Resident #18 was admitted to the facility on October 8, 2023 with diagnoses that included dementia, fracture of left femur, and abnormalities of gait and mobility.

A care plan dated October 9, 2023 for an actual impaired skin integrity related to admitted with surgical incision left hip. Admitted with deep tissue injury on (DTI) on right buttock and left heel. The resident admitted with a stage II pressure ulcer to sacrum.
-October 11, 2023 DTI right buttock is resolved.
-October 11, 2023, stage II sacrum is now an unstageable pressure ulcer on her sacrum.
-October 20, 2023, sacrum ulcer is resolved.
-November 6, 2023, left heel is now stage III.
Interventions include to treat left heel per order.

Wound order dated November 3, 2023 revealed skin prep, okay open to air daily, float heels in bed, offload wound, reposition per facility protocol, offloading mattress.

November 6, 2023 wound note revealed a facility acquired left heel non-blanchable redness
-October 9, 2023: 3 cm length x 3 cm width -November 6, 2023: 0.8 length cm x 0.5 cm width

On November 7, 2023 at 10:31 a.m. observed a Registered Nurse/Clinical Nurse Manager (RN/staff #1) clean a pressure ulcer on left heel. Staff #1 was observed:
-sanitzing hands
-donning gown and gloves
-placing a paper towel below resident's left foot (foot was elevated by a pillow and did not touch the paper towel
-removed the resident's sock and bandage/gauze
-bandage/gauze was placed on the paper towel
-cleansed the left heel with clean gauze and then placed gauze on the paper towel
-doffed dirty gloves and placed them on the paper towel
-reached under her gown and pulled out another pair of gloves from her pocket and did not sanitize hands prior to donning the gloves
-Collagen pad was applied and covered
-doffed gloves and washed hands

An interview was conducted on November 8, 2023 at 11:10 AM with (RN/staff #1), who stated that
she doesn't necessarily need to sanitize her hands after doffing soiled gloves and before donning the new gloves because she has already cleaned her hands prior to beginning wound care. She acknowledged that she didn't sanitize her hands after doffing the soiled gloves and donning a new pair of gloves when she cleaned the resident's wound on November 7, 2023. She also, stated that it would not be appropriate to take new gloves from her pocket beneath her gown because the gown could be contaminated and she acknowledged that she pulled her gloves from underneath her gown when providing wound care on November 7, 2023.

An interview was conducted on November 8, 2023 at 11:22 AM with the Director of Nursing (DON/staff #81), who stated that when wound care is provide, the nurse should doff her gloves after removing the bandage, sanitize hands, and don new gloves. She stated that the hands should be sanitized because the old gloves may be contaminated. She also stated that the inside of the gown has the potential to be contaminated because it is touching the staff's clothing, so reaching underneath the gown to get gloves from the pocket creates the potential for contamination.

The facility's policy "Isolation Procedures and Universal Precautions" states that hand washing is considered the single most important procedure for preventing infections. Hand washing is necessary before and after removal of gloves and barriers.

Based on observation, clinical record, staff interviews and the facility policy and procedures, the facility failed to use appropriate hand hygiene practices and PPE when providing wound care for one resident (#18). The deficient practice could result in infection.

Findings include:

Resident #18 was admitted to the facility on October 8, 2023 with diagnoses that included dementia, fracture of left femur, and abnormalities of gait and mobility.

A care plan dated October 9, 2023 for an actual impaired skin integrity related to admitted with surgical incision left hip. Admitted with deep tissue injury on (DTI) on right buttock and left heel. The resident admitted with a stage II pressure ulcer to sacrum.
-October 11, 2023 DTI right buttock is resolved.
-October 11, 2023, stage II sacrum is now an unstageable pressure ulcer on her sacrum.
-October 20, 2023, sacrum ulcer is resolved.
-November 6, 2023, left heel is now stage III.
Interventions include to treat left heel per order.

Wound order dated November 3, 2023 revealed skin prep, okay open to air daily, float heels in bed, offload wound, reposition per facility protocol, offloading mattress.

November 6, 2023 wound note revealed a facility acquired left heel non-blanchable redness
-October 9, 2023: 3 cm length x 3 cm width -November 6, 2023: 0.8 length cm x 0.5 cm width

On November 7, 2023 at 10:31 a.m. observed a Registered Nurse/Clinical Nurse Manager (RN/staff #1) clean a pressure ulcer on left heel. Staff #1 was observed:
-sanitzing hands
-donning gown and gloves
-placing a paper towel below resident's left foot (foot was elevated by a pillow and did not touch the paper towel
-removed the resident's sock and bandage/gauze
-bandage/gauze was placed on the paper towel
-cleansed the left heel with clean gauze and then placed gauze on the paper towel
-doffed dirty gloves and placed them on the paper towel
-reached under her gown and pulled out another pair of gloves from her pocket and did not sanitize hands prior to donning the gloves
-Collagen pad was applied and covered
-doffed gloves and washed hands

An interview was conducted on November 8, 2023 at 11:10 AM with (RN/staff #1), who stated that
she doesn't necessarily need to sanitize her hands after doffing soiled gloves and before donning the new gloves because she has already cleaned her hands prior to beginning wound care. She acknowledged that she didn't sanitize her hands after doffing the soiled gloves and donning a new pair of gloves when she cleaned the resident's wound on November 7, 2023. She also, stated that it would not be appropriate to take new gloves from her pocket beneath her gown because the gown could be contaminated and she acknowledged that she pulled her gloves from underneath her gown when providing wound care on November 7, 2023.

An interview was conducted on November 8, 2023 at 11:22 AM with the Director of Nursing (DON/staff #81), who stated that when wound care is provide, the nurse should doff her gloves after removing the bandage, sanitize hands, and don new gloves. She stated that the hands should be sanitized because the old gloves may be contaminated. She also stated that the inside of the gown has the potential to be contaminated because it is touching the staff's clothing, so reaching underneath the gown to get gloves from the pocket creates the potential for contamination.

The facility's policy "Isolation Procedures and Universal Precautions" states that hand washing is considered the single most important procedure for preventing infections. Hand washing is necessary before and after removal of gloves and barriers.