Advanced Health Care Of Glendale

Based on observations, resident and staff interviews, clinical record review, and policy review, the facility failed to ensure that dignity and privacy was maintained for one resident (#338).

Findings include:

Resident #338 was admitted on September 19, 2024 with diagnoses that included pneumonia, edema, type 2 diabetes mellitus, depression, and anxiety.

A review of clinical record Minimum Data Set (MDS) is still in process.

During an interview conducted on September 24, 2024 at 11:11 am, the resident stated that she had a one bad experience. Staff #27 stated that they are not allowed to tell personal information as it is HIPPA (Health Insurance Portability and Accountability Act) and they are here to answer their bell, and resident stated that they open the bathroom door without knocking.

A comprehensive care plan dated September 26, 2024 included that the resident has a diagnosis of anxiety. The approach or interventions included to provide support and reassurance and validate concerns. In addition, another care plan dated September 26, 2024 included that resident requires/receives staff assistant with activities of daily living completion related to limited mobility and generalized weakness due to medically complex condition-pneumonia, respiratory failure, asthma, bronchiectasis, hypertension, asthma, diabetes, anxiety, and depression. The approach or interventions included staff to allow for and encourage patient choices and preferences and staff to explain task at hand.

During an interview conducted on September 26, 2024 at 10:29 AM resident stated that when she came in the facility at night, they asked Staff #27 if she was a nurse, and staff #27 stated that they cannot tell them that as it is against HIPPA, and Staff #27 was asked what they you do, and Staff #27 stated that they answer the call bell, and then they asked what shift Staff #27 works and Staff #27 said they can't tell them that. Resident stated that they did not get herbal tea yesterday as the staff #27 stated that they do not know if they have any, and when resident went in the dining room she was able to get the tea.

An interview was conducted on September 26, 2024 at 1:55 pm a certified nursing assistant (CNA)/Staff #100. Staff #100 stated that her responsibilities include to communicate with her team, get report, start her shift where is needed and then begin her assignments such as giving showers, weights, helping during meals, and taking vital signs. She also answers the call lights and when entering the resident's' room, she will knock first. When performing care with their new residents, she stated that the admission nurse gives her a paper for the new admission, it tells them if they have to bring equipment such as oxygen, and any supply as needed in the room, and the paperwork tells them if they are on isolation so they can set it up. When meeting her resident the first time, she introduces herself, tells them what she does here, and explain about the place if the resident has not been there before, she will tell them that it is a skilled facility, she will not tell them what shift she works but explain that when they need something to press the call light. For meals, she will bring a menu because they have two menus, one is for breakfast and the other is a full set menu. The breakfast menu has its own paper, and the full set menu she will explain to the resident. She further stated that when a resident first gets in the facility, they will get for instant a lunch for them by writing it in the ticket and then she will explain how to take their meal by using an iPhone tablet and she will asked for their drink choice because they have a beverage menu. The drink menu includes apple juice, cranberry, lemonade, ice tea lemon lime, coffee, hot chocolate with/without sugar, orange juice, almond milk, tomato juice and a lot of teas, including hot teas.

An interview was conducted on September 26, 2024 at 2:39 pm with the director of nursing/Staff #119 and present during the interview is Regional Nurse/Staff #126 and assistant director of nursing/Staff #12. The DON stated that the process for welcoming new resident is they do a welcome call, they have a full-time admission nurse, and a CNA or any staff member would go in, then welcome the resident, they get a set of vital signs, and gives them a call light education. The DON expectation for her staff is to knock at the door, introduce themselves, let them know their position in the facility and what they are there to do. The DON stated to knock, and say hi welcome to advance healthcare, my name is, I'm the director of nursing, and if resident ask what shift they work, she stated that she will explain the way shift work in the facility and assure them. The DON stated, if a resident ask what shift their staff work, the expectation would be to give the resident accurate information regarding facility shift and it is not a policy violation.

The facility's policy "Resident Rights" included that (1) "A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality".

Based on observations, resident and staff interviews, clinical record review, and policy review, the facility failed to ensure that dignity and privacy was maintained for one resident (#338).

Findings include:

Resident #338 was admitted on September 19, 2024 with diagnoses that included pneumonia, edema, type 2 diabetes mellitus, depression, and anxiety.

A review of clinical record Minimum Data Set (MDS) is still in process.

During an interview conducted on September 24, 2024 at 11:11 am, the resident stated that she had a one bad experience. Staff #27 stated that they are not allowed to tell personal information as it is HIPPA (Health Insurance Portability and Accountability Act) and they are here to answer their bell, and resident stated that they open the bathroom door without knocking.

A comprehensive care plan dated September 26, 2024 included that the resident has a diagnosis of anxiety. The approach or interventions included to provide support and reassurance and validate concerns. In addition, another care plan dated September 26, 2024 included that resident requires/receives staff assistant with activities of daily living completion related to limited mobility and generalized weakness due to medically complex condition-pneumonia, respiratory failure, asthma, bronchiectasis, hypertension, asthma, diabetes, anxiety, and depression. The approach or interventions included staff to allow for and encourage patient choices and preferences and staff to explain task at hand.

During an interview conducted on September 26, 2024 at 10:29 AM resident stated that when she came in the facility at night, they asked Staff #27 if she was a nurse, and staff #27 stated that they cannot tell them that as it is against HIPPA, and Staff #27 was asked what they you do, and Staff #27 stated that they answer the call bell, and then they asked what shift Staff #27 works and Staff #27 said they can't tell them that. Resident stated that they did not get herbal tea yesterday as the staff #27 stated that they do not know if they have any, and when resident went in the dining room she was able to get the tea.

An interview was conducted on September 26, 2024 at 1:55 pm a certified nursing assistant (CNA)/Staff #100. Staff #100 stated that her responsibilities include to communicate with her team, get report, start her shift where is needed and then begin her assignments such as giving showers, weights, helping during meals, and taking vital signs. She also answers the call lights and when entering the resident's' room, she will knock first. When performing care with their new residents, she stated that the admission nurse gives her a paper for the new admission, it tells them if they have to bring equipment such as oxygen, and any supply as needed in the room, and the paperwork tells them if they are on isolation so they can set it up. When meeting her resident the first time, she introduces herself, tells them what she does here, and explain about the place if the resident has not been there before, she will tell them that it is a skilled facility, she will not tell them what shift she works but explain that when they need something to press the call light. For meals, she will bring a menu because they have two menus, one is for breakfast and the other is a full set menu. The breakfast menu has its own paper, and the full set menu she will explain to the resident. She further stated that when a resident first gets in the facility, they will get for instant a lunch for them by writing it in the ticket and then she will explain how to take their meal by using an iPhone tablet and she will asked for their drink choice because they have a beverage menu. The drink menu includes apple juice, cranberry, lemonade, ice tea lemon lime, coffee, hot chocolate with/without sugar, orange juice, almond milk, tomato juice and a lot of teas, including hot teas.

An interview was conducted on September 26, 2024 at 2:39 pm with the director of nursing/Staff #119 and present during the interview is Regional Nurse/Staff #126 and assistant director of nursing/Staff #12. The DON stated that the process for welcoming new resident is they do a welcome call, they have a full-time admission nurse, and a CNA or any staff member would go in, then welcome the resident, they get a set of vital signs, and gives them a call light education. The DON expectation for her staff is to knock at the door, introduce themselves, let them know their position in the facility and what they are there to do. The DON stated to knock, and say hi welcome to advance healthcare, my name is, I'm the director of nursing, and if resident ask what shift they work, she stated that she will explain the way shift work in the facility and assure them. The DON stated, if a resident ask what shift their staff work, the expectation would be to give the resident accurate information regarding facility shift and it is not a policy violation.

The facility's policy "Resident Rights" included that (1) "A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality".

Based on observations, staff interview, and policy review, the facility failed to ensure opioid medication regimen was administered according to physician's ordered parameters for one patient (#8).

Findings:
The subacute rehab patient (#8) was admitted on September 03, 2024 with diagnoses of GLF-ground level fall, acute respiratory failure with hypoxia, lobar pneumonia, single subsegmental thrombotic pulmonary embolism, gastrostomy, acute embolism and thrombosis of right distal lower extremity, edema, acute post hemorrhagic anemia, adult failure to thrive, dementia. History of breast cancer.

An Admission 5-day Minimum Data Set (MDS) included the patient's Brief Interview for Mental status (BIM) score of 12 out of 15 which indicated the resident was moderately impaired. The MDS also included the resident experienced frequent pain and was receiving (PRN) as needed pain medication.

A physician's order dated September 03, 2024 included oxycodone 5 mg tablet every 6 Hours PRN 5 mg, gastric tube, Every 6 Hours PRN, Pain parameters 8-10/10

Review of the Medication Administration Record (MAR) and the opioid oxycodone PRN pain management treatment was administered to patient outside of the provider's ordered pain level parameters of 8-10 of a pain scale 1-10. There is no evidence or documentation within the clinical records that the physician had been notified when oxycodone was administered outside of ordered perimeters on dates:

9/04/2024 at 19:09 for pain level 7
9/11/2024 at 19:41 for pain level 7
9/12/2024 at 19:33 for pain level 6
9/16/2024 at 21:04 for pain level 5
9/18/2024 at 19:14 for pain level 7
9/19/2024 at 02:16 for pain level 7

An interview was conducted on September 26, 2024 12:51 PM with nurse (#28) who stated about pain management opioid treatment, that if a patient has an order for pain medication, the patient has a related pain scale with parameters, and it is the facility policy and procedures to follow physician orders as written including parameters. Nurse referred to patient #8's oxycodone order having the pain scale of 1-10, and she stated that the opioid is prescribed for 8-10 pain level treatment on patient provider's order and that the floor nurse would only administer that opioid treatment if the patient's pain is within that range of 8-10 parameters. But, if the patient requested the opioid medication and their pain level is not within the prescribed 8-10 perimeters, then the nurse would call the patient's physician for clarification, then put in a new order or parameter change and document the change in either the MAR or progress note, or both locations.

Nurse #28 stated patient #8's oxycodone, that the oxycodone was given outside of provider's 8-10 pain level perimeters order and she counted six times this occurred from 9/4/24-9/19/24. She stated that the order is written for the pain scale of 8-10 and the medication should have been administered only for the pain levels in that range. She further stated, that when a medication is administered outside of provider's orders, the physician would be notified, and if a new one-time order was received, there should be documentation of a change in the current order or parameter. Nurse #28 reviewed the progress notes on patient #8 and stated there were no related notes that the physician had been notified nor a note of a change in orders. The Nurse (#28) expressed that the risk of administering an opioid outside of the ordered parameters could result in the resident becoming lethargic, respiratory distress, and the doctor would not know or beaware.

Interview was conducted September 27, 2024 08:15 AM with the Director of Nursing (DON staff #119) who stated, the facility's expectation of opioid oxycodone being dispersed to patient would be to follow the MD's (Medical Doctor's) orders, including parameters. The Director of Nursing expressed that the facility has a policy in place, that pain medication at times can be administer outside of parameters with documentations in place, or note that the opioid medication was requested by the patient and the MD is informed. Furthermore, that documentation should be in nursing progress note or within the patient's MAR, and it is expected that the nurses document in progress notes all MD order changes or parameter changes. Director of Nursing stated, the orders are changed to patient's needs by the physician.

DON mentioned that she did talk to nurse #28 on September 26, 2024 and they reviewed patient #8's MAR of the six times oxycodone medication that were given to patient outside of parameters. DON stated she did not see any orders to change those parameters, nor identified any nursing progress note of a nurse calling MD to change parameters nor change the order. DON stated, she expects the nursing to notified the physician and document, and that the risk of not following the MD administration order, is that the MD would not be aware.

Review of facility's policy Pain Management revealed that patients will be assessed for intensity of pain by utilizing a standard pain scale of 0-10 and the physician will be notified for further orders/interventions and asked to clarify parameters based upon pain intensity. Documentation of PRN medications will be documented on the EMAR. Additionally, the EMAR will prompt the administering nurse to include the reason given, location, and intensity of pain as per the 0-10 scale or FLACC numerical score prior to administration. The policy notes, it is not the purpose of this policy to neither dictate physician orders nor contradict current standards of care. Optimal pain control shall be determined with respect to patient goals in collaboration with the interdisciplinary team and the patient's physician.

Based on resident and staff interviews, review of clinical records and facility policies and procedure, the facility failed to ensure one resident (#27) is served and provided with resident's food preferences.

Findings include:

Resident #27 was admitted on August 12, 2024 with diagnoses of type 2 diabetes mellitus, hypertension, fibrillation, and hydronephrosis.

A review of resident's comprehensive care plan dated August 31, 2024 revealed resident is at risk for alteration in nutrition status due to increased nutrition risk secondary to recent history of unintentional weight loss due to inadequate and impaired by mouth intake requiring tube feeding during hospitalization with difficulty cutting and feeding self. Alteration in carbohydrate metabolism with diagnoses of: type 2 diabetes, therapeutic diet in place. The interventions include facility will honor resident requests and preferences.

A review of clinical record, "New Admission Nutrition Services Review", dated August 14, 2024 revealed a documentation of no fish/seafood for the question "are there any meats/poultry/fish/proteins you avoid?".

During an interview with resident #27 on September 24, 2024 at 11:48 am, resident stated that most part the staff treats him well, the staff are fairly responsive, they come within few minutes sometime and up to 30 minutes especially during lunch, dinner or breakfast time, but the rest of the time, they are responsive. Resident stated that the food is not too bad, he fills out the menu, and resident stated that for dinner yesterday, they were served tuna melt, then resident was given the alternate meal, and sometimes they wonder who is reading the menu. Resident was served seafood even though their meal ticket states "No Seafood". And, his meal sometimes is served cold by the time it gets to his room.

An interview was conducted on September 25, 2024 at 9:40 am with a certified nursing assistant (CNA)/Staff #6. Staff #6 stated that the process for taking meal orders is when he gets to work in the morning, he checks the halls, give residents fresh water, he grabs the iPad/tablet, he logs in then go to the dietary tab. He goes to each resident's room, give them the menu including the alternate menu. Their iPad/tablet, their system, has each resident's diet order, allergies, for instance. He stated that the Monday's menu on September 23, 2024 for dinner included a corn chowder and tuna melt sandwich. He types in in the iPad what resident requested. Staff #6 also stated that the resident's trays comes with a meal ticket that has a date, percent eaten, and they can write what resident requested and get sent back in the kitchen.

An interview was conducted with pastry cook/Staff #96 on September 26, 2024 at 11:17 AM. Staff #96 stated that there is a sheet that has a texture diet that tells him what to do for each diet, then he plates the regular diet, place texture diet separate, and during the food service , one of the dietary aid will match the diet with the ticket, and if a resident can't have the item, they have other options if allergic to the desert offered for that meal.

An interview was conducted with the Nutrition Service Director/Staff #88 on September 26, 2024 at 11:21 am. Staff #88 stated that his role is to oversee entire kitchen and staff, ordering and budget, meet new residents, do assessment, and work with dietician. Staff #88 stated that he will discuss height and weight, resdient's history, their food preferences, any issues with chewing and make referrals to Speech Therapy, do nutrition intervention, and work directly with their dietician. For residents' food preferences, staff #88 stated that he has an interview sheet and uses it to interview their residents, and any specific answer from the interview is in the resident's meal ticket. Staff #88 stated they have their own Tray Cart System so when new resident comes in their facility, it has the information for each resident. In addition, for resident food preferences, they have a list printed every day, that includes the residents' dislike section. Staff #88 stated that if something is overlooked, then correction happen, and if error happen several times, or becomes repetitive, he will do an intervention with his staff.

An interview was conducted on September 26, 2024 at 12:33 PM with licensed practical nurse (LPN)/Staff #28. Staff #28 stated that regarding resident meal tray, every day the CNAs go around to get residents' menu for the next day for all three meals. Staff #28 stated that they use a system to log in, and the system has food allergies and preferences that correlates into a physical ticket. Staff #28 stated that they look at the meal ticket during tray pass, the dietician will interview the resident for preferences and allergies, if an error occurs during tray pass, they will apologize, and they will take the tray away and offer something else for the resident. For residents who are cognitively impaired, they received one on one help with staff and the staff assigned to assist the resident to eat must verify the tray that they are servicing, that it matches the meal ticket and ticket has all allergies, diet type and preferences. Staff #28 stated that the first check is the kitchen, then the nursing staff check the tray with the meal ticket to make sure that the residents don't get anything they don't like or allergic to. Staff #28 added that for cognitively impaired residents but can feed themselves, they verify that the meal ticket matches what is in the tray for the resident.

An additional interview was conducted with Staff #88 on September 27, 2024 at 11:35 AM. Staff #88 stated that as soon as the meal tickets are turned in, someone starts the tray line, and the staff will look at the meal ticket. Staff #88 stated that when a resident receives food that is not their food preference, he stated that it must have been an oversight, or who ever took the orders did not take it correctly, and they should be verifying. Staff #88 stated that it should be verified, and double-checking meal ticket by the CNAs and they should be checking the tray before entering the resident's room.

A facility polity titled "Dietary Services" version A1110, revealed "food is prepared in a form designed to meet individual patient needs".

Based on clinical record review, interviews and review of facility policy, the facility failed to ensure residents are treated with dignity and respect. The deficient practice could lead to residents suffering from psychosocial harm.

Findings include:

Resident #4 was admitted to the facility on August 17, 2024 with a diagnosis of orthostatic hypotension and fracture of vertebrae.

Resident #20 was admitted to the facility on August 19, 2024 with a diagnosis of metabolic encephalopathy, sepsis, acute respiratory failure and chronic kidney disease.

Resident #60 was admitted to the facility on August 29, 2024 with a diagnosis of acute respiratory failure, acute pulmonary edema and pneumonia.

An interview was conducted on September 10, 2024 at 3:30 PM with Resident #20. He stated a male CNA (Certified Nursing Assistant, Staff# 42) entered his room and completed a brief change without providing peri care. Later that night, Resident #20 was sleeping and was awakened by the same CNA grabbing the front of his brief. Resident #20 asked him what he was doing and the CNA replied "you're dry" and left the room. Resident #20 stated he felt violated like he was groped, and that Staff #42 had no compassion. He stated Staff #42 should have woken him up and told him he was going to check his brief first. Resident #20 said, "if you don't do things at his pace then he just does if for you". "Like turning, I can turn but I need a little extra time but if that doesn't work for Staff #42 then he just rolls you over". There really isn't any compassion from him and that is a real problem".

Another interview was conducted on September 10, 2024 at 5:20 PM with Resident #20 and his spouse (via phone). Both stated that they had reported these incidents to the evening charge nurse, Staff #108, who apologized and stated she would educate Staff #42. Resident #20 stated he no longer wanted Staff #42 to care for him. Resident #20 also stated that Administration never followed up with him regarding these incidents, and he felt that they just didn't care.

An interview was conducted on September 10, 2024 at 6:06 PM with the Administrator, Staff #101, and the DON (Director of Nursing), Staff #105. When asked if any residents had reported any incidents with any CNA's,
Staff #105 stated yes, that a resident complained a CNA entered his room at night and checked his brief and left. When asked what was the issue, Staff #105 stated "that was it, oh and that he did not want that CNA back in his room so we just reassigned him to another hallway". When asked if she had personally interviewed the resident, she stated "no, I didn't have to because my nurse reported it to me". When asked what was the issue logged into the grievance log regarding a CNA , Staff #101 "I went and spoke with this resident, #60, he said he did not like the CNA's demeanor. Resident stated he rang his call bell, the CNA went in, he told him he needed his bedside commode emptied and the CNA said "that's what I get paid to do". Resident didn't like that he said it and he didn't want the CNA in his room anymore, so we made sure of this". When this author asked if it was the same CNA in both incidents,. Staff #101 stated "Actually, yes, it was now that I think about it".

An interview was conducted on September 10, 2024 at 6:40 PM with Resident #4. She stated "Well, I don't want to get anyone in trouble but I don't like Staff #42. He's rude, uncaring and full of himself. He's good looking and he knows it type attitude. I need help getting up because I have orthostatic blood pressure and he had an attitude and said to me why don't you have a fall bracelet on?" Staff #42 said "you should have a fall bracelet on if you need help getting up". So, I asked one of the nurses here about it and she said they don't even have fall bracelets here, so what is that guy talking about!" He's never been inappropriate with me but I'd prefer he does not come into my room".

An interview was conducted on September 10, 2024 at 7:00 PM with Resident #60. When asked why he filed a grievance on September 9, 2024, he stated "well, he (Staff 342) came in here because I rang the call bell because my commode needed emptied. He came in and said "it's a win-win, I get paid and you get taken care of". What kind of a statement is that? He's very uncaring, he's rude and I think all he cares about is money. I mean we are people that are having a hard time right now and need some help and someone is here and just cares about money. Actually, he took my commode out of the room, which I though was weird but when he returned it he said I was rude to him. So I said I was sorry if he misunderstood anything I said, but I apologized to him! Can you believe that? So, the next day I spoke with what's his name, the big boss (Staff #101) and told him what happened and that I did not want him back in my room. I just don't trust him and I'm not sure what he is really capable of".

An interview was conducted, via phone, on September 11, 2024 at 11:40 AM with RN, (Registered Nurse),
Staff #108. When asked if she received any complaints from any residents on the night of September 5th and 6th, she stated "yes". Resident #20 said that the CNA, (Staff #42), changed his brief and did not do peri-care. Then on the 6th, in the morning, the same CNA at about 4:00 AM came into the room and did not wake him and just checked his brief. He woke up and said "what are you doing?' and the CNA said "I'm checking your brief". Resident #20 said it was more of an attitude problem". When asked if Resident #20 told her that he felt like he was groped, she stated "what is groped?" It was explained that groped means when someone grabs your genital area without permission and feels you in an inappropriate manner. She then stated "oh no, he did not say that. Afterwards I talked to the management team, Staff #105, about the incident. Staff #105 told me to talk to the CNA and she would hold a class so this does not happen again. That's all I know".

The facilities policy on Resident Rights, Version A0717, states "Respect and Dignity-The resident has a right to be treated with respect and dignity".

Based on clinical record review, interviews and review of facility policy, the facility failed to ensure residents are treated with dignity and respect.

Findings include:

Resident #4 was admitted to the facility on August 17, 2024 with a diagnosis of orthostatic hypotension and fracture of vertebrae.

Resident #20 was admitted to the facility on August 19, 2024 with a diagnosis of metabolic encephalopathy, sepsis, acute respiratory failure and chronic kidney disease.

Resident #60 was admitted to the facility on August 29, 2024 with a diagnosis of acute respiratory failure, acute pulmonary edema and pneumonia.

An interview was conducted on September 10, 2024 at 3:30 PM with Resident #20. He stated a male CNA (Certified Nursing Assistant, Staff# 42) entered his room and completed a brief change without providing peri care. Later that night, Resident #20 was sleeping and was awakened by the same CNA grabbing the front of his brief. Resident #20 asked him what he was doing and the CNA replied "you're dry" and left the room. Resident #20 stated he felt violated like he was groped, and that Staff #42 had no compassion. He stated Staff #42 should have woken him up and told him he was going to check his brief first. Resident #20 said, "if you don't do things at his pace then he just does if for you". "Like turning, I can turn but I need a little extra time but if that doesn't work for Staff #42 then he just rolls you over". There really isn't any compassion from him and that is a real problem".

Another interview was conducted on September 10, 2024 at 5:20 PM with Resident #20 and his spouse (via phone). Both stated that they had reported these incidents to the evening charge nurse, Staff #108, who apologized and stated she would educate Staff #42. Resident #20 stated he no longer wanted Staff #42 to care for him. Resident #20 also stated that Administration never followed up with him regarding these incidents, and he felt that they just didn't care.

An interview was conducted on September 10, 2024 at 6:06 PM with the Administrator, Staff #101, and the DON (Director of Nursing), Staff #105. When asked if any residents had reported any incidents with any CNA's,
Staff #105 stated yes, that a resident complained a CNA entered his room at night and checked his brief and left. When asked what was the issue, Staff #105 stated "that was it, oh and that he did not want that CNA back in his room so we just reassigned him to another hallway". When asked if she had personally interviewed the resident, she stated "no, I didn't have to because my nurse reported it to me". When asked what was the issue logged into the grievance log regarding a CNA , Staff #101 "I went and spoke with this resident, #60, he said he did not like the CNA's demeanor. Resident stated he rang his call bell, the CNA went in, he told him he needed his bedside commode emptied and the CNA said "that's what I get paid to do". Resident didn't like that he said it and he didn't want the CNA in his room anymore, so we made sure of this". When this author asked if it was the same CNA in both incidents,. Staff #101 stated "Actually, yes, it was now that I think about it".

An interview was conducted on September 10, 2024 at 6:40 PM with Resident #4. She stated "Well, I don't want to get anyone in trouble but I don't like Staff #42. He's rude, uncaring and full of himself. He's good looking and he knows it type attitude. I need help getting up because I have orthostatic blood pressure and he had an attitude and said to me why don't you have a fall bracelet on?" Staff #42 said "you should have a fall bracelet on if you need help getting up". So, I asked one of the nurses here about it and she said they don't even have fall bracelets here, so what is that guy talking about!" He's never been inappropriate with me but I'd prefer he does not come into my room".

An interview was conducted on September 10, 2024 at 7:00 PM with Resident #60. When asked why he filed a grievance on September 9, 2024, he stated "well, he (Staff 342) came in here because I rang the call bell because my commode needed emptied. He came in and said "it's a win-win, I get paid and you get taken care of". What kind of a statement is that? He's very uncaring, he's rude and I think all he cares about is money. I mean we are people that are having a hard time right now and need some help and someone is here and just cares about money. Actually, he took my commode out of the room, which I though was weird but when he returned it he said I was rude to him. So I said I was sorry if he misunderstood anything I said, but I apologized to him! Can you believe that? So, the next day I spoke with what's his name, the big boss (Staff #101) and told him what happened and that I did not want him back in my room. I just don't trust him and I'm not sure what he is really capable of".

An interview was conducted, via phone, on September 11, 2024 at 11:40 AM with RN, (Registered Nurse),
Staff #108. When asked if she received any complaints from any residents on the night of September 5th and 6th, she stated "yes". Resident #20 said that the CNA, (Staff #42), changed his brief and did not do peri-care. Then on the 6th, in the morning, the same CNA at about 4:00 AM came into the room and did not wake him and just checked his brief. He woke up and said "what are you doing?' and the CNA said "I'm checking your brief". Resident #20 said it was more of an attitude problem". When asked if Resident #20 told her that he felt like he was groped, she stated "what is groped?" It was explained that groped means when someone grabs your genital area without permission and feels you in an inappropriate manner. She then stated "oh no, he did not say that. Afterwards I talked to the management team, Staff #105, about the incident. Staff #105 told me to talk to the CNA and she would hold a class so this does not happen again. That's all I know".

The facilities policy on Resident Rights, Version A0717, states "Respect and Dignity-The resident has a right to be treated with respect and dignity".

Based on closed clinical record review, resident and staff interviews, and facility policy and procedures, the facility failed to ensure one resident's (#15) with low oxygen level was monitored and treated. The deficient practice could result in residents not receiving the care needed and development of complications.

Findings include:

Resident #15 was admitted on February 10, 2023 with diagnoses of aftercare following joint replacement surgery, paroxysmal atrial fibrillation, and personal history of other venous thrombosis and embolism.

The baseline care plan dated February 10, 2023 included the resident was alert and oriented x 3 and had alterations in comfort. Approaches included medications as ordered.

The brief interview for mental status (BIMS) dated February 10, 2023 revealed a score of 15 indicating the resident was cognitively intact.

The nursing note dated February 12, 2023 included the resident was alert and oriented x 4.

A physician order dated February 14, 2023 included for oxygen (O2) per nasal cannula (NC) to maintain O2 saturation >90%, to document liters per minute (LPM) every shift and may titrate/discontinue O2 LPM as tolerated while maintaining O2 saturation >90% every shift.

Review of the resident's documented O2 levels on February 14, 2023 from 3:33 a.m. to 4:37 p.m. revealed that at 1:33 p.m., the O2 level was 85%. The documentation also included that the oxygen was last at 4:37 p.m. was documented at 92%.

A progress note dated February 14, 2023 at 4:41 p.m. written by a registered nurse (RN/staff #13) revealed the resident's left lower extremities were swollen; and that, an X-ray was done and the results were pending. Per the documentation the resident and the RN called her surgeon who instructed to send the resident to the hospital for an evaluation related to a recent hypoxia episode. The documentation also included the resident had no signs of distress; and that, transportation gave an estimated time of arrival of 4 hours.

The chest X-ray dated February 14, 2023 revealed the heart was mildly enlarged, mediastinum was normal without adenopathy and there was marked pulmonary venous congestion. Impression included mild cardiomegaly with marked congestive heart failure.

A progress note dated February 14, 2023 at 7:10 p.m. written by a (RN/staff #13) included that the lab and chest X-ray results were reported to the nurse practitioner (NP) and copies were placed in the resident's paperwork for transport to the hospital.

An interview was conducted on February 25, 2023 at 12:30 p.m. with a certified nursing assistant (CNA/staff #5) who stated that she and another CNA worked with the resident #15 who seemed agitated and was concerned about her breathing. The CNA stated that she took the resident's vitals and reported them to the nurse; and that, the resident was sent out to the hospital.

In interview conducted with the RN (staff #13) conducted on February 25, 2023 at 12:54 p.m. the RN stated the resident was a nurse and complained about her breathing to the CNA. The RN said she instructed the resident to take deep breaths, gave the resident O2 and the O2 level changed from 88% to 96%. She stated the resident called the surgeon who wanted the resident sent to the emergency room. The RN also said that she called the surgeon who told her if the facility provider agreed to send the resident to the emergency room. She stated that she explained to the resident that the resident would be transported to the emergency room as non-emergent transfer; and that, if her condition changed, the facility would respond appropriately by calling 911.

An interview was conducted on February 25, 2023 at 1:23 p.m. with resident #15 who stated that she was a nurse; and that, she went into heart failure and knew she needed to go to the hospital. She stated she called her physician who wanted her to go to the hospital. She said that she was hypoxic and was having trouble breathing; however, she does not remember if her O2 level was low. Resident #15 stated that her O2 level which was taken by transportation was 88% at that time.

An interview was conducted on February 25, 2023 at 1:53 p.m. with the Director of Nursing (DON/staff #7) and the licensed practical nurse (LPN/staff #42). The DON stated that based on the clinical record, the resident was transported to the hospital on February 14, 2023 at 9:00 p.m. The LPN (staff #42) said at the time of the incident, her shift began at 6:00 p.m. and the resident was transported to the hospital between 9:30 p.m. to 10:00 p.m. The LPN stated that the CNA took the resident's vitals and it should have been documented under the vitals section of the clinical record. The DON said that the resident was on O2 at 1 liter for comfort and it was continued until transport arrived. During the interview, a review of the clinical record was conducted with the DON who stated that the oxygen order was for O2 level to be kept above 90% and may titrate. The DON also stated that based on the clinical record, the resident's O2 was last checked at 4:37 p.m. on February 14, 2023; and that, the night shift staff should have checked the resident's pulse oximetry because the resident had a change of condition. The DON also said that the clinical record revealed documentation that the staff checked the resident's O2 level after 4:37 p.m.; and that, the resident's O2 level could have dropped and gone into respiratory distress. The DON reviewed the X-ray results and stated that the results showed mild cardiomegaly with congestive heart failure and the resident's low O2 level could be a symptom.

The facility policy on Oxygen Administration, dated September 28, 2022 included that only qualified personnel administer oxygen in accordance with a physician's order. Appropriate safety precautions are utilized to provide safe administration and storage of oxygen. It also included that before administering oxygen, and while the patient is receiving oxygen therapy, assess for the following:
-Signs or symptoms of cyanosis, hypoxia, and/or toxicity;
-Vital signs;
-Lung sounds;
-Oxygen saturation; and
-Other laboratory results, if applicable.

Continued review of the policy included that after completing the oxygen set-up or adjustment, document the following:
-Date and time the procedure was performed;
-The name/title of individual who performed the procedure;
-The rate of oxygen flow, route, and rationale;
-The frequency and duration of the treatment;
-All assessment data obtained before, during and after the procedure; and
-How the patient tolerated the procedure.

Based on closed clinical record review, resident and staff interviews, and facility policy and procedures, the facility failed to ensure one resident's (#15) with low oxygen level was monitored and treated.

Findings include:

Resident #15 was admitted on February 10, 2023 with diagnoses of aftercare following joint replacement surgery, paroxysmal atrial fibrillation, and personal history of other venous thrombosis and embolism.

The baseline care plan dated February 10, 2023 included the resident was alert and oriented x 3 and had alterations in comfort. Approaches included medications as ordered.

The brief interview for mental status (BIMS) dated February 10, 2023 revealed a score of 15 indicating the resident was cognitively intact.

The nursing note dated February 12, 2023 included the resident was alert and oriented x 4.

A physician order dated February 14, 2023 included for oxygen (O2) per nasal cannula (NC) to maintain O2 saturation >90%, to document liters per minute (LPM) every shift and may titrate/discontinue O2 LPM as tolerated while maintaining O2 saturation >90% every shift.

Review of the resident's documented O2 levels on February 14, 2023 from 3:33 a.m. to 4:37 p.m. revealed that at 1:33 p.m., the O2 level was 85%. The documentation also included that the oxygen was last at 4:37 p.m. was documented at 92%.

A progress note dated February 14, 2023 at 4:41 p.m. written by a registered nurse (RN/staff #13) revealed the resident's left lower extremities were swollen; and that, an X-ray was done and the results were pending. Per the documentation the resident and the RN called her surgeon who instructed to send the resident to the hospital for an evaluation related to a recent hypoxia episode. The documentation also included the resident had no signs of distress; and that, transportation gave an estimated time of arrival of 4 hours.

The chest X-ray dated February 14, 2023 revealed the heart was mildly enlarged, mediastinum was normal without adenopathy and there was marked pulmonary venous congestion. Impression included mild cardiomegaly with marked congestive heart failure.

A progress note dated February 14, 2023 at 7:10 p.m. written by a (RN/staff #13) included that the lab and chest X-ray results were reported to the nurse practitioner (NP) and copies were placed in the resident's paperwork for transport to the hospital.

An interview was conducted on February 25, 2023 at 12:30 p.m. with a certified nursing assistant (CNA/staff #5) who stated that she and another CNA worked with the resident #15 who seemed agitated and was concerned about her breathing. The CNA stated that she took the resident's vitals and reported them to the nurse; and that, the resident was sent out to the hospital.

In interview conducted with the RN (staff #13) conducted on February 25, 2023 at 12:54 p.m. the RN stated the resident was a nurse and complained about her breathing to the CNA. The RN said she instructed the resident to take deep breaths, gave the resident O2 and the O2 level changed from 88% to 96%. She stated the resident called the surgeon who wanted the resident sent to the emergency room. The RN also said that she called the surgeon who told her if the facility provider agreed to send the resident to the emergency room. She stated that she explained to the resident that the resident would be transported to the emergency room as non-emergent transfer; and that, if her condition changed, the facility would respond appropriately by calling 911.

An interview was conducted on February 25, 2023 at 1:23 p.m. with resident #15 who stated that she was a nurse; and that, she went into heart failure and knew she needed to go to the hospital. She stated she called her physician who wanted her to go to the hospital. She said that she was hypoxic and was having trouble breathing; however, she does not remember if her O2 level was low. Resident #15 stated that her O2 level which was taken by transportation was 88% at that time.

An interview was conducted on February 25, 2023 at 1:53 p.m. with the Director of Nursing (DON/staff #7) and the licensed practical nurse (LPN/staff #42). The DON stated that based on the clinical record, the resident was transported to the hospital on February 14, 2023 at 9:00 p.m. The LPN (staff #42) said at the time of the incident, her shift began at 6:00 p.m. and the resident was transported to the hospital between 9:30 p.m. to 10:00 p.m. The LPN stated that the CNA took the resident's vitals and it should have been documented under the vitals section of the clinical record. The DON said that the resident was on O2 at 1 liter for comfort and it was continued until transport arrived. During the interview, a review of the clinical record was conducted with the DON who stated that the oxygen order was for O2 level to be kept above 90% and may titrate. The DON also stated that based on the clinical record, the resident's O2 was last checked at 4:37 p.m. on February 14, 2023; and that, the night shift staff should have checked the resident's pulse oximetry because the resident had a change of condition. The DON also said that the clinical record revealed documentation that the staff checked the resident's O2 level after 4:37 p.m.; and that, the resident's O2 level could have dropped and gone into respiratory distress. The DON reviewed the X-ray results and stated that the results showed mild cardiomegaly with congestive heart failure and the resident's low O2 level could be a symptom.

The facility policy on Oxygen Administration, dated September 28, 2022 included that only qualified personnel administer oxygen in accordance with a physician's order. Appropriate safety precautions are utilized to provide safe administration and storage of oxygen. It also included that before administering oxygen, and while the patient is receiving oxygen therapy, assess for the following:
-Signs or symptoms of cyanosis, hypoxia, and/or toxicity;
-Vital signs;
-Lung sounds;
-Oxygen saturation; and
-Other laboratory results, if applicable.

Continued review of the policy included that after completing the oxygen set-up or adjustment, document the following:
-Date and time the procedure was performed;
-The name/title of individual who performed the procedure;
-The rate of oxygen flow, route, and rationale;
-The frequency and duration of the treatment;
-All assessment data obtained before, during and after the procedure; and
-How the patient tolerated the procedure.