VI At Silverstone

Based on document review and staff interview, the facility failed to provide documentation of new and existing staff review the emergency preparedness plan. Failure to have staff review the emergency preparedness plan consistent with their expected roles may cause harm to the patients and/or staff during an emergency.

Findings include:

Based on document review and staff interview on December 5, 2023, the facility failed to provide documentation that new and existing staff reviewed the emergency preparedness policies and procedures.

During the exit interview on December 5, 2023, the above finding was again acknowledged by the management team.

Based on facility records and staff interview the facility failed to document new and existing staff training pertaining to the handling and risk of medical gas. Failing to provide training for safety guidelines of oxygen cylinders could cause harm to the patients and/or staff.

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.2.4 "Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care Facilities." NFPA 99 2012 Edition Chapter 11 Section 11.5.2.1" Gas Equipment - Qualifications and Training of Personnel Personnel concerned with the application, maintenance and handling of medical gases and cylinders are trained on the risk. Facilities provide continuing education, including safety guidelines and usage requirements. Equipment is serviced only by personnel trained in the maintenance and operation of equipment.

Findings include:

Observations during the policy review and interview on December 5, 2023, revealed that the facility failed to provide documentation of a continuing oxygen risk training program for new personnel and annually to existing staff.

During the exit conference on December 5, 2023, the above was again acknowledged by the management staff. .

Based on clinical record review, staff and resident interviews, and observation of current practice the facility failed to ensure resident #1 was free from abuse from an employee. The deficient practice could result in residents experiencing emotional and mental trauma from the abuse.

Findings include:

Resident #1 was admitted to the facility on February 3, 2023 with diagnoses that included generalized muscle weakness, acute pulmonary edema, and acute respiratory failure with hypoxia.

The quarterly MDS (Minimum Data Set) assessment dated November 14, 2023 included a BIMS (Brief Interview for Mental Status) score of 11, indicating the resident was cognitively moderate impaired. The MDS also indicated the resident had no indicators of psychosis, behaviors, rejection of care, or wandering.

On November 3, 2023 at 2:44 PM the DON (Director of Nursing/Staff #30) reported an alleged abuse incident to the Arizona Department of Health Services.

A review of resident #1's progress notes revealed there was no documentation regarding the alleged incident of a staff member's abuse towards the resident on November 3, 2023. Further review of resident #1's electronic health record also revealed no documentation regarding the alleged incident.

An interview was conducted with resident #1 on November 28, 2023 at 8:36 AM. When asked about the alleged incident, the resident stated that a staff person used inappropriate language with him but the staff person has been fired. When asked about the name of the staff person, the resident stated it was staff #52 who was a Registered Nurse at the facility. Resident #1 indicated they currently felt safe and happy at the facility.

Interviews were conducted with the following residents on November 28, 2023: Resident #17, Resident #11, and Resident #12. They all stated they currently felt safe in the facility and that staff treated them with respect.

An interview was conducted on November 28, 2023 at 10:44 AM with a Registered Nurse (staff #54) who stated they remembered staff #52. Staff #54 indicated that she was not aware of any situations that occurred between staff #52 and any other residents but she was aware of the incident between staff #52 and resident #1. Staff #54 stated that staff #52 had a difficult personality and "the situation was a matter of time". She also stated that staff #52 was the type of person to come into work and "not give you the time of the day". When asked if resident #1 had exhibited any mood changes as a result of the alleged abuse, staff #54 denied any changes. Staff #54 also confirmed that she participates in Abuse training as a part of her annual training.

An interview was conducted on November 28, 2023 at 11:44 AM with a Housekeeper (staff #55) who witnessed the alleged incident. Staff #55 stated they were a few feet outside of resident #1's room and she saw the call light go on. The resident's door was open at the time. Staff indicated they could see staff #52 at the Nurses station down the hallway ignoring the resident's call light. Staff #55 then heard staff #54 on the phone stating "why are you hitting the button, why do you keep hitting the button?" "She then called him (resident #1) an asshole and hung up." Staff #55 observed a Certified Nurse Assistant (CNA/Staff #56) enter resident #1's room shortly after. Staff #55 then observed staff #56 come out of resident #1's room and inform an RNA what had happened. Staff #55 stated she then went to Human Resources to report the incident. When asked if staff #55 receives training on abuse, they stated they recently received the training when they were hired.

A review of staff #52's personnel file was conducted on November 28, 2023. It was revealed that staff #52 had taken a course module titled "Preventing, Recognizing, and Reporting Abuse" on the following dates: June 29, 2020; November 11, 2021; June 4, 2022; and March 28, 2023. Additional Abuse training titled "Abuse and Neglect" and "Abuse, Neglect, and Exploitation" were completed on July 21, 2020 and March 28, 2023.

An interview was conducted on November 28, 2023 at 12:42 PM with Human Resources (Staff #53). Staff #53 stated there was one disciplinary record in staff #52's file which reveals a written warning along with coaching was provided to staff #53 for unprofessional conduct with their co-workers. Staff #53 indicated they were the person who received the initial report from staff #55 regarding the alleged abuse towards resident #1. Upon hearing the initial report, they directed staff #55 to speak with the Human Resources Director (staff #53).

An interview was conducted on November 29, 2023 at 9:01 AM with staff #53 in his office. When asked about his knowledge of the incident, staff #53 indicated the witness to the incident was a housekeeper who was assigned to the care center that day. The witness (staff #55) reported the alleged abuse to him and he immediately went to inform the Assistant Director of Nursing (ADON/Staff #7) which triggered the investigation process. Staff #53 stated all employees receive training on abuse upon hire and then annually thereafter. He indicated he was familiar with staff #52 and they had one disciplinary action on file. He stated that staff #52 did have a history with other employees and did not have a lot of patience with them which was addressed in a counseling plan.

An interview was conducted on November 29, 2023 at 9:49 AM with the Director of Nursing (DON/Staff #30). Staff #30 indicated that after completing an internal investigation, staff #52 was terminated on November 6, 2023 due to "unprofessional behavior towards a resident". Staff #30 indicated that staff #52 had a corrective action in their personnel file due to conflicts with peers but they had no complaints from other residents in the facility.

A review of the facility's policy titled, "Abuse/Neglect Prevention Protocol," which was last reviewed/revised December 2022, defined verbal abuse as oral language used in a disparaging or derogatory manner towards residents or families.

Based on clinical record review, staff and resident interviews, and observation of current practice the facility failed to ensure resident #1 was free from abuse from an employee. The deficient practice could result in residents experiencing emotional and mental trauma from the abuse.

Findings include:

Resident #1 was admitted to the facility on February 3, 2023 with diagnoses that included generalized muscle weakness, acute pulmonary edema, and acute respiratory failure with hypoxia.

The quarterly MDS (Minimum Data Set) assessment dated November 14, 2023 included a BIMS (Brief Interview for Mental Status) score of 11, indicating the resident was cognitively moderate impaired. The MDS also indicated the resident had no indicators of psychosis, behaviors, rejection of care, or wandering.

On November 3, 2023 at 2:44 PM the DON (Director of Nursing/Staff #30) reported an alleged abuse incident to the Arizona Department of Health Services.

A review of resident #1's progress notes revealed there was no documentation regarding the alleged incident of a staff member's abuse towards the resident on November 3, 2023. Further review of resident #1's electronic health record also revealed no documentation regarding the alleged incident.

An interview was conducted with resident #1 on November 28, 2023 at 8:36 AM. When asked about the alleged incident, the resident stated that a staff person used inappropriate language with him but the staff person has been fired. When asked about the name of the staff person, the resident stated it was staff #52 who was a Registered Nurse at the facility. Resident #1 indicated they currently felt safe and happy at the facility.

Interviews were conducted with the following residents on November 28, 2023: Resident #17, Resident #11, and Resident #12. They all stated they currently felt safe in the facility and that staff treated them with respect.

An interview was conducted on November 28, 2023 at 10:44 AM with a Registered Nurse (staff #54) who stated they remembered staff #52. Staff #54 indicated that she was not aware of any situations that occurred between staff #52 and any other residents but she was aware of the incident between staff #52 and resident #1. Staff #54 stated that staff #52 had a difficult personality and "the situation was a matter of time". She also stated that staff #52 was the type of person to come into work and "not give you the time of the day". When asked if resident #1 had exhibited any mood changes as a result of the alleged abuse, staff #54 denied any changes. Staff #54 also confirmed that she participates in Abuse training as a part of her annual training.

An interview was conducted on November 28, 2023 at 11:44 AM with a Housekeeper (staff #55) who witnessed the alleged incident. Staff #55 stated they were a few feet outside of resident #1's room and she saw the call light go on. The resident's door was open at the time. Staff indicated they could see staff #52 at the Nurses station down the hallway ignoring the resident's call light. Staff #55 then heard staff #54 on the phone stating "why are you hitting the button, why do you keep hitting the button?" "She then called him (resident #1) an asshole and hung up." Staff #55 observed a Certified Nurse Assistant (CNA/Staff #56) enter resident #1's room shortly after. Staff #55 then observed staff #56 come out of resident #1's room and inform an RNA what had happened. Staff #55 stated she then went to Human Resources to report the incident. When asked if staff #55 receives training on abuse, they stated they recently received the training when they were hired.

A review of staff #52's personnel file was conducted on November 28, 2023. It was revealed that staff #52 had taken a course module titled "Preventing, Recognizing, and Reporting Abuse" on the following dates: June 29, 2020; November 11, 2021; June 4, 2022; and March 28, 2023. Additional Abuse training titled "Abuse and Neglect" and "Abuse, Neglect, and Exploitation" were completed on July 21, 2020 and March 28, 2023.

An interview was conducted on November 28, 2023 at 12:42 PM with Human Resources (Staff #53). Staff #53 stated there was one disciplinary record in staff #52's file which reveals a written warning along with coaching was provided to staff #53 for unprofessional conduct with their co-workers. Staff #53 indicated they were the person who received the initial report from staff #55 regarding the alleged abuse towards resident #1. Upon hearing the initial report, they directed staff #55 to speak with the Human Resources Director (staff #53).

An interview was conducted on November 29, 2023 at 9:01 AM with staff #53 in his office. When asked about his knowledge of the incident, staff #53 indicated the witness to the incident was a housekeeper who was assigned to the care center that day. The witness (staff #55) reported the alleged abuse to him and he immediately went to inform the Assistant Director of Nursing (ADON/Staff #7) which triggered the investigation process. Staff #53 stated all employees receive training on abuse upon hire and then annually thereafter. He indicated he was familiar with staff #52 and they had one disciplinary action on file. He stated that staff #52 did have a history with other employees and did not have a lot of patience with them which was addressed in a counseling plan.

An interview was conducted on November 29, 2023 at 9:49 AM with the Director of Nursing (DON/Staff #30). Staff #30 indicated that after completing an internal investigation, staff #52 was terminated on November 6, 2023 due to "unprofessional behavior towards a resident". Staff #30 indicated that staff #52 had a corrective action in their personnel file due to conflicts with peers but they had no complaints from other residents in the facility.

A review of the facility's policy titled, "Abuse/Neglect Prevention Protocol," which was last reviewed/revised December 2022, defined verbal abuse as oral language used in a disparaging or derogatory manner towards residents or families.

Based on observations, staff interviews, and policies and procedures, the facility failed to ensure that infection control standards were followed by failing to ensure the toilet seat riser available for resident use was cleaned for two residents (#1 and #2); and, failed to ensure the oxygen tubing were properly stored when not in use for two residents (#2 and #3).

Findings include:

Regarding resident #1

-Resident #1 was admitted on August 24, 2022 with diagnoses that included cancer, diabetes, and multiple-resistant organisms.

Review of the quarterly MDS (minimum data set) assessment dated May 22, 2023 revealed a BIMS (brief interview of mental status) score of 14 indicating the resident had no cognitive impairment. Per the MDS, the resident was frequently incontinent of bowel and bladder and required extensive assistance with toileting and hygiene needs.

During an observation conducted on August 2, 2023 at 10:00 a.m., resident #1 had a gray toilet seat riser that was placed over the regular toilet located in her bathroom. The toilet seat riser had multiple dried feces underneath the right arm rest, and underneath the toilet seat.

An interview with resident #1 was conducted immediately following the observation. Resident #1 stated that the toilet seat was not cleaned regularly; and, her private caregiver assisted her as needed to use the toilet but cleaning it was not a part of her job.

Regarding resident #2

-Resident was admitted on February 3, 2023 with diagnoses of pneumonia, malnutrition, and respiratory failure.

The significant change MDS assessment dated May 25, 2023 revealed a BIMS score of 14 indicating resident had no cognitive impairment. Per the MDS, the resident had an indwelling Foley catheter, required extensive assistance with toilet use and personal hygiene and was always incontinent of bowel function. The MDS also included that the resident was receiving oxygen therapy while a resident at the facility.

An observation was conducted on August 2, 2023 at 10:13 a.m. Resident #2 was in bed with an oxygen concentrator at the bedside, the oxygen tubing attached on the concentrator, and the nasal cannula was coiled and tucked in on the handle of the oxygen concentrator. There was an emergency oxygen tank attached to a wheelchair located in the resident's bathroom. An oxygen tubing was attached to the emergency oxygen tank and the nasal cannula was hanging on the right arm of the wheelchair. In the resident's bathroom, a gray toilet seat riser was placed on top of a regular toilet. The toilet seat riser had multiple dried feces on the toilet seat, the handle, and the front silver metal bar where the toilet seat was attached.

In an interview with resident #2 conducted immediately following the observation, resident #2 stated that he uses the oxygen daily and as needed when in bed or in a wheelchair; and goes to the bathroom with the assistance of the staff. Resident #2 stated he thinks the staff cleans the toilet seat riser after each use but he was not sure.

Regarding resident #3

-Resident #3 was admitted on May 7, 2023 with diagnoses of malnutrition and hypertension.

The 14-day MDS assessment dated May 11, 2023 revealed a BIMS score of 13 indicating the resident had intact cognition. The assessment included that the resident required extensive assistance with ADLs (activity of daily living); and that, the resident was on oxygen therapy while a resident in the facility.

During an observation conducted on August 2, 2023 at 10:06 a.m. the resident was found sitting in a chair near the window. The resident had an oxygen concentrator at the bedside with an oxygen tubing attached. However, the oxygen cannula was lying directly on the bed, away from the resident. Resident #3 stated that she uses oxygen daily and the staff helps her in placing the oxygen in her nose.

An interview was conducted on August 2, 2023 at about 2:00 p.m. with a certified nursing assistant (CNA/ staff #21) who stated the CNAs and the housekeeping were responsible for cleaning the toilet seat riser if they see it dirty. She stated the toilet riser should not have dried feces if it was cleaned every day.

In an interview with a housekeeper (staff #11) conducted on August 2, 2023 at 2:20 p.m. the housekeeper said that if the resident's toilet riser was not clean and was with feces, the nurses were responsible for cleaning it and were supposed to call the housekeeping to disinfect the toilet riser.

During an interview with the director of nursing (DON/ staff #22) conducted on August 2, 2023 at 2:40 p.m., the DON stated it was her expectation that nursing staff should be cleaning the DMEs (durable medical equipment) such as the toilet seat riser when there were visible feces on it. She stated the risk if the DMEs were not cleaned or disinfected included cross contamination and potential infection outbreak. Regarding the oxygen, the DON stated that it was her expectation that the oxygen tubing/nasal cannula is placed in a bag if not in use and changed every week. She stated the risk if oxygen tubing were not placed in the bag, included respiratory infections and MRSA (multiple resistant staphylococcus aureus).

Review of the facility policy on Respiratory Therapy-Infection Control, with a revision date of December 2017 included a process to keep oxygen cannula and tubing used as needed in a plastic bag when not in use.

The facility policy on Communicable Disease Outbreak Management Protocol, revealed the dedicated or disposable noncritical resident-care equipment is used or if not available, then equipment is cleaned and disinfected according to manufacturer ' s instructions using an EPA-registered disinfectant for healthcare setting prior to use on another resident.

Based on observations, staff interviews, and policies and procedures, the facility failed to ensure that infection control standards were followed by failing to ensure the toilet seat riser available for resident use was cleaned for two residents (#1 and #2); and, failed to ensure the oxygen tubing were properly stored when not in use for two residents (#2 and #3). The deficient practice could result in the spread of infection.

Findings include:

Regarding resident #1

-Resident #1 was admitted on August 24, 2022 with diagnoses that included cancer, diabetes, and multiple-resistant organisms.

Review of the quarterly MDS (minimum data set) assessment dated May 22, 2023 revealed a BIMS (brief interview of mental status) score of 14 indicating the resident had no cognitive impairment. Per the MDS, the resident was frequently incontinent of bowel and bladder and required extensive assistance with toileting and hygiene needs.

During an observation conducted on August 2, 2023 at 10:00 a.m., resident #1 had a gray toilet seat riser that was placed over the regular toilet located in her bathroom. The toilet seat riser had multiple dried feces underneath the right arm rest, and underneath the toilet seat.

An interview with resident #1 was conducted immediately following the observation. Resident #1 stated that the toilet seat was not cleaned regularly; and, her private caregiver assisted her as needed to use the toilet but cleaning it was not a part of her job.

Regarding resident #2

-Resident was admitted on February 3, 2023 with diagnoses of pneumonia, malnutrition, and respiratory failure.

The significant change MDS assessment dated May 25, 2023 revealed a BIMS score of 14 indicating resident had no cognitive impairment. Per the MDS, the resident had an indwelling Foley catheter, required extensive assistance with toilet use and personal hygiene and was always incontinent of bowel function. The MDS also included that the resident was receiving oxygen therapy while a resident at the facility.

An observation was conducted on August 2, 2023 at 10:13 a.m. Resident #2 was in bed with an oxygen concentrator at the bedside, the oxygen tubing attached on the concentrator, and the nasal cannula was coiled and tucked in on the handle of the oxygen concentrator. There was an emergency oxygen tank attached to a wheelchair located in the resident's bathroom. An oxygen tubing was attached to the emergency oxygen tank and the nasal cannula was hanging on the right arm of the wheelchair. In the resident's bathroom, a gray toilet seat riser was placed on top of a regular toilet. The toilet seat riser had multiple dried feces on the toilet seat, the handle, and the front silver metal bar where the toilet seat was attached.

In an interview with resident #2 conducted immediately following the observation, resident #2 stated that he uses the oxygen daily and as needed when in bed or in a wheelchair; and goes to the bathroom with the assistance of the staff. Resident #2 stated he thinks the staff cleans the toilet seat riser after each use but he was not sure.

Regarding resident #3

-Resident #3 was admitted on May 7, 2023 with diagnoses of malnutrition and hypertension.

The 14-day MDS assessment dated May 11, 2023 revealed a BIMS score of 13 indicating the resident had intact cognition. The assessment included that the resident required extensive assistance with ADLs (activity of daily living); and that, the resident was on oxygen therapy while a resident in the facility.

During an observation conducted on August 2, 2023 at 10:06 a.m. the resident was found sitting in a chair near the window. The resident had an oxygen concentrator at the bedside with an oxygen tubing attached. However, the oxygen cannula was lying directly on the bed, away from the resident. Resident #3 stated that she uses oxygen daily and the staff helps her in placing the oxygen in her nose.

An interview was conducted on August 2, 2023 at about 2:00 p.m. with a certified nursing assistant (CNA/ staff #21) who stated the CNAs and the housekeeping were responsible for cleaning the toilet seat riser if they see it dirty. She stated the toilet riser should not have dried feces if it was cleaned every day.

In an interview with a housekeeper (staff #11) conducted on August 2, 2023 at 2:20 p.m. the housekeeper said that if the resident's toilet riser was not clean and was with feces, the nurses were responsible for cleaning it and were supposed to call the housekeeping to disinfect the toilet riser.

During an interview with the director of nursing (DON/ staff #22) conducted on August 2, 2023 at 2:40 p.m., the DON stated it was her expectation that nursing staff should be cleaning the DMEs (durable medical equipment) such as the toilet seat riser when there were visible feces on it. She stated the risk if the DMEs were not cleaned or disinfected included cross contamination and potential infection outbreak. Regarding the oxygen, the DON stated that it was her expectation that the oxygen tubing/nasal cannula is placed in a bag if not in use and changed every week. She stated the risk if oxygen tubing were not placed in the bag, included respiratory infections and MRSA (multiple resistant staphylococcus aureus).

Review of the facility policy on Respiratory Therapy-Infection Control, with a revision date of December 2017 included a process to keep oxygen cannula and tubing used as needed in a plastic bag when not in use.

The facility policy on Communicable Disease Outbreak Management Protocol, revealed the dedicated or disposable noncritical resident-care equipment is used or if not available, then equipment is cleaned and disinfected according to manufacturer's instructions using an EPA-registered disinfectant for healthcare setting prior to use on another resident.