The Center At Val Vista, LLC

Based on observation the facility failed to maintain several special locking exit doors located in the facility. Failing to ensure the correct amount of force needed to release of the exit doors could cause harm to patients and/or staff in an emergency

NFPA 101 Life Safety Court, 2012, Chapter 18, Section, 18.2.2.2.4 "Doors within a required means of egress shall not be equipped with a latch or lock that requires the use of a tool or key from the egress side." Exception No. 2 "Delayed-egress locks complying with 7.2.1.6.1 shall be permitted, provided that not more than one such device is located in any egress path. Section 7.2.1.6.1 "Special Locking Arrangements" " (c) An irreversible process shall release the lock within 15 to 30 seconds upon application of a force to the release device required in 7.2.1.5.4 that shall not be required to exceed 15 lbs nor be required to be continuously applied for more than 3 seconds. The initiation of the release process shall activate an audible signal in the vicinity of the door. Once the door lock has been released by the application of force to the releasing device, relocking shall be by manual means only."

Findings include:

Observations made while on tour on January 3, 2024, revealed the following;

1) the third floor "C" Hall delayed egress door exit door failed to open with a force of less than 15 lbf. The panic bar was pushed and set off the irreversible process at 34 lbf
2) the third floor "B" Hall delayed egress door exit door failed to open with a force of less than 15 lbf. The panic bar was pushed and set off the irreversible process at 25 lbf
3) the third floor "A" Hall delayed egress door exit door failed to open with a force of less than 15 lbf. The panic bar was pushed and set off the irreversible process at 45 lbf
4) the second floor "C" Hall delayed egress door exit door failed to open with a force of less than 15 lbf. The panic bar was pushed and set off the irreversible process at 45 lbf
5) the second floor "B" Hall delayed egress door exit door failed to open with a force of less than 15 lbf. The panic bar was pushed and set off the irreversible process at 35 lbf
6) the second floor "A" Hall delayed egress door exit door failed to open with a force of less than 15 lbf. The panic bar was pushed and set off the irreversible process at 46 lbf

During the exit conference on January 3, 2024, the above findings were again acknowledged by the management team.

Based on observations, clinical record review, staff and family interviews and facility policy review, the facility failed to ensure reasonable care for the protection of the resident's medical assistive property from loss or theft for one resident (#219). The deficient practice could result in resident not provided with a homelike environment.

Findings include:

Resident #219 was admitted on December 21, 2023 with diagnoses of laceration without foreign body of other part of head, hypo-osmolality and hyponatremia, syndrome of inappropriate secretion of antidiuretic hormone, muscle weakness, difficulty in walking, essential (primary) hypertension, dysphagia, oropharyngeal phase, cognitive communication deficit, hypokalemia, long term (current) use of anticoagulants, encounter for surgical aftercare following surgery on the circulatory system, personal history of transient ischemic attack, and cerebral infarction without residual deficits.

Observation and resident interview conducted on December 26, 2023 at 10:03 AM the resident stated, "My hearing aids were lost when I got here, both sides are missing, I just had them adjusted and they can take up to two weeks to get new ones. I could cry! I had them when I came in. I told the nurses and all they say is, oh dear how terrible." Observed the resident's hearing aid case with no hearing aids but a package of batteries was found in the residents hearing aid case. Observed the resident in having difficulty hearing and resulted in nearly shouting to resident in order to hear questions. Observed the resident tearfully distraught in describing her missing hearing aids.

The Resident Dashboard (December 24, 2023) reports a BIMS (Brief Interview for Mental Status) score of 8 indicating the resident had moderately impaired cognition.

Review of Nursing Comprehensive Admission Data Collection V8 document (December 21, 2023) and revealed that a Licensed Practical Nurse (staff #60) annotated the resident to use hearing aids on admission.

Review of resident Care Plan and revealed the Focus statement (December 26, 2023), "Patient's is hard of hearing Patient has hearing aid in both ears". The Goal states, "Patient's needs will be met every shift X 90 days." The Interventions states, "Eliminate distractions or background noise. Give clear & simple directions. Staff to adjust tone and volume of voice as needed." The resident Care Plan was initiated 12/26/2023 and created by a Registed Nurse (staff #421), MDS Coordinator and revised on 12/27/2023 by (staff #421), MDS Coordinator.

Review of Case Management Progress Note (December 21, 2023 at 4:24 PM) and revealed admission was conducted with the resident expressing verbal understanding and all questions were answered at this time. Note Text: Suzann arrived safely to the facility via stretcher with AZ Patient Transport. This writer welcomed & greeted patient upon her arrival to the facility and provided the room number she will be going into. This writer spoke with the resident's daughter in law at 480-229-1704 and informed her of patient's safe arrival to the facility & reiterated visiting policy & procedure. This writer explained that any scheduled appointments do need to pertain to admitting diagnosis and it is important that family meet them at the appointment to provide proper insurance cards and identification. Care Plan meeting with IDT members, patient & family was offered at this time, but declined. The daughter in-law was informed to contact case management to arrange per request and she expressed verbal understanding & all questions were answered at this time.

Family interview conducted on December 27, 2023 at 12:45 PM via phone with the resident's son and he stated, "She got in there on Thursday and it was Saturday that we discovered it was no longer there and they stated they have no idea what idea what happened to them, spoke with staff #521 one of the nurses. She had her hearing aids at the time of admission. I am in the process of getting her hearing aids replaced at Costco and making appointments to have her hearing tests done for her hearing aid replacement."

Interview conducted on December 27, 2023 at 1:07 PM with a Registered Nurse (staff #210) and the , Staff Development Coordinator (staff #740). Staff #210 stated, "I was told that that we can't find her hearing aids. I started her care on December 24, 2023. I wasn't here during her admission."Staff #740 stated, "For facility policy in regards to missing property, case management completes a grievance. When patient arrive, they sign consents for their own property, they are responsible for their own items, we recommend that they send valuables homes, we do have a policy for reimbursing."

During an interview conducted on December 27, 2023 1:34 PM with a Licensed Practical Nurse,(staff #50) Director of Case Management. Staff #50 stated, "Her son called yesterday to find out why she was at the facility and I was informed about her missing hearing aids yesterday. The resident was admitted on December 21, 2023, Thursday and was interviewed by the case manager, on Friday and she didn't mention anything about the hearing aids. For residents with cash we do an inventory for their cash and put into a safe, we don't inventory personal property, we suggest to the family to take their property home and for those who refuse we say we are not responsible for lost or stolen property. The policy that address this might be in the admission packet. Medical assistive devices are documented in the care plan, we've had residents who have lost dentures and we've replaced them depending on the situation."

Reviewed facility policy PATIENT RIGHTS: PLANNING AND IMPLEMENTING CARE and revealed the statement "Personal clothing and effects including personal property are patient responsibility per admission agreement. The Patient agrees to take reasonable precautions to safe keep this property by indelibly marking personal belongings at or before time of admission. The Patient shall be responsible for providing any desired insurance protection covering loss of property."

Reviewed facility policy ADMISSION CRITERIA and revealed the statement "2. Residents (and potential residents) will not be asked or required to: c. waive facility liability for losses of personal property..."

Interview conducted on December 27, 2023 at 2:26 PM with the Executive Director (staff #235). Staff #235 stated, "When they admit, we ask family members to take valuables home we don't do the personal property inventory because patients are in and out in a short time and when family would often bring items and it was hard to keep up inventory and corporate changed the policy on personal inventory. For medical assistive devices we keep in the room and keep an eye on it, like for hearing aids and dentures. When they come up missing we typically replace them and work with the family. For missing items, I didn't think we had to do a facility report if it was rectified but it if was stolen then we would report. I'm understanding if it something is lost then we do a grievance and replace if needed. I expect my staff to report missing items pretty quick because it can be time sensitive. I expect my team to call me at any time and I have a charge nurse to begin to look for it. I do have leadership here seven days a week to report as needed." In regards to the risk of missing medical assistive devices, the Executive Director (staff #235 stated), "There are safety concerns, a resident cant' eat if dentures are lost, for hearing aids ...we want to replace quickly."

The Director of Nursing (DON, staff #357) entered the facility meeting room with the surveyors on December 28, 2023 at 9:05 AM and presented her staff interviews and Nursing Comprehensive Admission Data Collection documentation in regards to the resident's mis

Based on observations, resident and staff interviews, and facility documentation, the facility failed to ensure that one resident (#42) was free from the accident hazard of self-administering medications not ordered by the physician. This deficient practice could result in resident taking medications with contraindications.

Findings include:

Resident #42 admitted to the facility on November 18, 2023 with a hip fracture, Deep Venous Thrombosis Prophylaxis, and history of breast cancer.

She had a physician's order for an injection of the anticoagulant Enoxaparin 40 mg (milligram) one time a day dated 11/19/23, and supplement which included two 500mg Ascorbic Acid Tablets ordered 11/18/2023 and two tablets of Cholecalciferol Oral Tablet 25 micrograms ordered 11/18/2023.

Review of the Medication Administration Record for December 2023 showed she received all the above medications as ordered.

According to the Minimum Data Set assessment conducted on 11/21/23 she scored a 10 on the Brief Interview for Mental Status, which indicates moderate cognitive impairment.

In the care plan initiated on 11/18/2023, Resident #42 has a goal for not having any complications due to not receiving cancer treatment during her stay at the facility. Resident #42 is also care planned for anticoagulant use. Interventions for these goals includes administer medications per physician orders and monitor frequently.

On 12/26/23 at 10:01 AM, surveyor observed a pill box with medication on Resident #42's bedside table. On another counter in her room were medications including Triphala 1000 mg capsules, Vitamin D3, Vitamin K, and 800 mg calcium supplement.

On a second observation on 12/26/23 at 2:22 PM, surveyor observed Registered Nurse (RN) Staff #210 inside Resident #42's room passing medication.

On 12/26/23 at 2:27 PM surveyor entered the room to interview Resident #42 privately. Her husband was present. Resident #42 stated she did not recall doing a self-administration of medications assessment. She confirmed she does take the medications and the doctor is aware and had told her he is okay with it. Husband stated the pill box still had some days with pills in it and expressed upset that his wife had not been taking them as she should have been.

In an interview with RN Staff #210 on 12/26/23 at 2:32 PM when asked how residents are assessed for whether they can self-administer medications or not, she stated the nurse will determine if the patient is eligible and if so, let the provider know so that they can input an order for self-administration of medications. If approved for self-administration of medications, then the resident will keep their medications in their room in the bedside drawer. When asked specifically about the medications in Resident #42's room, Staff #210 stated she would need to check in the EHR (electronic health record) for the orders and if she could self-administer medications.

In a follow up interview with staff #210 on the same day at 3:01 PM, she clarified that before they could self-administer medications residents were required to demonstrate they could safely and properly administer medications, receive education about safety, verbalize understanding, and store medication in a cabinet. She stated that earlier she had not seen the pill box, only the pill bottles. She advised that the husband had brought the medications in and had now been educated about not bringing pills into the facility for his wife.

During an interview on 12/26/23 at 3:02 PM with the Director of Nursing (DON) Staff #357, when asked if residents are able to bring in medications, vitamins, etc. and keep in room she stated they can if the facility knows about it. For even OTC (over the counter) medications the facility would need to call the doctor to make sure it is safe and okay. They then encourage residents not to leave medications out. For example, an inhaler would need to be in drawer or for allergy shots administered by a family member, they would need to demonstrate they could administer them without a nurse.
The self-administration assessment process starts with the nurse completing the assessment. Then the provider will specify on the order if administration needs to be supervised or not. The DON stated that with regards to Resident #42, they had talked to the husband about bringing pills in. He had left the building at the time of surveyor requesting a list of the bedside medications and facility staff were not able to identify the pills. DON reiterated that RN Staff #210 had said husband brought them in from home today.

In a follow up interview with the DON on 12/26/23 at 3:43 PM when asked about potential risks of Resident #42 being on an anticoagulant and taking Vitamin K, she stated in general it would probably be counterproductive but depended on the blood thinner. If coumadin, it would essentially be an antidote, but with Lovenox she would need to know exact dosage of the Vitamin K and would follow up with the pharmacist. DON confirmed they went through Resident #42's room and did not find any other medications. After following up with the pharmacist about the risks of Lovenox, DON returned on 12/27/23 at 8:15 AM to confirm there was no current risk for Resident #42 if she had taken or been taking Vitamin K.

A review of physician orders and Resident #42's electronic chart on 12/26/2023 revealed no self-administration of medications evaluation as well as no orders from the physician and no orders for any of the vitamins.

In a clarifying interview with Resident #42 on 12/27/23 at 2:39 PM, she stated the doctor at this facility had been in her room to speak with her and seen the pill bottles she keeps on the countertop. According to her, he stated she could take them as they were just regular vitamins. She was adamant that she had been taking the medications since she arrived at this facility.

In a final interview with the DON on 12/28/23 at 8:29 AM, she stated that while residents are encouraged not to bring medications from home, her expectations for her staff are to fill the requested medications from the pharmacy to ensure it is the same dose each time, that it is the actual medication that is listed on the bottle, and that the pills are not expired. She stated that this is important for patient safety. If staff does not know what a patient is taking and the patient were to become unresponsive, they would not be able to know if it was an allergic reaction or an interaction between medications. When emergency medical services arrive, they would need to be able to let them know about risks of contraindications, medication reactions, allergies, etc. Medications can also change from home to the hospital to the skilled nursing facility and patient may not be aware. For Resident #42 specifically, the DON stated she was not on Lovenox at home and would therefore have been unaware of any potential risk if she had taken Vitamin K.

In facility policy titled " Self-Administration of Medications" last revised 02/08/2021, it states "the nursing staff will document their findings and the choices of patients who are able to self-administer medications ... Self-administered medications must be stored in a safe and secure place which is not accessible by other patients ...Staff shall identify and give to the charge nurse any medications found at the bedside table that are not authorized for self-administration."

Based on observations, resident and staff interviews, and facility documentation, the facility failed to ensure that one resident (#42) was free from the accident hazard of self-administering medications not ordered by the physician. This deficient practice could result in resident taking medications with contraindications.

Findings include:

Resident #42 admitted to the facility on November 18, 2023 with a hip fracture, Deep Venous Thrombosis Prophylaxis, and history of breast cancer.

She had a physician's order for an injection of the anticoagulant Enoxaparin 40 mg (milligram) one time a day dated 11/19/23, and supplement which included two 500mg Ascorbic Acid Tablets ordered 11/18/2023 and two tablets of Cholecalciferol Oral Tablet 25 micrograms ordered 11/18/2023.

Review of the Medication Administration Record for December 2023 showed she received all the above medications as ordered.

According to the Minimum Data Set assessment conducted on 11/21/23 she scored a 10 on the Brief Interview for Mental Status, which indicates moderate cognitive impairment.

In the care plan initiated on 11/18/2023, Resident #42 has a goal for not having any complications due to not receiving cancer treatment during her stay at the facility. Resident #42 is also care planned for anticoagulant use. Interventions for these goals includes administer medications per physician orders and monitor frequently.

On 12/26/23 at 10:01 AM, surveyor observed a pill box with medication on Resident #42's bedside table. On another counter in her room were medications including Triphala 1000 mg capsules, Vitamin D3, Vitamin K, and 800 mg calcium supplement.

On a second observation on 12/26/23 at 2:22 PM, surveyor observed Registered Nurse (RN) Staff #210 inside Resident #42's room passing medication.

On 12/26/23 at 2:27 PM surveyor entered the room to interview Resident #42 privately. Her husband was present. Resident #42 stated she did not recall doing a self-administration of medications assessment. She confirmed she does take the medications and the doctor is aware and had told her he is okay with it. Husband stated the pill box still had some days with pills in it and expressed upset that his wife had not been taking them as she should have been.

In an interview with RN Staff #210 on 12/26/23 at 2:32 PM when asked how residents are assessed for whether they can self-administer medications or not, she stated the nurse will determine if the patient is eligible and if so, let the provider know so that they can input an order for self-administration of medications. If approved for self-administration of medications, then the resident will keep their medications in their room in the bedside drawer. When asked specifically about the medications in Resident #42's room, Staff #210 stated she would need to check in the EHR (electronic health record) for the orders and if she could self-administer medications.

In a follow up interview with staff #210 on the same day at 3:01 PM, she clarified that before they could self-administer medications residents were required to demonstrate they could safely and properly administer medications, receive education about safety, verbalize understanding, and store medication in a cabinet. She stated that earlier she had not seen the pill box, only the pill bottles. She advised that the husband had brought the medications in and had now been educated about not bringing pills into the facility for his wife.

During an interview on 12/26/23 at 3:02 PM with the Director of Nursing (DON) Staff #357, when asked if residents are able to bring in medications, vitamins, etc. and keep in room she stated they can if the facility knows about it. For even OTC (over the counter) medications the facility would need to call the doctor to make sure it is safe and okay. They then encourage residents not to leave medications out. For example, an inhaler would need to be in drawer or for allergy shots administered by a family member, they would need to demonstrate they could administer them without a nurse.
The self-administration assessment process starts with the nurse completing the assessment. Then the provider will specify on the order if administration needs to be supervised or not. The DON stated that with regards to Resident #42, they had talked to the husband about bringing pills in. He had left the building at the time of surveyor requesting a list of the bedside medications and facility staff were not able to identify the pills. DON reiterated that RN Staff #210 had said husband brought them in from home today.

In a follow up interview with the DON on 12/26/23 at 3:43 PM when asked about potential risks of Resident #42 being on an anticoagulant and taking Vitamin K, she stated in general it would probably be counterproductive but depended on the blood thinner. If coumadin, it would essentially be an antidote, but with Lovenox she would need to know exact dosage of the Vitamin K and would follow up with the pharmacist. DON confirmed they went through Resident #42's room and did not find any other medications. After following up with the pharmacist about the risks of Lovenox, DON returned on 12/27/23 at 8:15 AM to confirm there was no current risk for Resident #42 if she had taken or been taking Vitamin K.

A review of physician orders and Resident #42's electronic chart on 12/26/2023 revealed no self-administration of medications evaluation as well as no orders from the physician and no orders for any of the vitamins.

In a clarifying interview with Resident #42 on 12/27/23 at 2:39 PM, she stated the doctor at this facility had been in her room to speak with her and seen the pill bottles she keeps on the countertop. According to her, he stated she could take them as they were just regular vitamins. She was adamant that she had been taking the medications since she arrived at this facility.

In a final interview with the DON on 12/28/23 at 8:29 AM, she stated that while residents are encouraged not to bring medications from home, her expectations for her staff are to fill the requested medications from the pharmacy to ensure it is the same dose each time, that it is the actual medication that is listed on the bottle, and that the pills are not expired. She stated that this is important for patient safety. If staff does not know what a patient is taking and the patient were to become unresponsive, they would not be able to know if it was an allergic reaction or an interaction between medications. When emergency medical services arrive, they would need to be able to let them know about risks of contraindications, medication reactions, allergies, etc. Medications can also change from home to the hospital to the skilled nursing facility and patient may not be aware. For Resident #42 specifically, the DON stated she was not on Lovenox at home and would therefore have been unaware of any potential risk if she had taken Vitamin K.

In facility policy titled " Self-Administration of Medications" last revised 02/08/2021, it states "the nursing staff will document their findings and the choices of patients who are able to self-administer medications ... Self-administered medications must be stored in a safe and secure place which is not accessible by other patients ...Staff shall identify and give to the charge nurse any medications found at the bedside table that are not authorized for self-administration."