Singleton Health Care Center

Based on resident record review, resident interview, staff interview and facility policy review, the facility failed to ensure Resident #42 was treated with respect and dignity. This affected one resident (#42) of two residents reviewed for respect and dignity. The facility census was 48.

Findings include:

Review of the medical record for Resident #42 revealed she was admitted to the facility on 02/02/22 with diagnoses including Alzheimer's disease, dementia, schizophrenia, and schizoaffective disorder.

Review of the care plan dated 02/14/22, revealed Resident #42 behaved in a problematic manner characterized by ineffective coping with paranoia and suspicious behaviors related to psychiatric illness. Interventions included reassuring safety and talking in a low pitch, calm voice to decrease and/or eliminate undesired behaviors and provide diversional activities.

Review of the Minimum Data Set (MDS) assessment dated 08/27/24, revealed Resident #42 had a Brief Interview for Mental Status (BIMS) score of three, indicating she had severe cognitive impairment. She was independent with some setup assistance with activities of daily living (ADL). Review of the MDS assessment revealed Resident #42 had a history of delusional thoughts.

Observation on 11/13/24 at 3:44 P.M. revealed Resident #42 approached the locked secured door adjacent to the receptionist's desk and began knocking. Medical Secretary (MS) #562 got up from the seated position, opened the door in a forceful manner, and approached Resident #42 stating in a rude, blunt tone What do you want? Why are you knocking on the door that hard? Resident #42 was observed taking a step back from the door and asked MS #562 a question that was unclear. MS #562 revealed she did not know the answer to Resident #42's question, and Resident #42 turned and walked away.

Interview on 11/13/24 at 3:45 P.M. with MS #562, while turning her eyes upward, revealed she did not always speak to residents in that manner, but Resident #42 was knocking on the door really hard. MS #562 confirmed and verified the interaction with Resident #42.

Interview on 11/13/24 at 3:46 P.M. was attempted with Resident #42, but she declined to speak.

Interview on 11/14/24 at 8:55 A.M. with Resident #42 revealed she was sometimes treated with respect and dignity. Resident #42 revealed MS #562 was sometimes mean and rude when she approached her.

Review of the facility document titled Resident Rights and Dignity Policy

Based on record review, interview and facility policy review, the facility failed to ensure Resident #200's baseline care plan was completed timely. This affected one resident (#200) of two residents reviewed for baseline care plans. The facility census was 48. Findings include: Review of the medical record for Resident #200 revealed an admission date of 10/05/24 with diagnoses including diabetes mellitus and malignant neoplasm of pancreas (cancer). Resident #200 was discharged to the hospital on 10/10/24 and did not return to the facility. Review of the baseline care plan in the electronic health record dated 10/07/24 revealed it was blank and had not been completed. Interview on 11/14/24 at 9:48 A.M. with Licensed Practical Nurse (LPN) #569 revealed she assisted in completing the baseline care plans. She stated Resident #200 was admitted on 10/05/24 and was discharged on 10/10/24. She stated she had initiated the baseline care plan, printed it out, and then began filling in the information by hand on the form with information provided through staff interviews and observations. She verified she had not completed the baseline care plan within 48 hours or entered it into the computer so nursing staff had it available. LPN #569 verified the baseline care plan should have been in the computer completed by 48 hours and reviewed with the resident and family. Review of the facility policy titled, Baseline Care PlanBased on record review, interview and facility policy review, the facility failed to ensure Resident #200's baseline care plan was completed timely. This affected one resident (#200) of two residents reviewed for baseline care plans. The facility census was 48.

Findings include:

Review of the medical record for Resident #200 revealed an admission date of 10/05/24 with diagnoses including diabetes mellitus and malignant neoplasm of pancreas (cancer). Resident #200 was discharged to the hospital on 10/10/24 and did not return to the facility.

Review of the baseline care plan in the electronic health record dated 10/07/24 revealed it was blank and had not been completed.

Interview on 11/14/24 at 9:48 A.M. with Licensed Practical Nurse (LPN) #569 revealed she assisted in completing the baseline care plans. She stated Resident #200 was admitted on 10/05/24 and was discharged on 10/10/24. She stated she had initiated the baseline care plan, printed it out, and then began filling in the information by hand on the form with information provided through staff interviews and observations. She verified she had not completed the baseline care plan within 48 hours or entered it into the computer so nursing staff had it available. LPN #569 verified the baseline care plan should have been in the computer completed by 48 hours and reviewed with the resident and family.

Review of the facility policy titled, Baseline Care Plan

Based on record review, interviews and facility policy review, the facility failed to ensure fall prevention interventions were documented on the Kardex, failed to ensure an accurate falls risk assessment, and failed to do post fall assessments for 72 hours according to the facility policy for Resident #34. In addition, the facility failed to ensure safety of Resident #200 during care. This affected two residents (#34 and #200) of two residents reviewed for accidents. The facility census was 48.

Findings include:

1. Review of the medical record revealed Resident #34 was admitted to the facility on 09/23/19 with diagnoses including epilepsy, hypertension, bradycardia, conversion disorder with seizures, cognitive communication deficit, dementia with behaviors, schizophrenia, cardiomyopathy, congestive heart failure, and vitamin B12 deficiency.

Review of Resident #34's medication orders for July 2024 through September 2024 revealed orders for Norvasc, Losartan Potassium, Metoprolol Succinate ER (antihypertensives), Torsemide, hydralazine HCL, Furosemide, spironolactone (diuretics) and Depakote ER and Keppra (anti-seizure medications).

Review of the fall incident description dated 09/29/24 at 6:07 P.M. revealed Resident #34 was in his room with a Certified Nurse Aide (CNA) present, and he tripped over a book bag that was kept underneath his bed. Resident #34 was observed on floor on all fours and was assessed by the nurse and had no injuries. He was educated to educated to keep the walkway free of clutter.

Review of medical record dated 09/29/24 to 10/01/24 revealed the facility failed to assess Resident #34 every shift post fall for 72 hours according to their policy.

Review of the Medication Administration Record (MAR) for September 2024 revealed Resident #34 had been receiving the antihypertensives, antiseizure and diuretic medications as ordered.

Review of the fall risk assessment dated 10/02/24 for Resident #34 revealed under section G. Medications, the resident took only one to two of the following medications in the last seven days: anesthetics, antihistamines, antiseizure, antihypertensives, benzodiazepines, cathartics, diuretics, hypoglycemics, narcotics, psychoactives, sedatives/hypnotics. Further review revealed under section H. Predisposing diseases included CVA, Parkinson's disease, seizures, arthritis, loss of limb, arthritis, osteoporosis, fractures, multiple sclerosis, vertigo and hypotension, and the assessment indicated Resident #34 had none of the predisposing diseases.

Review of the plan of care, dated 10/07/24, revealed Resident #34 had a risk for falls related to seizure disorder. An intervention included to ensure the floor was free of clutter.

Review of Resident #34's current Kardex revealed the intervention dated 10/07/24 to ensure the resident's floor remained free of clutter had not been added.

Interview with the Director of Nursing (DON) on 11/13/24 at 1:35 P.M. confirmed the new fall intervention dated 10/07/24 ensure floor remain free of clutter was not on the Kardex.

Interview with CNA #524 on 11/14/24 at 9:28 A.M. revealed that she refers to the Kardex or will ask the nurse regarding any changes or updates to a resident's care.

Interview with Minimum Data Set 3.0 (MDS) Licensed Practical Nurse (LPN) #569 on 11/13/24 at 1:42 P.M. confirmed incorrect documentation was identified on the falls risk assessment dated 10/02/24 based on the record review pertaining to the medications and predisposing diseases.

Interview with the Director of Nursing (DON) on 11/13/24 at 2:53 P.M. confirmed that nursing documentation was not completed on every shift for 72 hours per Singleton Health Care Post Fall Protocol

Based on record review and interview, the facility failed to ensure pharmacy recommendations were followed up on for Resident #1. This affected one resident (Residents #1) of five residents reviewed for unnecessary medications. The facility census was 48.

Findings include:

Review of the medical record for Resident #1 revealed an admission date of 09/18/19 with diagnoses including arthritis, schizophrenia and insomnia.

Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated 10/01/24 revealed Resident #1 was cognitively intact. She required set up assistance for eating and oral hygiene and substantial or maximum assistance for dressing, toileting, showering and personal hygiene.

Review of the Medication Administration Record (MAR) for July 2024 revealed an order for Haldol (an antipsychotic medication) 0.5 milligrams (mg) intramuscularly (IM) every six hours as needed (prn). The order began on 07/22/24 and was discontinued on 08/29/24.

Review of the document titled Note to Attending Physician/Prescriber dated 07/18/24 revealed pharmacist #570 requested Medical Director (MD) #571 to consider adding an end date of 08/05/24 to Haldol IM 0.5 mg. There was no evidence MD #572 addressed the recommendation.

Interview on 11/14/24 at 10:36 A.M. with the Director of Nursing confirmed the recommendation by Pharmacist #570 for Resident #1 dated 07/18/24 was not addressed by MD #572 regarding the end date of 08/05/24 for the Haldol.

Review of the facility policy titled Medication Monitoring dated 06/21/17 revealed residents who received psychotropic medications would receive gradual dose reductions unless clinically contraindicated.

Based on interview and record review, the facility failed to ensure fall risk assessments were documented accurately for Resident #34 who was at risk of falls. This affected one resident (Resident #34) of three residents reviewed for falls. The facility census was 48.

Findings include:

Review of the medical record revealed Resident #34 was admitted to the facility on 09/23/19 with diagnoses including epilepsy, hypertension, bradycardia, conversion disorder with seizures, cognitive communication deficit, dementia with behaviors, schizophrenia, cardiomyopathy, congestive heart failure, and vitamin B12 deficiency.

Review of Resident #34's medication orders for July 2024 through September 2024 revealed orders for Norvasc, Losartan Potassium, Metoprolol Succinate ER (antihypertensives), Torsemide, hydralazine HCL, Furosemide, spironolactone (diuretics) and Depakote ER and Keppra (anti-seizure medications).

Review of the fall risk assessments dated 07/05/24 and 10/02/24 for Resident #34 revealed under section G. Medications, the resident took only one to two of the following medications in the last seven days: anesthetics, antihistamines, antiseizure, antihypertensives, benzodiazepines, cathartics, diuretics, hypoglycemics, narcotics, psychoactives, sedatives/hypnotics.

Review of the Medication Administration Record (MAR) for September 2024 revealed Resident #34 had been receiving the antihypertensives, antiseizure and diuretic medications as ordered.

Further review of the fall risk assessments dated 07/05/24 and 10/02/24 revealed under section H. Predisposing diseases included CVA, Parkinson's disease, seizures, arthritis, loss of limb, arthritis, osteoporosis, fractures, multiple sclerosis, vertigo and hypotension, and the assessment indicated Resident #34 had none of the predisposing diseases.

Interview with Minimum Data Set (MDS) Licensed Practical Nurse (LPN) #569 on 11/13/24 at 1:42 P.M. confirmed that incorrect documentation was identified on the falls risk assessments dated 10/2/24 and 07/05/24. LPN #569 confirmed that each of the assessments had identical documentation that was incorrect based on the record review pertaining to the medications and predisposing diseases.

Based on interview, record review and review of the facility staffing tool, the facility failed to ensure adequate minimum staffing levels were met. This had the potential to effect all 50 residents residing at the facility.

Findings include:

On 10/27/22, the facility staffing tool was conducted to include the period of time 10/21/22 through 10/27/33 which revealed, on 10/22/22 the facility only had 2.08 hours per resident of direct care staff and on 10/23/22 the facility had only 2/24 hours per resident of direct care staff which did not meet the minimum staffing requirement of 2.5 hours.

Interview on 10/27/22 at 11:30 A.M. with the Director of Nursing (DON) and the Staffing Coordinator/ State Tested Nurse Aide (STNA) #504 verified, on 10/22/22 and 10/23/22, their staffing levels did not meet the required 2.5 hours per resident of direct care. STNA #504 stated, on 10/22/22 the facility had two STNA's call off and the facility was not able to fill the vacant assignments that day. Also, on 10/223/22, they had one STNA report off work and they were unable to fill the vacant assignment that day.

Review of the facility Assessment Tool dated 09/01/22 revealed the facility was licensed for 50 residents and the facility uses one to three licensed nurses, three to five State Tested Nurse Aides, one or two other nursing personnel, one dietitian and three to four food service/ nutrition services staff per shift.

This violation represents noncompliance investigated under Complaint Number OH00137006.