St Augustine Manor

2. During screening on 5/21/24 at approximately 9:43am, R448 was observed in bed. R448's urinary drainage bag was observed halfway filled with yellowish urine output. R448's door was open, and the uncovered drainage bag was facing the doorway, exposing R448's urine. R448's drainage bag was not covered, attached to the lower bed frame, and could easily be viewed from R448's doorway. Another surveyor confirmed the observation.

Review of R448's health record revealed an admission date of 5/18/24.

Review of R448's baseline care plan dated 5/18/24 revealed a care plan was developed related to indwelling urinary catheter. However, there was no evidence that a cover or privacy bag was addressed in the baseline care plan.

Review of R448's Kardex (documentation system that gives a brief overview of individual resident care) revealed Bladder/Bowel. Catheter: the resident has 16Fr [French] 5 cc [cubic centimeter] indwelling urinary catheter. Position catheter bag and tubing below the level of the bladder and check for kinks at least q [every] shift. Empty foley catheter every eight hours and record output. Five-day bladder diary. However, there were no instructions on how to protect R448's dignity.

During an interview with State Tested Nursing Assistant (STNA) STNA #421 on 5/22/24 at approximately 1:05PM, STNA #421 revealed she was familiar with R448. When asked about the care and resident needs, STNA #421 stated they used the Kardex. When asked how she provided privacy for residents with catheter and urinary drainage bag, STNA#421 stated, We close the door. We have a bath blanket or sheet to put over them. We have a Foley [catheter] cover.

In an interview with the Licensed Practical Nurse (LPN) #824 on 5/22/24 at approximately 1:12pm, when asked how staff including STNAs knew what kind of care they need to provide to residents, LPN #824 stated, When they [staff] come from another floor, they get a report from the aides [outgoing STNA] and they get a report from me. When asked how they would protect R448's privacy who had a catheter and was using a drainage bag, LPN #824 stated, You won't let it sit on the floor. Dignity, that's the whole purpose of that. When asked to check R448's Kardex if provision of a cover or privacy bag had been included, LPN #824 stated, No. But they know. I don't know if that's a Kardex thing. When asked how STNA would know to provide privacy bag for residents with catheters and urinary drainage bags, LPN #824 stated, They should know that.

In an interview with the Director of Nursing (DON) on 5/22/24 at approximately 3:13pm, the DON confirmed that R448's Kardex did not include the use of privacy bag. The surveyor informed the DON of the above-mentioned observation. When asked if staff should provide a cover or privacy bag for the urinary drainage bag, the DON stated, It depends if the resident requests for a privacy bag [for a resident who is inside his/her room]. The DON added, Maybe we need re-education too [for the nursing assistant that needed the re-education].

Review of the facility policy titled Maintenance of Urinary Catheters dated 10/14 revealed ...When the resident is out of their [sic] room, a foley bag cover must be in place... However, the policy did not instruct how to protect the dignity of residents with urinary drainage bags while inside their rooms when visible by residents and visitors from the hallway when the door is open.

Based on observation, record review, and interview, the facility failed to ensure a comprehensive care plan, physician orders, and interventions of monitoring and evaluation was in place for Resident #144's hand restraint. This affected one resident (Resident #144) of two residents reviewed for restraint use. The total census was 188.

Findings include:

Record review of Resident #144 revealed he admitted to the facility 10/04/23 and had diagnoses including sepsis, dementia, and tracheostomy status.

Review of Resident #144's comprehensive care plan revealed the resident had a tracheostomy due to respiratory failure with an intervention initiated on 10/17/23 for bilateral hand mitts at all times to prevent decannulation. Remove and provide care every two hours and as needed. The care plan had not been revised and did not include specific interventions as to how often to monitor and evaluate the use of the restraint.

Review of Resident #144's restraint assessment dated 03/04/24 revealed he required PRN (as-needed) mitt restraints to minimize risk for pulling out tracheostomy tubing due to agitated behavior and risk for serious injury or death.

Review of Resident #44's Minimum Data Set assessment dated 04/29/24 revealed he was rarely or never understood and did not use restraints.

Review of Resident #144's nurse practitioner note dated 05/21/24 revealed the resident had an unwitnessed JP ('Jackson-Pratt') drain dislodgement and was to receive a trial of mitt restraints for two hours and to remove them if there was no restlessness or agitation.

Review of Resident #144's active and discontinued orders revealed no evidence the restraints were ordered.

Record review of Resident #144's progress notes and assessments revealed no specific documentation of when the restraints were applied and removed, no documentation of notification made to family of restraint use, and no monitoring or evaluation of the resident while the restraint was in use.

Observation of Resident #144 on 05/21/24 at 10:05 A.M. revealed he was not interviewable. He wore a mitt restraint (a restraint made to prevent the wearer from closing their fingers around an object) on his right hand. The restraint was no longer present during a follow-up observation at 4:32 P.M.

Interview with Licensed Practical Nurse #937 on 05/21/24 at 4:39 P.M. revealed she recalled Resident #144 had a history of needing mitt restraints but he had not needed them recently until this morning. She did not apply the restraint this morning, but did take them off the resident at roughly 12:00 P.M.

Interview with the Director of Nursing on 05/22/24 at 2:25 P.M. confirmed Resident #144 did not receive any documented orders, monitoring, or family notification for the restraint use on 05/21/24.

Review of the facility's restraint use policy updated 04/2024 revealed it stated restraints required an order when used for a period in excess of six hours. The facility was to determine the direct monitoring and supervision used during the period of restraint.

Following surveyor intervention, the facility acquired a paper order dated 05/21/24 for the resident to trial hand mitts for two hours to the right hand and remove if there was no restlessness or agitation.

4.) During observation and interview with R154 on 5/21/24 at approximately 5:05pm, R154 stated he goes to dialysis (a treatment for people whose kidneys are failing). R154 stated, Yes, three times [a week] Monday, Wednesday, Friday. When asked about his dialysis access site, R154 showed the surveyor his right upper arm. The site was covered with a dressing and secured with a tape. R154 stated he would get weighed at the dialysis unit. When asked if staff had been checking his vital signs when he returned from dialysis, R154 stated, No. R154 explained that staff checked him in the morning before but not after his dialysis treatment.

Review of R154's Medical Diagnosis in Point Click Care (PCC, healthcare software and electronic health record) included end stage renal disease (kidney failure) and dependence on renal dialysis.

Review of R154's quarterly Minimum Data Set (MDS), a federally mandated assessment tool) dated 4/29/24 revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. In the section related to Special Treatments and programs

Based on observation, record review and interview the facility failed to ensure call lights were within reach and accessible for Residents #14, and #72. This affected two residents (#14 and #72) of 197 residents reviewed for call light placement. The facility census was 197.

Findings include:

1. Record review revealed Resident #14 was admitted on 09/25/20 to the facility with diagnoses that included but not limited to seizures, hemiplegia, epilepsy, and multiple fractures of the pelvis. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated 04/21/23 revealed Resident #14 was moderately cognitively impaired and required extensive assistance of two staff for mobility, transfer, and toilet.

Observation on 05/07/23 at 11:45 A.M. revealed Resident #14 was lying in bed. Resident #14's call light was observed lying on nightstand and not within reach of resident. Resident # 14 stated that she was getting over pneumonia. At the time of observation, Licensed Practical Nurse (LPN) #626 verified call light was out of reach and that Resident #14 can utilize call light.

Review of care plans dated 09/28/20 with a revision date of 07/05/22 revealed Resident #14 had a potential risk for falls related to impaired mobility. Interventions include but are not limited to making sure the resident's call light is within reach and encouraging the resident to use it for assistance as needed.

2. Record review revealed Resident #72 was admitted on 02/21/18 to the facility with diagnoses that included but not limited to heart failure, paranoid schizophrenia, dementia, and repeated falls. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated 03/21/23 revealed Resident #72 was cognitively intact and required extensive assistance of two staff for mobility, transfer, and toilet.

Observation on 05/07/23 at 10:49 A.M. revealed Resident #72 was lying in bed. Resident #72's call light was observed lying on the floor and not within reach of the resident. At time of observation, State Tested Nurse Aide (STNA) #800 verified call light was out of reach and that Resident #72 can utilize call light.

Review of care plans dated 01/31/19 with a revision date of 08/03/22 revealed Resident #14 had a potential risk for falls related to weakness and falls prior to admission. Interventions include but are not limited to a working and reachable call light.

Based on observation, record review and interview, the facility failed to ensure wound care was completed as ordered. This finding affected one (Resident #143) of three residents reviewed for wounds.

Findings include:

Review of Resident #143's medical record revealed she was readmitted on 01/17/23 with diagnoses including diabetes, difficulty in walking and chronic obstructive pulmonary disease. Review of Resident #143's Minimum Data Set (MDS) 3.0 assessment dated 01/27/23 revealed she exhibited intact cognition.

Review of Resident #143's physician orders revealed an order dated 02/20/23 to cleanse the left lower extremity skin tear with normal saline, pat dry, apply an adaptic (non stick dressing) followed by a foam dressing three times a week and as needed. The wound care was due every day shift on Monday, Wednesday and Friday.

Review of Resident #143' treatment administration records (TARS) from 05/01/23 to 05/08/23 revealed the skin tear wound treatment was documented as completed on 05/05/23 on the TAR.

Observation on 05/07/23 at 10:24 A.M. revealed the dressing on Resident #143's left shin skin tear was dated 05/03/23.

Interview on 05/05/23 at 10:25 A.M. with Licensed Practical Nurse (LPN) #756 verified the skin tear dressing was not completed on 05/05/23 as ordered but it was documented as completed on the TAR.

Based on observation, record review and interview, the facility failed to ensure Resident #165's pressure relieving foam boots were implemented as ordered. This finding affected one (Resident #165) of two residents reviewed for pressure wounds. The facility census was 197.

Findings include:

Review of Resident #165's medical record revealed he was admitted on 10/24/22 with diagnoses including muscle weakness, aphasia following a cerebral infarction and diabetes insipidus. Review of Resident #165's Minimum Data Set (MDS) 3.0 assessment dated 01/31/23 revealed he exhibited a memory problem. The medical record did not reveal current pressure ulcer wounds.

Review of Resident #165's physician orders revealed an order dated 11/28/22 for pressure reduction boots to the bilateral feet as a preventative measure and check for placement.

Review of Resident #165's Skin Care Plan indicated he was at risk for the development of skin breakdown and the intervention dated 11/29/22 indicated to apply pressure reduction boots to both feet as a preventative measure. Check placement every shift.

Review of Resident #165's medication administration records (MARS) and treatment administration records (TARS) from 05/01/23 to 05/08/23 revealed the pressure reduction boots placement checks were scheduled twice daily from 7:00 A.M. to 7:00 P.M. and 7:00 P.M. to 7:00 A.M.

Observation on 05/07/23 at 10:17 A.M. revealed Resident #165 was lying in bed. His right foot was observed outside of the sheet and his foot was lying on the bed with no pillow in place. He did not have a pressure reduction boot on his right foot during the observation.

Interview on 05/07/23 at 10:22 A.M. with Licensed Practical Nurse (LPN) #636 confirmed Resident #165's pressure reduction boots were not on his bilateral feet and he was lying in bed with both heels on the bed. She denied he had skin breakdown or pressure ulcers.

Observation on 05/09/23 at 8:20 A.M. revealed Resident #165 was lying in bed and his bilateral heels were observed on the bed. He did not have pressure reduction boots in place.

Interview on 05/09/23 at 8:24 A.M. with Assistant Director of Nursing (ADON) #634 confirmed Resident #165's bilateral pressure reduction boots were not implemented per the order.

Review of the Prevention of Skin Breakdown policy revised 08/18 indicated the charge nurse would communicate with the caregivers related to appropriate prevention measures including, but not limited to turn and reposition orders, incontinence care, pressure reduction devices and input from nutrition.

Based on record review and interview, the facility failed to ensure Resident #193 was provided adequate supervision during care to prevent a fall. This finding affected one (Resident #193) of two residents reviewed for falls. The facility census was 197

Findings include:

Review of Resident #193's medical record revealed he was admitted 11/15/22 and readmitted on 02/28/23 with diagnoses including post traumatic seizures, muscle weakness and aphasia. Review of Resident #193's Minimum Data Set (MDS) 3.0 assessment dated 01/09/23 indicated he exhibited severe cognitive impairment and required extensive two person assist for bed mobility and toilet use. He required total dependence two person assist for transfers and total dependence one person assist for dressing and eating.

Review of Resident #193's physician orders revealed an order dated 11/16/22 and discontinued 05/04/23 to transfer the resident with a Hoyer mechanical lift with the assistance of two staff members every shift.

Review of Resident #193's Morse Fall Scale form dated 12/26/22 revealed the resident was high risk for falls.

Review of Resident #193's Un-Witnessed Fall Investigation form dated 01/25/23 at 11:53 A.M. indicated the resident was observed sitting on the floor with his legs stretched out in front of him on the right side of the bed. The nurse observed the resident's bed in a raised position with a Hoyer pad on the bed.

Review of Resident #193's progress note dated 01/25/23 at 3:32 P.M. authored by Registered Nurse (RN) Unit Manager #708 indicated at approximately 11:53 A.M., the nurse was informed the resident was on the floor. Upon entering the resident's room, the nurse observed the resident sitting on the floor, with his legs stretched out in front of him on the right side of the bed. Non-skid socks were on his bilateral feet. The nurse observed the resident's bed to be locked and in a raised position with a Hoyer pad on the bed. The State Tested Nurse Aide (STNA) indicated she provided the resident with personal care, placed a Hoyer pad underneath the resident and turned around to get assistance as well as the Hoyer mechanical lift when she heard a loud noise and observed the resident on the floor. Resident #193 was sent to the hospital and no apparent injuries were noted.

Interview on 05/09/23 at 9:23 A.M. with RN Unit Manager #708 indicated the STNA told her that Resident #193 was on the floor. She assessed the resident with no apparent injuries. She confirmed his bed was in a high position.

Interview on 05/09/23 at 9:41 A.M. with Rehab Director #797 indicated Resident #193 did not have an attention span and would try to jump out of the bed at any given moment.

Telephone interview on 05/09/23 at 9:46 A.M. with STNA #900 stated she was providing personal care to Resident #193 with the bed in a high position and then left the room to get assistance with transferring the resident using a Hoyer mechanical lift. She indicated she was outside of the room when she heard a crash and observed Resident #193 on the floor. She denied Resident #193 had any injuries.

Review of the Fall Management policy dated 11/16 indicated the facility would identify residents who were at risk for falls and would develop a Plan of Care and implement resident-specific interventions to manage falls and to try to keep the resident free from injury.

Based on observation, record review and interview, the facility failed to ensure a medication error rate of less than 5% (percent). This finding affected two (Residents #75 and #125) of six residents observed for medication administration. A total of 26 medications were administered with two errors for a medication error rate of 7.69%.

Findings include:

1. Review of Resident #125's medical record revealed he was readmitted on 11/10/21 with diagnoses including type two diabetes, end stage renal disease and muscle weakness. Review of Resident #125's Minimum Data Set (MDS) 3.0 assessment dated 02/19/23 revealed he exhibited intact cognition.

Review of Resident #125's physician orders revealed an order dated 10/09/22 to administer lispro insulin (fast acting) if the blood sugar was zero to 149 administer then administer no units; 150 to 199 administer one unit; 200 to 249 administer two units, 250 to 299 administer three units, 300 to 349 administer five units, 350 to 399 administer seven units and if greater than 400 call the provider. Administer the insulin before meals for diabetes mellitus.

Observation on 05/07/23 at 8:12 A.M. with Registered Nurse (RN) #737 of Resident #125's medication administration revealed eight medications were administered with one error. She checked his blood sugar using a glucometer blood glucose testing (BGT) machine with a result of 164. She stated she had to go to the medication storage room for the lispro insulin. Upon entering the resident's room, the breakfast tray was sitting on the bedside table and the meal was 100% consumed.

Interview on 05/07/23 at 8:26 A.M. with RN #737 indicated she was unaware Resident #125's breakfast tray had arrived. She also confirmed she obtained the BGT after the breakfast meal was consumed and administered the insulin after the breakfast meal. She also indicated she did not administer Resident #78 or #71's insulin prior to the breakfast meal because she had been busy and she had yet to administer the insulin. She confirmed all meal trays had been delivered.

2. Review of Resident #75's medical record revealed he was admitted on 07/23/21 with diagnoses including unspecified dementia, muscle weakness and difficulty in walking. Review of Resident #75's MDS 3.0 assessment dated 02/13/23 revealed he exhibited a memory problem.

Review of Resident #75's physician orders revealed an order dated 07/24/21 for cholecalciferol tablet (vitamin D3) administer 75 mcg (micrograms) by mouth one time a day for a deficiency (3000 units).

Observation on 05/07/23 at 8:20 A.M. revealed Licensed Practical Nurse (LPN) #672 administered six medications to Resident #75 with one error. LPN #672 administered vitamin D3 1000 units (one tablet) and the order was for vitamin D3 3000 units (three tablets).

Interview on 05/07/23 at 8:25 A.M. with LPN #672 confirmed she did not administer Resident #75's correct dosage of vitamin D3.

A total of 26 medications were administered with two errors for a medication error rate of 7.69%.

Review of the Medication Administration Times policy revised 10/14 indicated medication administration would be scheduled according to the resident's preference, past history and manufacturer's recommendations and physician orders.

2. Review of Resident #143's medical record revealed she was readmitted on 01/17/23 with diagnoses including diabetes mellitus, endocarditis and muscle weakness.

Review of Resident #143's physician orders revealed an order dated 02/14/23 to administer lispro (fast acting insulin) per sliding scale if the blood glucose test (BGT) was 150 to 200 inject two units; 201 to 250 inject four units; 251 to 300 inject six units; 301 to 350 inject eight units; 351 to 400 inject 10 units and if greater than 401 inject 12 units and call the physician subcutaneously before meals and at bedtime for diabetes.

Review of Resident #166's medical record revealed he was initially admitted on 02/10/21 and readmitted on 03/23/23 with diagnoses including type one diabetes mellitus with hyperglycemia, chronic respiratory failure and major depressive disorder.

Review of Resident #166's physician orders revealed an order dated 03/23/23 revealed to administer lispro per sliding scale and if the BGT was 150 to 200 inject two units; 201 to 250 inject six units, 251 to 300 inject eight units; 301 to 350 inject 10 units, 351 to 400 inject 14 units and call the physician for a BGT above 400 before meals and at bedtime related to type one diabetes mellitus with hyperglycemia.

Observation on 05/07/23 at 11:03 A.M. with LPN #756 completed a BGT test for Resident #143 with a result of 116 and the resident did not require insulin.

Observation on 05/07/23 at 11:07 A.M. revealed LPN #756 sanitized the BGT machine with an alcohol wipe (70% isopropyl alcohol).

Observation on 05/07/23 at 11:08 A.M. revealed LPN #756 obtained Resident #166's blood sugar using the BGT machine with a result of 255. She then sanitized the glucometer with an alcohol wipe.

Observation on 05/07/23 at 11:16 A.M. revealed LPN #756 adminsitered eight units of humalog to Resident #166 for a BGT of 255.

Interview on 05/07/23 at 11:30 A.M. with LPN #756 confirmed she did not have the appropriate sanitizing wipes in the medication cart so she used an alcohol wipe to sanitize the glucometer following Resident #143's blood sugar and then she obtained Resident #166's blood sugar using the improperly sanitized BGT machine. She also confirmed she did not have the appropriate sanitizing wipes for the morning medication pass and she used the alcohol wipes to clean the glucometer after she completed BGT's for Residents #143, #166 and #99 during the morning medication pass. She acknowledged the alcohol wipe did not disinfect the BGT machine to prevent the potential for cross-contamination of blood borne pathogens per the facility policy.

Review of the Blood Glucose Testing policy revised 10/14 indicated to clean the machine with a bleach wipe.

This deficiency represents non-compliance investigated under Complaint Number OH00141614.