Stonespring of Vandalia

Based on medical record review, observation, staff interview, and review of the facility policy the facility failed to ensure call lights were accessible to two (Residents #428 and #439) of 28 sampled residents. The facility census was 134.

Findings include:

1. Review of medical record for Resident #428 revealed an admission date of 04/13/24 with diagnoses including chronic obstructive pulmonary disease (COPD), diabetes mellitus, dementia, and atrial fibrillation.

Review of the Minimum Data Set (MDS) assessment for Resident #428 dated 08/19/23 revealed that the resident was cognitively impaired and was dependent on staff assistance for activities of daily living (ADLs.)

Review of plan of care for Resident #428 dated 04/13/24 revealed the resident was at risk for an ADL self-care performance deficit related to atrial fibrillation, COPD, chronic kidney disease, glaucoma, and DM. Interventions included the following: assist with positioning to help maintain proper body alignment, encourage rest periods, keep call light within reach while in room.

Observation on 04/17/24 at 7: 40 A.M. revealed Resident #428 was lying in bed and was awake. Resident #428's call light was on the right side of the bed on the floor, covered in the blanket and falling off the bed.

Interview on 04/17/24 at 7:47 A.M. with Registered Nurse (RN)#154 confirmed Resident #428's call light was not in reach. RN #154 further confirmed Resident #428 was able to use her call light and the resident's call light should be kept within the resident's reach at all times.

2. Review of the medical record for Resident #429 revealed an admission date 04/12/24 with diagnoses including hemiplegia, hemiparesis, DM, cognitive deficit, and hypertension.

Review of plan of care for Resident #429 revealed the resident was at risk for an ADL self-care performance deficit related to hemiplegia, left side weakness, gastric tube, pulmonary embolism, DM, dysphagia, and dysarthria. Interventions included the following: assist with ADLs, encourage rest periods, provide privacy, keep resident's call light within reach while in room.

Observation on 04/17/24 at 8:14 A.M. of Resident #429 revealed the resident was up in her reclining geri chair in her room with the call light on the bed and out of the resident's reach.

Interview on 04/17/24 at 8:14 A.M. with RN #154 confirmed Resident #429 was able to use the call light to summon assistance but the call light was out of reach. RN #154 confirmed Resident #429's call light should be accessible to the resident while in the room.

Review of the facility policy titled Call Lights dated August 2016 revealed the facility maintained a functioning communication system that registered residents' calls from rooms, toilet, and bathing facilities. It was the responsibility of each nurse to ensure the residents' call lights were working and within reach.

Based on medical record review, observation, resident interview, staff interview, and review of the facility policy, the facility failed to ensure carpet in resident rooms was maintained in a clean and sanitary manner. This affected one (Resident #421) of 28 sampled residents. The facility census was 134.

Findings include:

Review of medical record for Resident #421 revealed an admission date of 03/26/24 with diagnoses including skin cancer, atrial fibrillation, and post-traumatic stress disorder (PTSD.)

Review of the Minimum Data Set (MDS) assessment for Resident #421 dated 03/26/24 revealed the resident was cognitively intact and was dependent on staff for assistance with activities of daily living (ADLs.)

Observation on 04/15/24 at 11:00 A.M. of Resident #421's room revealed there were six large dark red stains on the carpet next to television and dresser stand.

Interview on 04/15/24 at 11:00 A.M. with Resident #421 confirmed the stains on the carpet were made when he had fallen, and his blood had dripped all over the floor.

Interview on 04/15/24 at 2:30 P.M. with State Tested Nursing Assistant (STNA) #250 confirmed Resident #421's carpet had six large stains due to the resident had bled on the floor when he fell.

Observation on 04/16/24 at 1:40 P.M. revealed the stains to Resident #421's carpet were present and unchanged from the observation on 04/15/24.

Interview on 04/18/24 at 1:40 P.M. with the Administrator confirmed Resident #421 had bled from a skin tear on 03/30/24 which had resulted in the blood stains to the resident's carpet. The Administrator further confirmed the facility had not removed the blood stains from Resident #421's carpet.

Review of the facility policy titled Residents Rights dated 1987 revealed that residents at a nursing home had the right to provide a safe, and clean-living environment.

Based on medical record review, observation, staff interview, and review of the facility policy, the facility failed to ensure staff followed physician's orders for treatment of pressure ulcers. This affected one (Resident #429) of 17 facility-identified residents with pressure ulcers. The facility census was 137.

Findings include:

Review of medical record for Resident #429 revealed an admission date 04/12/24 with diagnoses including hemiplegia, hemiparesis, type two diabetes, and hypertension.

Review of physician's order for Resident #429 dated 04/12/24 revealed an order for State Tested Nursing Assistant (STNA) to apply Remedy barrier cream after each incontinent episode.

Review of physician's orders for Resident #429 dated 04/17/24 revealed an order to cleanse the pressure ulcer to the resident's sacrum with normal saline, pat dry with sterile gauze, cover with collagen, cover with gauze or abdominal pad, then secure with tape every day and night shift.

Observation on 04/17/24 at 11:10 A.M. revealed Unit Manager (UM) #240 removed an old dressing that was saturated with urine and blood from Resident #429's sacral pressure ulcer. UM #240 performed hand hygiene, then donned gloves and used a peri wipe to clean the peri wound area to sacral pressure ulcer. UM #240 did not clean the wound bed. UM #240 then performed hand hygiene, donned clean gloves and applied Remedy barrier cream to a border gauze dressing which she placed over the resident's sacral pressure ulcer.

Interview on 04/17/24 at 11:12 A.M. with UM #240 confirmed Resident #429 had an order to cleanse the sacral pressure ulcer with normal saline, pat dry with sterile gauze, cover with collagen, cover with gauze or abdominal pad, then secure with tape every day and night shift. UM #429 confirmed she cleansed the peri wound to the resident's sacrum with a peri wipe and she applied Remedy barrier cream to the peri wound and covered the pressure ulcer with a gauze dressing. UM #240 confirmed she did not follow Resident #429's physician's orders for care of the resident's sacral pressure ulcer.

Review of the facility policy titled Skin Integrity Team-Skin Monitoring Process dated January 2023 revealed the facility team would provide care and services to promote healing of pressure ulcers or other skin related issues in accordance with professional standards of care.

Based on medical record review, observation, and staff interview, the facility failed to ensure non-edible products were secured and not accessible to residents with cognitive impairments. This affected one (Resident #94) of two residents reviewed for accidents. The facility census was 134.

Findings include:

Review of the medical record for Resident #94 revealed an admission date of 10/06/22 with diagnoses including dementia without behavioral disturbance, psychotic disturbance, mood disturbance, chronic obstructive pulmonary disease (COPD), acute respiratory failure with hypoxia, and anxiety disorder.

Review of the Minimum Data Set (MDS) assessment for Resident #94 dated 04/02/24 revealed the resident had severely impaired cognition and required supervision for eating, moderate assistance for oral hygiene, maximal assistance for personal hygiene, and was dependent on staff for toileting, bathing, dressing, bed mobility, and transfer.

Review of the plan of care for Resident #94 dated 10/26/22 revealed the resident had impaired cognition and decision-making skills related to dementia. Interventions included the following: administering medications as ordered, ask yes/no questions to determine the resident's needs, cue, reorient, and supervise as needed.

Review of the progress note for Resident #94 dated 03/24/24 revealed the nurse was alerted by the aide that Resident #94 had ingested about two fluid ounces of no-rinse foam cleanser for cleansing and conditioning hair and skin. The facility staff contacted Poison Control and were informed the cleanser was non-toxic, but could cause gastrointestinal issues.

Observation on 04/15/24 at 11:39 A.M. of Resident #94 revealed the resident was lying in bed. There was a bedside table next to the bed, and on the top of the table were various personal care items, including clinical no-rinse foam cleanser.

Interview on 04/15/24 at 11:39 A.M. with Licensed Practical Nurse (LPN) #169 confirmed clinical no-rinse foam cleanser was on the bedside table next to Resident #94.

Based on medical record review, observation, staff interview, and review of the facility policy, the facility failed to ensure gastrostomy tube (g-tube) feedings were administered in a safe and proper manner. The affected one (Resident #86) of seven facility-identified residents with g-tubes. The facility census was 134.

Findings include:

Review of medical record for Resident #429 revealed an admission date of 04/12/24 with diagnoses including hemiplegia, hemiparesis, type two diabetes, cognitive deficit, and hypertension.

Review of plan of care for Resident #429 dated 04/12/24 revealed the resident was at nutritional risk. Interventions included the following: administer tube feeding and flush per orders, maintain the head of the bed elevated 30 degrees during and thirty minutes after tube feeding, monitor and report signs and symptoms of aspiration.

Review of plan of care for Resident #429 dated 04/12/24 revealed the resident required tube feeding related to dysphagia. Interventions included the following: administer tube feed and flush per orders, head of bed elevated 30 degrees during and thirty minutes after tube feed, verify tube placement, monitor for signs and symptoms of aspiration.

Review of physician's orders for Resident #429 revealed an order dated 04/12/24 for the resident to have nothing by mouth.

Review of physician's orders for Resident #429 revealed an order dated 04/17/24 for Glucerna 1.2 per g-tube via continuous pump at 60 milliliters (ml.) per hour.

Observation on 04/17/24 revealed Resident #429 was lying flat in the bed and receiving care with the g-tube pump continuously running at 60 ml per hour.

Interview on 04/17/24 at 11:20 A.M. with Unit Manager (UM) #240 confirmed Resident #429 was lying flat with the tube feeding running. UM #240 confirmed the tube feeding should have been placed on hold while the resident was receiving care which required the head of the bed to be lowered.

Review of facility policy titled Gastric Tube dated March 2012 revealed that a resident who had a gastric tube should have the head of bed elevated at least 30 degrees while the tube feeding was infusing. Staff should turn the pump to the hold position while providing care that required the head of bed to be lowered.

Based on medical record review, staff and resident interviews, and policy review, the facility failed to ensure medications were administered as ordered. This affected one (#134) out of the three residents reviewed for medications. The facility census was 129.

Findings included:

Review of the medical record for Resident #134 revealed an admission date of 03/16/22 with medical diagnoses of hypothyroidism, end stage renal disease, dependence on dialysis, chronic obstructive pulmonary disease (COPD), and diabetes mellitus.

Review of the medical record for Resident #134 revealed a quarterly Minimum Data Set (MDS) assessment, dated 08/17/23 which indicated Resident #134 was cognitively intact. The MDS indicated Resident #134 required limited staff assistance with bed mobility and extensive staff assistance with transfers, toileting, dressing, and bathing.

Review of the medical record for Resident #134 revealed a physician order, dated 08/16/23, for ipratropium-albuterol inhalation aerosol 20-100 microgram (mcg) per actuation (act), one inhalation by mouth three times per day on Monday, Wednesday, and Fridays for COPD.

Review of the medical record for Resident #134 revealed a Medication Administration Record (MAR) for October 2023 which did not contain documentation to support Resident #134 received ipratropium-albuterol inhalation aerosol as ordered on 10/02/23, 10/04/23, 10/09/23, 10/11/23, 10/13/23, 10/16/23, 10/18/23, 10/23/23, and 10/27/23. Review of the MAR for November 2023 revealed no documentation to support Resident #134 received ipratropium-albuterol inhalation aerosol as ordered on 11/03/23, 11/06/23, 11/08/23, 11/13/23, 11/15/23, 11/17/23, and 11/20/23.

Interview on 11/20/23 at 11:05 A.M. with Resident #134 confirmed the nursing staff administer her medications and that she had not received her ipratropium-albuterol inhalation medication as ordered. Resident #134 stated she was told by the nursing staff that the medication had not been delivered by the pharmacy. Resident #134 denied any medical concerns related to not receiving the ipratropium-albuterol inhalation medication as ordered.

Interview on 11/20/23 at 3:00 P.M. with Director of Nursing (DON) confirmed Resident #134 had the ipratropium-albuterol aerosols ordered Monday, Wednesday and Friday routinely and an as needed medication for use other days/times. The DON confirmed Resident #134 did not receive the ipratropium-albuterol aerosol as ordered on 11/03/23, 11/06/23, 11/08/23, 11/13/23, 11/15/23, 11/17/23, and 11/20/23. DON stated the pharmacy changed the medication from an inhaler administration to nebulizer administration and some of the nursing staff were not aware of the change. DON confirmed nursing staff documented the ipratropium-albuterol aerosol as not available from pharmacy as the reason the medication was not given. DON was not able to determine the date in which the pharmacy changed to administration of the medication from an inhaler to via nebulizer.

Interview on 11/21/23 at 1:04 P.M. with DON confirmed Resident #134 did not receive the ipratropium-albuterol aerosol as ordered on 10/02/23, 10/04/23, 10/09/23, 10/11/23, 10/13/23, 10/16/23, 10/18/23, 10/23/23, and 10/24/23.

Review of the policy titled, Administration Oral Medications

Based on observation, medical record review, resident and staff interview, and review of a policy, the facility failed to ensure medications were stored in a safe and secure manner. This affected one (#10) of one residents observed for medications. The census was 130.

Findings include:

Review of the medical record of Resident #10 revealed an admission date of 07/27/23. Diagnoses include hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominate side, anxiety, and depressive disorder.

Review of the Minimum Data Set assessment dated 08/02/23 revealed Resident #10 was assessed with severely impaired cognition.

Review of the October 2023 medication administration record (MAR) revealed Resident #10 was ordered the pain medication aspirin 81 milligrams (mg) one tablet, the supplement levothyroxine 137 micrograms (mcg) one tablet, the supplement selenium 200 mcg one tablet, the supplement vitamin D3 125 mcg one tablet, the antianxiety medication alprazolam 0.25 mg one tablet, the supplement magnesium 500 mg two tablets, the blood pressure medication metoprolol succinate 50 mg one capsule, the supplement sodium chloride one (1) gram one tablet, and the antidepressant venlafaxine 25 mg one tablet.

Observation on 10/18/23 at 9:15 A.M. revealed a small plastic medication cup with 10 unidentified tablets and capsules sitting on Resident #10's breakfast tray. Further observation revealed Resident #10 was eating in her room.

Interview on 10/18/23 at 9:15 A.M. with Resident #10 revealed the resident could not identify any of the medications in the medication cup on her breakfast tray, but stated she thought she was supposed to take them.

Observation and interview on 10/18/23 at approximately 9:30 A.M. with Registered Nurse (RN) #200 verify the medications that were left at Resident #10's bedside.

Review of the facility policy titled, Administration Oral Medications

Based on record review and interview, the facility failed to ensure a resident had the right to refuse treatment and failed to ensure the resident understood the intent of an advanced directive. This affected one (Resident #200) of three residents reviewed for advanced directives. The census was 128.

Findings Include:

Resident #200 was admitted to the facility on 05/05/23. Diagnoses included chronic respiratory failure with hypoxia and chronic obstructive pulmonary disease. Review of her Minimum Data Set (MDS) assessment, dated 08/01/23, revealed she was cognitively intact.

Review of Resident #200 physician orders revealed she had an advanced directive of full code status from admission until 08/01/23. On 08/01/23, it was changed to Do Not Resuscitate Comfort Care (DNRCC) status.

Review of Resident #200 progress notes, dated 08/01/23, revealed a note written by Nurse Practitioner #300 that stated, She is satting [oxygen saturation dropping] in the 50's. Put her on Cpap and told her that she needed to keep that on to hopefully bring oxygen level up. Spoke about being sent to the hospital for evaluation and treatment. She refused. Explained that with her being a full code that we would need to send her. She is alert and oriented. Discussed code status with the resident. Explained that a DNRCC would allow her to stay here and would keep her comfortable. Nurse Practitioner #300 also wrote in the same note, The unit manager and nurse was at the bedside also through the conversation. DNRCC paperwork completed, and the resident signed without difficulty.

During interview on 08/25/23 at 11:05 AM, Nurse Practitioner #300 stated she told Resident #200 that the facility would need to send her to the hospital if she remained a full code status. She also confirmed they spoke to Resident #200 about the DNRCC status, and they would not need to send her to the hospital if she changed her code status to a DNR.

During interview on 08/25/23 at 2:10 PM, Registered Nurse (RN) #301 stated she was in the room when Nurse Practitioner #300 talked to Resident #200 about her current code status. She confirmed that it was relayed to Resident #200 that they would have to send her out to the hospital if she had respiratory distress, and if she remained a full code status.

This deficiency represents non-compliance investigated under Complaint Number OH00145348.