Aviva Glendale

Based on medical record review, observations, video surveillance observation, resident and staff interviews, review of a self-reported incident (SRI), review of written statements, review of an employee file, and review of a facility policy, the facility failed to ensure a resident was free from physical abuse. This affected one (#1) of three residents reviewed for abuse. The census was 51.

Findings include:

Review of Resident #1's medical record revealed an admission date of 11/22/22. Diagnoses included cognitive dysfunction, congestive heart failure, diabetes mellitus, hypertension, and paroxysmal atrial fibrillation.

Review of a nursing progress note dated 12/30/22 at 11:18 A.M. revealed on 12/28/22 an incident was observed between a care team member and Resident #1. Resident #1 was not harmed during the incident and the physician and Resident #1's family were notified.

Review of a SRI dated 12/28/22 revealed an allegation that Nurse Aide (NA) #300 physically abused Resident #1 when she was observed shoving a blanket in Resident #1's face. The facility substantiated the allegation of abuse and closed the investigation on 12/30/22.

Review of Licensed Practical Nurse (LPN) #200's written statement dated 12/28/22 revealed she was standing at the medication cart across from the nurse office and noticed NA #300 trying to get a gray blanket from Resident #1. LPN #200 documented she witnessed Resident #1 remove the blanket from another resident (Resident #3) that was sitting beside her. LPN #200 documented NA #300 came into the living room area and noticed Resident #1 took the blanket off Resident #3 and was trying to get it back. Resident #1 was refusing to let the blanket go so NA #300 took part of the blanket and threw it back over Resident #1's head.

Review of NA #300's written statement dated 12/28/22 revealed Resident #1 took a blanket that did not belong to her and belonged to Resident #3. NA #300 documented she tried to grab the blanket and when Resident #1 pulled it, NA #300 let go and told the nurse.

Review of Operations Specialist (OS) #250's written statement dated 12/28/22 revealed she was walking up the hall toward the living area when she saw NA #300 roughly shove a blanket at Resident #1 and caused Resident #1's hat to come off her head.

Review of the ED's written statement dated 12/28/22 revealed on 12/28/22 at approximately 11:15 A.M., OS #250 informed her she witnessed resident abuse. The ED documented she took NA #300 into her office and informed her that NA #300 saw Resident #1 grab Resident #3's blanket and went to take it back for Resident #3. The ED documented when NA #300 went to grab the blanket from Resident #1 she tugged on it and NA #300 let go. The ED placed NA #300 on administrative leave at that time pending investigation of the incident. The ED documented after watching video of the incident NA #300 approached Resident #1 and tried to grab the blanket, and they played tug-of-war with the blanket before NA #300 shoved the blanket toward Resident #1 knocking Resident #1's hat off her head.

Review of skin assessments dated 12/28/22 at 12:00 P.M., on 12/29/22 at 11:44 A.M., and on 12/30/22 at 9:30 A.M. revealed Resident #1 had no injuries.

A telephone interview was completed on 01/05/23 at 8:59 A.M. with OS #250 and stated she was in the facility that day training when she walked toward the central living area and saw NA #300 had part of a blanket and forcefully pushed it at Resident #1 and her hat came off her head. OS #250 stated she could not believe what she witnessed and as NA #300 was walking away she was mumbling something. OS #250 stated she told the administrative team what she saw and they took NA #300 into an office to get her statement and NA #300 was suspended. OS #250 stated she assessed Resident #1 for injuries on 12/28/22, 12/29/22, and 12/30/22 with no injuries noted and Resident #1 had no change from her baseline as a result of the incident.

Observation of surveillance video on 01/05/23 at approximately 10:00 A.M., with the ED, verified the video was of the common living area of the facility recorded on 12/28/22 and the video had no audio. Further observation of the video revealed Resident #1 was sitting in a chair in the common living area wearing a black baseball style hat and sitting to her left was Resident #3, who was sitting in a wheelchair and was covered with a blanket. At 11:25:52 A.M., Resident #3 stood up from her wheelchair and Resident #1 took the blanket from her and Resident #3 sat back down without incident. At 11:27:20 A.M., NA #300 approached Resident #1 and Resident #3. At 11:27:37 A.M., NA #300 grabbed a portion of the blanket now covering Resident #1 and tried to pull it away from her. NA #300 and Resident #1 began tugging the blanket back and forth when at 11:27:42 A.M., NA #300 pulled the blanket forcefully toward herself jerking Resident #1's arms, and at 11:27:44 A.M., Resident #1 pulled the blanket back from NA #300. At 11:27:55 A.M., NA #300 stopped tugging at the blanket, moved Resident #3 out of her way, and at 11:28:00 A.M. went back to pulling at the blanket on Resident #1. Resident #1 and NA #300 continue to tug the blanket back and forth when at 11:28:04 A.M., NA #300 took the portion of the blanket she had in her hand and threw it at Resident #1 which hit Resident #1 and caused her baseball hat to come off her head. NA #300 then walked away down E Hall and into the nurse office at 11:28:12 A.M. Resident #1 remained in the common living area between 11:25:52 A.M. and 11:37:11 A.M. and was not observed to have any physical injuries or impairments. Resident #1 remained in behavioral control and was observed talking to the ED during this time frame.

Interview on 01/05/23 at 10:31 A.M. with LPN #200 stated she was standing at the medication and was on the telephone with pharmacy to order medications for a resident when she noticed Resident #1 was trying to help Resident #3 as LPN #200 stated Resident #1 was always trying to be helpful to others. LPN #200 stated she saw Resident #3 trying to stand up and at that time Resident #1 took Resident #3's blanket. LPN #200 stated she went over to Resident #3 to have her sit down so she would not fall and at that time Resident #1 had the blanket. LPN #200 stated at some point NA #300 came to the common living area and was trying to take the blanket from Resident #1. LPN #200 stated Resident #1 and NA #300 were tugging the blanket back and forth but Resident #1 would not give it to her. LPN #200 stated NA #300 then took the part of the blanket she was holding and threw it at Resident #1 and it knocked the hat she was wearing off her head. LPN #200 stated she never saw or heard NA #300 do anything like that before and stated OS #250 took over and was talking to the administrative team about the incident because she witnessed it as well. LPN #200 stated Resident #1 did not have any injuries she saw and she had no changes in her behavior or demeanor following the incident.

Review of NA #300 employee file revealed a hire date of 07/21/22 and was also educated on abuse policies and procedures on this date. Further review of NA #300's employee file revealed no prior abuse concerns or disciplinary action related to abuse.

Review of a letter dated 12/29/22 revealed NA #300's employment in the facility was terminated immediately as a result of the recent investigation.

Interview on 01/05/23 at 9:12 A.M. with Resident #1 stated she was never abused by anyone in the facility. Resident #1 stated no staff members were ever rude to her or tried to grab anything away from her. Resident #1 stated she loved staying in the facility and felt safe. Resident #1 had no recollection of the abuse incident during questioning.

Observation on 01/05/23 at 9:12 A.M., at 11:23 A.M., and at 1:45 P.M. revealed Resident #1 was up sitting in the common area interacting with her peer and staff members and had no visible injuries. Resident #1 was pleasant and interacting appropriately with no apparent psychological effects from the incident on 12/28/22.

Interview on 01/05/23 at 3:25 P.M. with the Executive Director (ED) verified she was the staff member responsible for reporting abuse allegations. The ED stated after obtaining the witness statements, and watching the surveillance video, she determined what NA #300 did to Resident #1 was abuse so she reported it.

Review of a facility policy titled, Abuse, Suspected or Reported

Based on medical record review, staff interview, review of the facility incident report, and review of facility policy, the facility failed to provide appropriate care and treatment to Resident #10 when he expressed suicidal thoughts. This resulted in Real and Present Danger with the potential for serious life-threatening harm, injuries, and/or death when Resident #10 reported suicidal ideation to the Executive Director. The Executive Director failed to respond appropriately resulting in Resident #10 attempting to strangle himself using trash bags. Resident #10 was transferred to the hospital for psychiatric stabilization and treatment. This affected one (Resident #10) of three residents reviewed for adequate and appropriate treatment for residents at risk for self-harm. The facility census was 56.

On 10/05/22 at 12:48 P.M., the Executive Director was notified Real and Present Danger began on 10/02/22 at approximately 9:54 A.M. when Resident #10 told the Executive Director he wanted to hurt himself. The Executive Director offered Resident #10 to be seen by the Nurse Practitioner on the following workday. Resident #10 stated tomorrow would be too late and even a couple hours would be too late. Certified Nurse Assistant (CNA) #203 was present during the interaction between Resident #10 and the Executive Director. CNA #203 walked outside with Resident #10 and monitored him until approximately 10:15 A.M., when Resident #10 re-entered the facility and returned to his room. The Executive Director left the facility during this time. No notifications were made to the nursing staff of Resident #10's self-harm statements. On 10/02/22 at 10:25 A.M., Licensed Practical Nurse (LPN) #220 went into Resident #10's room to administer medications and found Resident #10 on the floor, at the foot of the bed laying on his left side. Resident #10 had garbage bags tied around his neck. LPN #220 used scissors to cut the bags from Resident #10's neck. LPN #220 alerted the other nurse of the incident and stayed with Resident #10 until emergency services and police arrived at 10:45 A.M. Resident #10 was transferred to the hospital.

The Real and Present Danger was removed on 10/06/22 when the facility implemented the following corrective actions:

On 10/02/22, Resident #10 was sent to the hospital for evaluation.

On 10/05/22, the Executive Director determined Resident #10 would not be returning to the facility. The Executive Director informed his Power of Attorney verbally and would also be sending a discharge notice via certified mail. The ED also contacted the Social Worker at the hospital and informed him the facility could not accept Resident #10 back to their community.

Observation on 10/05/22 at 1:32 P.M. of all facility areas found no concerns for resident safety or neglect.

On 10/05/22 at 5:00 P.M., the Executive Director began educating all employees on the immediate responsibility to report suicidal ideations. As of 10/06/22 at 6:45 A.M., the Executive Director and the Director of Nursing (DON) had completed in-servicing from Registered Nurse Education Consultant (RNEC) #240. Training was completed for all staff via one-on-one in-service, telephone in-service, and group in-service at shift change for all employees. All 37 employees had completed the in-service training from 10/05/22 through 10/06/22.

Observation on 10/05/22 at 5:20 P.M. of all facility areas found no concerns for resident safety or neglect.

On 10/06/22, the DON had assessed all residents to determine if any other residents were at risk for self-harm. Four additional residents (#12, #25, #35, and #57) were assessed to be at risk and safety plans were developed.

Observation on 10/06/22 at 6:40 A.M. of all facility areas found no concerns for resident safety or neglect.

On 10/05/22 at 5:30 P.M. and on 10/06/22 between 9:02 A.M. and 9:23 A.M., interviews with Caregiver #214, Caregiver #217, Housekeeping Attendant (HKA) #223, HKA #236, LPN #220, and LPN #225 verified they had been in-serviced on 10/05/22 on suicidal risk and reporting.

Observation on 10/06/22 at 9:02 A.M. of all facility areas found no concerns for resident safety or neglect.

Review of the medical records for two additional residents (#11 and #12), who received mental health services, revealed no concerns with any potential for self-harm.

Observation on 10/06/22 at 11:02 A.M. of all facility areas found no concerns for resident safety or neglect.

The DON will monitor staff to ensure understanding of the policy regarding suicide risk and reporting one time per week for four weeks.

Although the Real and Present Danger was abated on 10/06/22, the violation continues as the facility is still in the process of implementing their corrective action and monitoring to ensure on-going compliance.

Findings included:

Review of Resident #10's medical record revealed an admission date of 01/21/19. Diagnoses included urinary retention, dementia, hypertension, and depression.

Review of Resident #10's service plan dated 07/29/22 revealed Resident #10 required level two services which entailed psychosocial prompting, cuing and reminding, including reminders to groom, reminders for meals, and required total assistance with medications. Resident #10 was cognitively intact.

Review of Resident #10's physician orders for the month of September revealed no current medications for depression. An order with the start date of 08/15/21 and discontinuation date of 03/20/22 was found for Seroquel 25 milligrams (mg) half tablet twice a day. It was noted Resident #10's Seroquel was discontinued due to refusals of medications. The nurse practitioner discontinued all medications other than Resident #10's aspirin.

Review of Resident #10's Medication Administration Record (MAR) revealed in March 2022, Resident #10 had documented daily refusals of medications including Seroquel. Resident #10's physician discontinued Seroquel 12.5 mg twice a day on 03/20/22.

Review of Resident #10's Narrative Charting revealed on 10/02/22 LPN #220 found Resident #10 on the floor, at the foot of the bed laying on his left side. LPN #220 asked Resident #10 if he had fallen. He reported no. Resident #10 was assessed for injuries and no injuries were found; however, it was discovered Resident #10 had a garbage bag tied around his neck. LPN #220 used scissors to cut the bag from Resident #10's neck. LPN #220 alerted the other nurse of the incident and stayed with Resident #10 until emergency services and police arrived. Resident #10's Power of Attorney (POA) was notified. Resident #10's physician was notified. His vitals were taken and were within normal limits. Resident #10 was transferred to the hospital for evaluation.

Review of the Incident Report dated 10/02/22 revealed LPN #220 found Resident #10 on the floor, at the foot of the bed laying on his left side at 10:25 A.M. LPN #220 asked Resident #10 if he had fallen. He reported no. Resident #10 was assessed for injuries and no injuries were found; however, it was discovered Resident #10 had a garbage bag tied around his neck. LPN #220 used scissors to cut the bag from Resident #10's neck. LPN #220 alerted the other nurse of the incident and stayed with Resident #10 until emergency services and police arrived at 10:45 A.M. Resident #10's Power of Attorney was notified on 10/02/22 at 10:30 A.M. Resident #10's physician was notified on 10/02/22 at 11:31 A.M. Vitals were taken and were within normal limits. Resident #10 was transferred to the hospital for evaluation. The completed incident report was submitted on 10/02/22 at 11:30 A.M. by LPN #220. The DON reviewed the incident report on 10/03/22 at 9:50 A.M.

Observation on 10/04/22 at 1:00 P.M. found Resident #10 was not in the facility.

Interview on 10/04/22 at 2:00 P.M. with CNA #211 revealed she was familiar with Resident #10. CNA #211 reported Resident #10 was able to make his needs known and he was independent with most of his day-to-day care. CNA #211 reported Resident #10 went out to the hospital for a suicide attempt and had not returned yet. CNA #211 reported she was working the day of the incident but was not working on Resident #10's hallway. She reported Resident #10 had never reported suicidal thoughts to her when she worked with him.

Interview on 10/04/22 at 2:19 P.M. with LPN #225 revealed she was familiar with Resident #10. LPN #225 reported Resident #10 was not cooperative with his medications and he was able to make his needs known. LPN #225 reported redirection worked with him and he had expressed no concerns for suicidal or self-harm thoughts to her.

Interview on 10/05/22 at 8:52 A.M. with LPN #220 revealed she was the nurse who found Resident #10 with the bags tied around his neck on 10/02/22. LPN #220 reported Resident #10 had never expressed suicidal ideation or self-harm thoughts to her. LPN #220 reported on 10/02/22 she entered Resident #10's room for medication administration and found him lying on the floor. He told her he had not fallen, and she found he had clear plastic bags tied together, with one end tied around his neck and the other end tied to the right-hand corner of his bed. LPN #220 reported she called out for help from the other nurse and cut the bags off Resident #10's neck with scissors. LPN #220 reported Resident #10 was not resistant to the removal of the bags and was assessed with no injuries. LPN #220 reported she stayed with Resident #10 until the Emergency Medical Services (EMS) arrived. LPN #220 reported she had learned (after the situation), Resident #10 reported thoughts of suicide to the Executive Director earlier in the morning. LPN #220 reported this information was not provided to her or the other nurse on the floor and no safety checks or increased supervision were done because they were not aware of the risk.

Interview on 10/05/22 at 9:12 A.M. with CNA #203 revealed she was working at the front desk on 10/02/22 when Resident #10 told the Executive Director he wanted to hurt himself. CNA #203 reported it was Sunday and the Executive Director was in the facility. Between 9:30 A.M. and 10:00 A.M., Resident #10 walked up to the front and said he needed to talk to someone. The Executive Director spoke with Resident #10, and he told her he was feeling suicidal. The Executive Director discouraged him from talking like that and said she would be able to get the Nurse Practitioner in to talk with him, but she most likely would not be able to come to the facility until Monday. Resident #10 stated tomorrow would be too late. He said a couple hours would be too late. The Executive Director continued to say don't talk like that, and as she did Resident #10 moved closer to her. CNA #203 stated Resident #10 had never been physically aggressive toward anyone but she stood up so she would be between them because he was obviously angry. CNA #203 reported Resident #10 went outside and she reported she asked him if he wanted company and went with him. They talked for a little bit then Resident #10 went back into the building and back into his room. During this time, CNA #203 reported the Executive Director left the building. CNA #203 reported she was provided no direction to inform the nursing staff of the situation and had assumed the Executive Director had updated them since she had spent some time in the building before leaving and had been walking toward the nurses on the floor when CNA #203 and Resident #10 went outside. CNA #203 reported about ten or fifteen minutes, later LPN #220 was heard yelling for help with Resident #10. Resident #10 had tied three or four clear trash bags together and had tied them around his neck. CNA #203 said when she saw him, all she could think about was he had just told the Executive Director he was going to kill himself. CNA #203 reported LPN #220 was upset and asking why no one told them anything. LPN #220 stated they could have had someone sitting by the door watching him or sitting with him to help prevent this. CNA #203 was with Resident #10 and LPN #220 when LPN #220 cut the trash bags from around Resident #10's neck. CNA #203 reported LPN #220 stayed with Resident #10 until the EMS arrived and took Resident #10 to the hospital.

Interview on 10/05/22 at 9:22 A.M. with the Executive Director revealed Resident #10 had no history of suicidal ideation or attempts. The Executive Director reported they reviewed the camera footage and found on 10/02/22, Resident #10 came up to the front area of the facility at 9:54 A.M. The ED verified Resident #10 told her he was tired of this place, and he was going to hurt himself. The ED reported she talked him down. The ED stated CNA #203 was working at the front desk and heard all of the conversation. Resident #10 went outside, and CNA #203 went with him. The ED stated she had told CNA #203 to call her if she needed anything and to keep an eye on Resident #10. The ED said she then left the facility. The ED reported only herself and CNA #203 were aware of Resident #10's statements. The ED stated she thought CNA #203 informed the nurses of Resident #10's suicidal thoughts. The ED reported she got a call and was informed LPN #220 had found Resident #10 in his room with trash bags tied around his neck and 9-1-1 was called immediately and the EMS was there within seven minutes of the report. The ED stated she had been on a conference call with behavioral health, and they determined they would not be comfortable taking Resident #10 back in the facility. His psychiatric care needs were higher than they were suited for.

Review of the Incident Accident Log from 07/08/22 through 10/04/22 revealed Resident #10's incident was noted to have occurred on 10/02/22. It was noted Resident #10 was found on the floor of his room with garbage bags tied around his neck. The bags were cut away by staff and one-on-one was provided until the EMS arrived and transported Resident #10 to the hospital.

Review of the undated facility policy titled, Resident Abuse and Neglect

Based on record review, staff interview, and policy review, the facility failed to ensure resident's safety and ensure the physician was notified of changes in condition. This affected one (Resident #23) of three residents assessed for elopement and one (#48) of three residents reviewed for change in condition. The facility census was 56.

Findings include:

1. Review of the medical record revealed Resident #23 was admitted on 03/28/22. Diagnosis included aphasia, other amnesia, unspecified dementia without behavioral disturbance, major depressive disorder recurrent, and unspecified fall.

Review of the medical record revealed the record had no elopement assessment.

Review the hospital admission notes dated 03/16/22 revealed on 03/15/22 Resident #23 presented to the hospital for evaluation and treatment of confusion and suicidal ideation. Per Resident #23's daughter and legal guardian he had moved to independent living housing in 2021 and had stated her father had been declining over the last six months but has further declined in the last two weeks. Resident #23 had not been taking his medications for two weeks and had been making suicidal statements that he was going to kill himself. Resident #23 had made suicidal statements just prior to the day that he jumped in front of a car and was hit. Resident #23's daughter reports Resident #23 has a history of suicide attempts by attempting to drown himself in a large river.

Review of a physician note dated 07/01/22 revealed Resident #23 continued to follow with psychiatric services. Resident #23's depression was not controlled and Zoloft was recently increased. Staff reported Resident #23 had been cutting his wanderguard off and ambulating outside the building after meals. Staff were encouraged to keep the resident inside the building due to previous episodes of throwing himself in front of a moving car and being hit due to depression and suicidally. Resident #23 should not be allowed outside the building unless accompanied by staff or family.

Review of a physician order dated 07/08/22 revealed Resident #23 had an order for a wandergaurd with an additional remark stating the resident may not leave the building without supervision.

Review of a psychiatric nurse's note dated 08/30/22 revealed Resident #23 appeared with poor hygiene and dress with difficulty comprehending simple questions. Resident #23 had poor insight and judgement. Resident #23 denied feeling depressed and denies thoughts of self-harm. Reasoning impairment, immediate memory deficit and short term memory are all determined to be severely deficit. Resident #23's psychiatric condition was improving but inadequately controlled.

Interview on 09/22/22 at 9:18 A.M. with Licensed Practical Nurse (LPN) #200 revealed Resident #23 cuts his wanderguard off and the facility tried to keep watch of him. LPN #200 states generally after every meal he goes outside to exercise.

Observation on 09/22/22 at 9:25 A.M. of Resident #23 verified there was no wanderguard in place. Subsequent interview with LPN #200 verified the wanderguard was not in place.

Interview on 09/22/22 at 9:32 A.M., with Aide #201 verified Resident #23 goes outside unattended and walks around the building daily.

Interview on 09/22/22 at 10:42 A.M., with Aide #203 revealed Resident #23 goes outside by himself daily and would walk or jog. Aide #203 does not believe he had a wanderguard on.

Interview on 09/22/22 at 11:46 A.M., with the Assistant Executive Director #300 and Director of Health and Wellness #350. Assistant Executive Director #300 verified there was a verbal contract between the facility and Resident #23's family regarding the resident going outside independently after meals. Assistant Executive Director #300 reported when Resident #23 was first admitted a wandergaurd was placed on the resident but the resident always took it off. Resident #23 has a routine of walking or jogging for five to ten minutes after each meal. Resident #23 walks the same path which includes leaving the facility property. Assistant Executive Director #300 stated it was discussed with Resident #23's daughter and she agreed to allow this. Assistant Executive Director #300 verified there was no written risk agreement in place. Director of Health and Wellness #350 verified a physician order was in place for a wanderguard and for the resident to not be allowed outside unsupervised.

Observation on 09/22/22 at 12:42 P.M. revealed Resident #23 leave the inside of the facility through the front doors unattended. At 12:43 P.M. Resident #23 walked back in and stated it was too cold today.

Interview on 09/22/22 at 12:45 P.M. with Assistant Executive Director #300 verified Resident #23 left the building unattended and returned after determining it was too cold.

Review of the policy titled Resident Elopement and Wandering, effective 04/01/22 revealed any identified concerns related to resident wandering or elopement risk will be communicated to the executive director and/or the Health and Wellness Director as soon as the concern is identified. The ED/Health and Wellness Director will develop a plan to ensure resident safety needs can be met/maintained in the community or assist wth resident and/or the legally authorized responsible part and physician to arrange for an appropriate transfer of the resident. The ED/Health and Wellness Director will be responsible to report concerns related to resident wandering or elopement risk with the resident's physician/primary provider and legally authorized responsible party.

2. Review of the medical record revealed Resident #48 was admitted to the facility on 07/07/20. Diagnosis included atrial fibrillation, dementia, and high blood pressure.

Review of a nurse's note dated 09/05/22 revealed during a phone call with daughter, the daughter expressed concern with the resident being congested and coughing. Resident was assessed and COVID-19 test completed with positive results. The family and the Director of Nursing were notified. The record had no evidence notification was made to Resident #48's physician.

Interview on 09/05/22 at 3:00 P.M., with the Director of Health and Wellness #350 verified there was no documentation the physician was notified of the COVID-19 positive result.

This violation substantiates Complaint Number OH00135797.