The Gardens of St Francis

Based on observation, medical record review, staff interview, review of the manufacturer's instructions and review of facility policy, the facility failed to ensure insulin pens were primed (removal of air bubbles from the needle and cartridge to ensure accurate dosing) prior to administration. This affected one resident (#32) of three residents reviewed for medication administration. The facility census was 37.

Findings include:

Review of Resident #32's medical record revealed an admission date of 10/19/20. Diagnoses included diabetes mellitus, heart disease, major depressive disorder, and hyperlipidemia.

Review of the physician orders revealed an order dated 10/19/23 for NovoLog FlexPen subcutaneous solution pen-injector (fast-acting insulin) 100 units/milliliter (mL), inject per sliding scale (dependent on blood sugar levels) before meals and at bedtime related to diabetes mellitus. Further review of the physician orders revealed an order dated 01/31/24 that Resident #32 may self-administer oral medications.

Observation on 02/25/25 at 12:21 P.M. of medication administration revealed Licensed Practical Nurse (LPN) #115 checked Resident #32's blood sugar and determined the resident required two units of insulin, per the sliding scale. LPN #115 prepared the NovoLog insulin administration by applying a needle to the pen-injector, dialing the insulin pen to two units, cleansed the area on Resident #32 where the injection would be administered, and proceeded to to administer the two units of insulin without priming the needle. Concurrent interview with LPN #115 verified she did not prime the needle prior to administering the insulin to resident #32. LPN #115 stated she was aware insulin pens should be primed prior to administration but the needles used for the resident's NovoLog pens could not be primed and, if she attempted to prime it, the needle could not be used to administer the insulin.

Interview on 02/25/25 at 2:09 P.M. with LPN Clinical Coordinator (LPN/CC) #200 verified Resident #32's insulin needle should have been primed prior to administration and confirmed she was unaware of any reason that could not be done. While Resident #32 was able to self-administer oral medications, LPN/CC #200 confirmed Resident #32 required a nurse to administer her insulin.

Review of the NovoLog manufacture's administration instructions, revised March 2021, revealed small amounts of air may collect in the cartridge during normal use. To avoid injecting air and ensure proper dosing, turn the dose selector to two units of insulin, hold the NovoLog FlexPen with the needle pointing up, tap the cartridge gently a few times to make any air bubbles collect at the top of the cartridge, keep the needle pointing upwards, press the push-button all the way in until the dose selector returns to zero. A drop of insulin should appear at the needle tip. If not, change the needle and repeat the procedure.

Review of the facility policy titled, Insulin Administration, dated September 2014, revealed the nursing staff would have access to the manufacturer's instructions on all forms of insulin delivery systems prior to their use.

Based on record review, staff interview, and review of the policy, the facility failed to ensure functional assessments were completed annually. This affected three (Residents #11, #12, and #13) of three residents reviewed for functional assessments. The facility census was 37.

Findings include:

1. Review of the medical record for Resident #11 revealed an admission date of 02/27/23 with a readmission date of 04/27/23. Resident #11 was transferred to the hospital on 10/04/24 and remained out of the facility.

Review of the most recent Admit/Readmit Screen, dated 02/27/23, revealed Resident #11 had mild disorientation, moderately impaired judgement and occasionally impaired recall. Additionally, Resident #11 required hands on assist of two staff for transfers, bathing and toileting, hands on assist of one staff for incontinence care, and was totally dependent for ambulation.

Review of the undated service plan for Resident #11 revealed staff should provide personal hygiene assistance for bathing as needed and was hands on for showers.

Further review of the record revealed no annual assessment of Resident #11's ability to perform activities of daily life (ADLs).

2. Review of the medical record for Resident #12 revealed an admission date of 03/18/21 with a diagnosis of Alzheimer's disease.

Review of the Admit/Readmit Screen for Resident #12, dated 07/22/22, revealed she ambulated and transferred independently. Resident #12 was moderately disoriented, had moderately impaired judgement, and regularly impaired recall.

Review of the undated Service Plan for Resident #12 revealed she required assistance with toileting, dressing, and grooming.

Further review of the record revealed no annual assessment of Resident #12's ability to perform ADLs.

3. Review of the medical record for Resident #13 revealed an admission date of 02/01/22 with a diagnosis of dementia.

Review of the Admit/Readmit Screen, dated 04/19/23, revealed Resident #13 had mildly impaired judgement and occasionally impaired recall. Resident #13 required hands on assist of one person for all ADLs.

Review of the undated Service Plan for Resident #13 revealed she required assistance with toileting, dressing, and grooming, and required hands on assistance during showers.

Further review of the record revealed no annual assessment of Resident #13's ability to perform ADLs.

Interview on 10/24/24 at 12:24 P.M. with the Director of Nursing (DON) confirmed the Admit/Readmit Screen evaluation was completed for residents upon admission. The DON further stated the facility did not conduct routine (scheduled) functional assessments, which would include a re-assessment of residents' abilities to perform ADLs. The DON further stated changes in ADLs were assessed on as as-needed basis and reassessments resulted in updates to the Service Plan. The DON further confirmed the Service Plan did not record dates when changes were made.

Interview on 10/24/24 at 3:40 P.M. with Clinical Coordinator #201 and concurrent review of the medical record confirmed the most recent Admit/Readmit Screen was completed on 02/27/23 for Resident #11, on 07/22/22 for Resident #12, and on 04/19/23 for Resident #13.

Review of the undated policy, RCF (Residential Care Facility) Initial and Functional Assessment Policy

Based on medical record review and staff interview, the facility failed to ensure a resident identified at high risk for falls and who required two-assist with toileting was not left alone during toileting. This resulted in actual harm when Resident #11 was left alone in the bathroom during toileting and fell, resulting in a hip fracture. This affected one (Resident #11) of three residents reviewed for falls. The facility census was 37.

Findings include:

Review of the medical record for Resident #11 revealed an admission date of 02/27/23 with a readmission date of 04/27/23. Resident #11 was transferred to the hospital on 10/04/24 and remained out of the facility.

Review of the most recent functional assessment, dated 02/27/23, revealed Resident #11 had mild disorientation, moderately impaired judgement and occasionally impaired recall. Additionally, Resident #11 required hands on assist of two for transfers and hands on toileting, hands on assist of one for incontinence care, and was dependent for ambulation.

Review of the undated service plan for Resident #11 revealed no guidance regarding her requirements for mobility, transfers, or toileting.

Review of the point-of-care system in the electronic medical record, used by Resident Assistants, revealed Resident #11 required two-assist with hands on for transfers, required as-needed personal hygiene assistance, and as-needed assistance with incontinence care and cleaning. The record revealed no guidance regarding standby assistance during toileting.

Review of an amended progress note dated 10/03/24 revealed Resident #11 was found on her knees in the bathroom calling for help. Resident #11 complained of pain to bilateral knees and hips.

Review of a late entry progress note written 10/07/24, and dated 10/04/24, revealed the interdisciplinary team determined Resident #11 was placed on the toilet, and then staff left the room. Resident #11 did not use the call light but attempted to self-transfer and fell in the bathroom. Further review revealed x-rays showed a nondisplaced fracture of the 5th metacarpal and acute intertrochanteric right hip fracture.

Interview on 10/24/24 at 12:24 P.M. with the Director of Nursing (DON) revealed Resident #11 was at high risk for falls and the DON wanted staff to stay with her in the bathroom. The DON confirmed Resident #11's record did not reflect a need for one-on-one (1:1) attendance while actively using the toilet.

This violation represents non-compliance investigated under Complaint Number OH00158938.