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Iowa Department of Inspections and Appeals Health Facilities Division

Citation

of 26 Facility Administrator Date If, within thirty (30) days of the receipt of the citation, you (1) do not request a formal hearing or withdraw your request for formal hearing, and (2) pay the penalty, the assessed penalty will be reduced by thirty–five percent (35%) pursuant to Iowa Code section 135C.43A (Supp. 2009).

FC#6307 Date: October 13, 2016

Trinity Center at Luther Park

Survey Dates: September 1,6-8,13-15,19-22, 2016

1555 Hull Avenue

Des Moines, Iowa 50316

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56.6(1) + 58.28(3)e

481-56.6 (135C) Treble and double fines. 56.6(1) Treble fines for repeated violations. The director of the department of inspections and appeals shall treble the penalties specified in rule 481-56.3(135C) for any second or subsequent class I or class II violation occurring within any 12-month period, if a citation was issued for the same class I or class II violation occurring within that period and a penalty was assessed therefor. 481—58.28 (135C) Safety. The licensee of a nursing facility shall be responsible for the provision and maintenance of a safe environment for residents and personnel. (III) 58.28(3) Resident safety. e. Each resident shall receive adequate supervision to ensure against hazard from self, others, or elements in the environment. (I,II, III) DESCRIPTION: Based on observation, record review and staff interview, the facility failed to provide adequate supervision and assistive devices to mitigate the risk for elopement, falls and resident to resident altercations. (Resident #2, #3, #4, #6, #13 and #17) The facility reported a census of 116 residents and the sample consisted of 17 residents. Findings include: Resident #2/elopement

I

$30,000 (trebled at $10,000 x 3) Held in suspension

Upon Receipt


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According to the Minimum Data Set (MDS) assessment with a reference date of 7/10/16, Resident #2 had short and long term memory problems and severely impaired cognitive skills for daily decision making. Resident #2 required extensive assistance to total dependence on staff with dressing, toilet use and personal hygiene needs. Resident #2 was independently mobile and wanders daily. Resident #2's diagnosis included non-Alzheimer's dementia, aphasia (inability to communicate and formulate language) and arthritis. The MDS indicated the resident had behaviors of rejecting care 1-3 days of the assessment period and wandering each day. An Elopement Assessment form dated 7/11/16 indicated Resident #2 at risk for elopement. The Care Plan dated 7/20/16 noted Resident #2 at risk for elopement due to dementia, history of wandering and exit seeking behavior. The approaches included and directed the staff to redirect Resident #2 away from doors, offering diversion activities and a WanderGuard bracelet to be worn. The August 2016 Treatment Administration Record (TAR) indicated the Wanderguard bracelet to be worn at all times, check function and placement every shift. The TAR indicated Resident #2's WanderGuard in place and functioning properly throughout the entire month of August 2016. The Departmental Notes dated 8/26/16 at 2:34 p.m.


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identified the facility sent Resident #2 to the emergency room following a fall and the resident returned to the facility at 7:00 p.m. The Departmental Notes dated 8/30/16 at 4:06 p.m. (noted as late entry for 6-2 shift) indicated mid-morning a resident's spouse informed nursing staff that on Sunday 8/28/16, spouse saw Resident #2 walking in the front parking lot and he brought Resident #2 back in to the facility. The spouse did not inform anyone at the time. In an interview on 9/1/16 at 12:05 p.m. Staff D, Director of Nursing, stated on 8/30/16 it was discovered Resident #2 had exited the facility without staff's knowledge. Staff D stated Resident #2 would shadow people and walk off the unit behind a guest on 8/28/16. The guest noticed Resident #2 in the parking lot and returned Resident #2 to the unit without notifying staff. The guest reported the incident on 8/30/16. Staff D stated Resident #2 had a Care Plan to wear a WanderGuard bracelet and it is to be checked for placement and functioning status every shift daily (3x). The documentation reflected the checks were conducted, yet there was no WanderGuard alarm sounding when Resident #2 exited the unit and facility on 8/28/16. Staff D stated when checked (8/30/16); Resident #2's WanderGuard was not present. Further investigation found that the WanderGuard was removed during a hospital visit on 8/26/16 and staff failed to ensure the bracelet then replaced upon return from the hospital. Staff D stated she disciplined five staff involved in falsely


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documenting the WanderGuard bracelet was present and functioning from 8/26/16 through 8/30/16. Resident #4, #3 resident to resident altercation According to the Minimum Data Set (MDS) assessment with a reference date of 7/24/16, Resident #4 had short and long term memory deficits and moderately impaired cognitive abilities for daily decision making. The MDS identified the resident as independently mobile, but required extensive assistance with dressing, toilet use and personal hygiene needs. Resident #4 resided in a CCDI (chronic confusion or a dementing illness) unit and had diagnosis including non-Alzheimer's dementia, anxiety and psychotic disorder. The Care Plan dated 8/3/16 noted Resident #4 with potential for impaired social interactions. The approach included and on 8/22/16, directed the staff to keep Resident #4 occupied after the evening meal until Resident #3 goes to his/her room. The Resident Information Sheet (RIS) indicated to Separate from Resident #3 if possible and after evening meal direct Resident #4 into common area bathroom and keep Resident #4 entertained in the common area until Resident #3 walks by an goes to his/her room if possible. According to the Minimum Data Set (MDS) assessment with a reference date of 7/3/16, Resident #3 had a Brief Interview for Mental Status


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(BIMS) score of 3. A score of 3 identified the resident had severely impaired cognitive status. The MDS identified the resident as independently mobile, but required extensive assistance with dressing, toilet use and personal hygiene needs. Resident #3 resided in the CCDI unit. The MDS identified the resident had diagnosis including traumatic brain injury, non-Alzheimer's dementia, anxiety and psychotic disorder. In an interview on 9/14/16 at 10:15 a.m. Staff F, Licensed Practical Nurse, stated on the evening of 8/21/16 at around 5:30 p.m. Resident #3 was walking up the hall and Resident #4 was walking down the hall. As the residents passed one another and without any observed provocation, Resident #4 struck Resident #3 in the chest three times. Staff immediately responded and separated the two residents. Resident #3 was assessed and found without injury. Resident #4 was provided 1:1 supervision the remainder of the shift. Staff F stated Resident #4 was not overtly agitated at the time of the incident. Staff F noted Resident #4 can get agitated and when observed staff will redirect him/her and separate him/her from other residents. Staff F stated she was unaware of Resident #3 ever being aggressive towards another resident. Staff F stated she was not aware of any interventions which address keeping Resident #4 away from Resident #3. In an interview on 9/14/16 at 5:30 p.m. Staff R, certified nurse aide, stated he was in the hallway on 8/21/16 when Resident #4 struck Resident #3 in the


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chest two to three times. Staff R stated it happened without notice. Staff R stated he helped separate the two residents. Staff R stated since the incident, they try to keep Resident #4 and Resident #3 separated and know their whereabouts at all times. Staff R stated he has never known Resident #4 to be aggressive towards other residents. In an interview on 9/14/16 at 5:20 p.m. Staff S, certified nurse aide, stated she has worked at the facility a couple of months. Staff S knew of no interventions related to Resident #4's potential for aggression. Staff S stated they try to redirect Resident #4 when he/she approaches other residents or exit seeks. Staff S was not aware of any interventions regarding keeping Resident #4 separated from Resident #3. In an interview on 9/14/16 at 10:27 a.m. Staff T, certified nurse aide, stated Resident #4 can become agitated with staff when assisting with toileting, but she has never know Resident #4 to direct his/her agitation towards other residents. When Resident #4 becomes agitated, staff will provided 1:1 supervision or redirect in an attempt to get him/her to calm. Staff T knew of no interventions to maintain separation of Resident #4 from Resident #3. In an interview on 9/15/16 at 8:20 a.m. Staff D, Director of Nursing, stated Care Plans are developed by the management team. Staff D stated regarding the altercation between Resident #4 and Resident #3 on 8/21/16, the management


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team discussed moving one of the residents to another unit, but didn't believe this would be in the best interest of either. Resident #3 has a pretty set routine in which he/she only leaves his/her room during meals and promptly returns after meals. Resident #3 has been known to raise his/her voice towards staff. Resident #4 is more known as the protector and seems to want to defend staff from Resident #3. Staff D stated she thought the Care Plan directed staff to keep Resident #4 separated from Resident #3 at meal times. Record review noted one similar incident in which Resident #4 struck Resident #3 in the chest on 5/25/16. Resident #13/fall with fracture According to the Minimum Data Set (MDS) assessment with a reference date of 6/26/16, Resident #13 had a Brief Interview for Mental Status (BIMS) score of 9. A score of 9 indicated a moderate cognitive impairment. Resident #13 required limited assistance with transfers, dressing, toilet use and personal hygiene needs. The MDS identified the resident as independently mobile, but needed supervision. The MDS indicated the resident’s diagnosis included Alzheimer's disease. The Care Plan dated 7/6/16 noted Resident #13 had a potential for falls. The approaches included directed the staff the resident needed stand by assistance as needed when ambulating independently as needed, ensure the reminder is


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located on the wheel walker to remind the resident to use it, lip mattress on bed and perform frequent visual checks in early morning hours. In an interview on 9/15/16 at 9:48 a.m. Staff F, Licensed Practical Nurse, stated on the evening of Friday, 8/26/16, she and other aides had noticed Resident #13 was getting weaker and attempting to self-transfer more often. Staff F feared Resident #13 was becoming a high risk for fall and injury. Staff F suggested to the unit nurse, Staff Q, that they place an alarm on Resident #13. Staff Q stated Resident #13 would likely refuse an alarm. Staff F then contacted Staff C, house coordinator, and asked if they could get an alarm for Resident #13. Staff C instructed Staff F to change Resident #13's status to assist of one with transfers and a personal alarm. Staff F stated she informed Staff Q of the change. Staff Q stated there was no available alarms and Staff F suggested he get an alarm off a dining room chair and Staff Q agreed. On Monday 8/29/16, after supper, Staff F was on A-hall when someone hollered for Staff Q, noting Resident #13 had fallen in his/her room. Staff F assisted with an assessment and assisted with getting Resident #13 in a chair. Staff F discovered later that Resident #13 had fractured his/her hip. In an interview on 9/15/15 at 10:35 a.m. Staff C, household coordinator, stated on the evening of 8/26/16, she received a call from Staff F. Staff F stated Resident #13 was attempting to get up unassisted was weak and Staff F feared he/she might fall. Staff C instructed Staff F to use a


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pressure alarm and make him/her an assist of one with transfers and ambulation. Staff C stated she did not realize until later that Staff F was working on a different hall and Staff Q was actually responsible for Resident #13. In an interview on 9/19/16 at 8:33 a.m. Staff Q, Registered Nurse, stated on the evening of 8/26/16, Staff F instructed him to place an alarm on Resident #13. Staff Q stated he did, but once Resident #13 was in bed he removed the alarm and returned it to the dining room. Staff Q stated Resident #13 was capable of using his/her call light and summoning assistance when needed. Staff Q stated he did not formally make the changes to add an alarm on Resident #13's plan of care, resident information sheets or 24 hour sheets. Nor did he pass on the changes in shift report. In an interview on 9/15/16 at 1:30 p.m. Staff D, Director of Nursing, stated on the evening of 8/26/16 Staff F contacted the on call supervisor, Staff C, and noted Resident #13 was getting weaker and getting up unassisted. Staff C instructed Staff F to make Resident #13 an assist of one staff with transfers and to use a pressure alarm pad in his/her chair. Staff F informed the primary care nurse, Staff Q. The pressure alarm was never initiated and on the evening of 8/29/16, Resident #13 fell in his/her room while attempting to go to the bathroom unassisted. Staff D stated she spoke with Staff Q who admitted Staff F had instructed him to implement a pressure alarm and that those instructions came from a supervisor, Staff C.


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1555 Hull Avenue


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Nevertheless Staff Q didn't believe Resident #13 needed an alarm and therefore did not implement it. Resident #13 returned to the facility and placed on hospice care. Resident #13 expired on 9/4/16. Radiology report dated 8/30/16 identified Resident #13 had an acute fracture at the base of the left femoral neck with foreshortening. Resident #17, #6 resident to resident altercation According to the Minimum Data Set (MDS) assessment with assessment reference date of 7/3/16, Resident #17 had a Brief Interview for Mental Status (BIMS) score of 3 indicating a severely impaired cognitive status. The MDS identified Resident #17 was independently mobile, but required extensive assistance with dressing, toilet use and personal hygiene needs. Resident #17 resides on the CCDI unit. The MDS identified diagnoses including Alzheimer's disease, anxiety and psychotic disorder. The Care Plan dated 7/13/16 noted Resident #17 with potential for confusion and agitation with an approach which included when agitated/aggressive remove residents nearby. Resident Information Sheet (RIS) indicated to separate resident from other residents when he/she is agitated or when other residents are agitated. According to the Minimum Data Set (MDS) assessment with a reference date of 6/26/16,


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1555 Hull Avenue


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Resident #6 had short and long term memory deficits and impaired cognitive abilities for daily decision making. Resident #6 was independently mobile, but required total dependence with dressing, toilet use and personal hygiene needs. Resident #6 resides on a chronically confused demented individual (CCDI) unit and diagnosis included Alzheimer's Disease. In an interview on 9/21/16 at 2:10 p.m. the Director of Nursing, stated on the evening of 9/15/16 the 2 overnight staff went into the room of a resident, while the 2 evening shift aides remained in the commons area. Before the overnight staff returned to the commons area, the 2 evening shift aides left, leaving the residents in the common area unsupervised. Upon returning the 2 overnight aides observed Resident #17 grasping the forearms of Resident #6 as Resident #6 was attempting to free him/herself. The residents were separated without injury. The Director of Nursing stated since the event, the facility has provided 1:1 supervision of Resident #17. The Director of Nursing stated she reviewed the facility video which confirmed the evening aides left the facility leaving the area unsupervised for about 3 minutes. The Director of Nursing stated it was an expectation that when any resident(s) are in the commons area that a staff member be present. FACILITY RESPONSE:


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58.19(2)a

481-58.19(135C) Required nursing services for residents. The resident shall receive and the facility shall provide, as appropriate, the following required nursing services under the 24-hour direction of qualified nurses with ancillary coverage as set forth in these rules:

58.19(2) Medication and treatment

a. Administration of all medications as ordered by the physician including oral, instillations, topical, injectable (to be injected by a registered nurse or licensed practical nurse only); (I,II).

DESCRIPTION:

Based on record review, staff interviews and review of facility policy/procedures, the facility failed to administer medications as ordered by the physician and facility policy/procedures which resulted in a significant medication error (Resident #1). During the investigation, 4 nurses were observed administering 31 medications to 6 residents with zero error. The facility reported a census of 116 residents. Findings include: Resident #1 had a MDS (Minimum Data Set) assessment with a reference date of 8/14/16. The MDS indicated Resident #1 had long and short term memory deficits and severely impaired cognitive status for daily decision making. Resident #1 required total dependence on staff for bed mobility,

I

$6,000 Held in suspension

Upon Receipt


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dressing, toilet use and personal hygiene. The MDS identified the resident’s diagnosis included Alzheimer's disease, psychotic disorder, anxiety, depression and hypertension. The physician orders dated 8/25/16 included to increase Seroquel (antipsychotic medication) to 150 milligrams twice daily. On 9/6/16 at 3:48 p.m. Staff K, Licensed Practical Nurse, was interviewed and stated on 8/25/16 she received an order which included increasing Resident #1's Seroquel from 100 milligrams twice daily to 150 milligrams twice daily. Staff K initiated the medication order process, placing the new order on the medication administration record, notifying the family and faxing the pharmacy of the changes. Staff K stated she left the old dosage bubble pack of Seroquel in Resident #1's supply and assumed when the new dosage bubble pack arrived from pharmacy, they would pull the old bubble pack and return it to the pharmacy per protocol. Staff K stated she informed the on-coming nurse at 2:00 p.m. that the process was not complete. The next morning (8/26/16) Staff K was passing Resident #1 his/her Seroquel and noticed two bubble packs. Staff K stated she thought one bubble pack was 100 milligrams twice daily (old dosage) and the other one said 50 milligrams twice daily (new dosage 150 milligrams). Staff K stated she knew Resident #1 was to get 150 milligrams of Seroquel and thought she administered the correct dose. Staff K stated she was unaware of the error until informed on 8/28/16.


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In an interview on 9/7/16 at 9:57 a.m. Staff J, Licensed Practical Nurse, stated she worked the day shift on 8/27/16 and administered Resident #1's medications. Staff J stated she did not recall whether there was 1 or 2 bubble packs of Seroquel in Resident #1's supply. Staff J stated she checked the bubble pack label with the medication administration record (MAR), but admitted she did not always do it every time. Staff K did not recall whether she checked the labels with the MAR on 8/27/16. On 9/6/16 at 11:47 a.m. Staff L, Licensed Practical Nurse, was interviewed and stated on the morning of 8/28/16 (Sunday) he was setting up Resident #1's medications and noticed Resident #1's Seroquel had been increased from 100 milligrams twice daily to 150 milligrams twice daily on 8/25/16 and both the 100 milligram bubble pack and 150 milligram bubble pack remained in her supply. Staff L noticed the morning 100 milligram doses for 8/26/16 and 8/27/16 had been punched out. Not certain whether the 100 milligram doses had been given, Staff L removed the bubble pack and placed a note on it to bring it to the attention of his supervisor on Monday. Staff L stated he checked Resident #1 and found him/her to be quieter than normal, but not significant. Staff L gave Resident #1 the morning dose of Seroquel. At the end of his shift, Staff L reported the medication error to the on-coming nurse, Staff M. On 9/6/16 at 4:30 p.m. Staff M, Registered Nurse,


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was interviewed and stated she worked the evening shift (2:00 p.m. to 10:00 p.m.) on 8/27/16 and 8/28/16. Staff M did not recall Resident #1 having any issues on 8/27/16. On 8/28/16 shift change report, Staff L reported a medication error in which Resident #1 had received an extra 100 milligrams of Seroquel on both 8/26/16 and 8/27/16. Staff L stated he left a note for his supervisor who was scheduled to come in the next day (Monday). Staff M stated she assumed Staff L had taken care of everything like notifying the physician, family and supervisor. Staff M stated her responsibility was to monitor Resident #1. Staff M stated she checked Resident #1's vital signs around 2:00 p.m. and noticed no changes. Staff M administered the scheduled 4:00 p.m. dose of Seroquel to Resident #1. At 6:00 p.m. Staff M noticed Resident #1 coughing during supper and being lethargic. Staff M checked Resident #1's vital signs and noted a significant drop in blood pressure and an oxygen saturation level of 68%. Staff M administered oxygen and contacted the evening supervisor, who directed her to contact the physician and family. Resident #1 went to the emergency room for an evaluation. The Departmental Notes dated 8/28/16 at 8:49 p.m. and signed by Staff M noted Staff M aware of a medication error involving Resident #1 at shift change report (2:00 p.m.). Resident #1 was monitored and at around 6:00 p.m. a change in condition was noted. Vital signs included a blood pressure 84/49, pulse rate 92 and irregular, respirations 16 and shallow. Oxygen saturation


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level ranging from 68% to 75%. Resident #1 also observed change in sensorium as resident generally loud and restless and now lethargic and quiet. Lips also noted as cyanotic. Administered oxygen at 5 liters per minute. Physician notified and orders to send Resident #1 to the emergency room for an evaluation. The Discharge Summary dated 8/31/16 indicated Resident #1 had an admission date to the hospital on 8/29/16 with unresponsiveness and acute hypoxic respiratory failure. Resident #1 was currently on Seroquel 150 milligrams twice a day and believed he/she might have received a higher dose for her agitation. Resident #1 was found unresponsive, struggling to breath and hypoxic. The nurse placed Resident #1 on oxygen and transferred to the emergency room. There he/she was noted as hypotensive (low blood pressure) in sinus tachycardia (heart rate above 100) and elected to proceed with comfort care. The hospital course noted Resident #1 as admitted for palliative care. On 9/6/16 at 12:45 p.m. Staff N, Licensed Practical Nurse, was interviewed and stated she came into the facility on the evening of 8/28/16 to piece together what had happened to Resident #1. Upon reviewing the records and visiting with Staff M, Staff N discovered Staff K had not removed the old dosage bubble pack of Seroquel from Resident #1's supply and consequently both Staff K and Staff J had administered an extra 100 milligrams of Seroquel to Resident #1 on 8/26/16 and 8/27/16.


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On the morning of 8/28/16 Staff L caught the error and removed the bubble pack from the supply. Staff L failed to fill out a medication error report or notify a physician. Staff L reported the error to Staff M at shift change report. Staff M also failed to report the error or notify a physician. Staff N stated she spoke with Staff K who admitted she likely gave both the 100 milligram dose and 150 milligram dose of Seroquel on the morning of 8/26/16. In an interview on 9/7/16 at 2:43 p.m. Resident #1's nurse practitioner stated Resident #1's death was most likely due to generalized decline related to Alzheimer's disease and a failure to thrive. The nurse practitioner stated she had not yet had an opportunity to thoroughly review Resident #1's entire record; therefore, her opinion was not conclusive. The nurse practitioner stated the extra doses of Seroquel on 8/26/16 and 8/27/16 likely contributed to his/her demise, but noted Resident #1's life expectancy was probably less than a month regardless. In an interview on 9/1/16 at 10:30 a.m. the Director of Nursing, stated the process of noting new medication orders include removing the discontinued bubble packs from the resident's supply and sending it back to pharmacy. The Director of Nursing stated nurses are also expected to follow professional standards when passing medications which include checking the packaging label with the medication administration record three times before administering the medication to ensure accuracy. The Director of Nursing stated


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nurses are also expected to immediately report any suspected medication error to their supervisors and follow medication error protocols. The facility policy and procedures titled Telephone Orders (dated 9/1/16) directed the staff of the following: When a nurse receives a telephone order to change a pre-existing medication order they need to remove the existing medication card from the med cart and return it to the pharmacy bin. The facility policy and procedures titled Administering Medications (date revised 12/2012) included and directed the following: The individual administering the medication must check the label 3 times to verify the right resident, right medication, right dosage, right time, right method (route) of administration before giving the medication.

The facility policy and procedure titled Medication Errors (not dated) included and directed if staff members noting a discrepancy will complete a medication error report, assess the resident and notify the physician and family

FACILITY RESPONSE:


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56.12 + 58.45 + 58.43

481-56.12 (135C) Class I violation as a result of multiple lesser violations. The director of the department of inspections and appeals may issue a citation for a class I violation when a physical condition or one or more practices exist in a facility which are a result of multiple lesser violations of the statutes or rules, but which taken as a whole constitute an imminent danger or a substantial probability of resultant death or physical harm to the residents of the facility. 481-58.45(135C) Dignity preserved. The resident shall be treated with consideration, respect and full recognition of dignity and individuality, including privacy in treatment and in care for personal needs. (II) 481-58.43(135C) Resident abuse prohibited. Each resident shall receive kind and considerate care at all times and shall be free from mental, physical, sexual, and verbal abuse, exploitation, neglect, and physical injury. Each resident shall be free from chemical and physical restraints except as follows; When authorized in writing by a physician for a specific period of time; when necessary in an emergency to protect the resident from injury to the resident or to others, in which case restraints may be authorized by designated professional personnel who promptly report the action taken to the physician; and in the case of an intellectually disabled individual when ordered in writing by a physician and authorized by a designated qualified intellectual disabilities professional for use during behavior modification sessions. Mechanical

I $24,000 (Trebled $8,000 x 3) Held in suspension

Upon Receipt


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supports used in normative situations to achieve proper body position and balance shall not be considered to be a restraint. (II) DESCRIPTION: Based on record review and staff interviews, the facility failed to ensure Residents #3, #6 are kept free from abuse and failed to ensure the residents are treated with dignity and respect by Residents #12 and #4. The facility reported a census of 116 residents. The sample consisted of 17 residents. Findings include: RESIDENT #3 Resident #4 had a MDS (Minimum Data Set) assessment with a reference date of 7/24/16. Resident #4 had short and long term memory deficits and impaired cognitive abilities for daily decision making. Resident #4 was independently mobile, but required extensive assistance with dressing, toilet use and personal hygiene needs. Resident #4 resided in the CCDI (Chronic Confusion or a dementing illness) unit and diagnosis included non-Alzheimer's dementia, anxiety and psychotic disorder. The Care Plan dated 8/3/16 noted Resident #4 with potential for impaired social interactions with an approach which included on 8/22/16 to keep Resident #4 occupied after the evening meal until Resident #3 goes to his/her room.


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The Resident Information Sheet (RIS) used by the aides, indicated to separate from Resident #3 if possible and after evening meal direct Resident #4 into common area bathroom and keep Resident #4 entertained in the common area until Resident #3 walks by an goes to his/her room if possible. According to the MDS assessment with a reference date of 7/3/16, Resident #3 had a Brief Interview for Mental Status (BIMS) score of 3 indicating a severely impaired cognitive status. Resident #3 was independently mobile, but required extensive assistance with dressing, toilet use and personal hygiene needs. Resident #3 resides on a chronically confused demented individual (CCDI) unit and diagnosis included traumatic brain injury, Non-Alzheimer's Dementia, anxiety and psychotic disorder. In an interview on 9/14/16 at 10:15 a.m. Staff F, Licensed Practical Nurse, stated on the evening of 8/21/16 at around 5:30 p.m. Resident #3 was walking up the hall and Resident #4 was walking down the hall. As the resident's passed one another and without any observed provocation Resident #4 struck Resident #3 in the chest three times. Staff immediately responded and separated the two residents. Resident #3 was assessed and found without injury. Resident #4 was provided 1:1 supervision the remainder of the shift. Staff F stated Resident #4 was not overtly agitated at the time of the incident. Staff F noted Resident #4 can get agitated and when observed staff will redirect him/her and separate him/her from other residents.


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Staff F stated she was unaware of Resident #3 ever being aggressive towards another resident. Staff F stated she was not aware of any interventions which address keeping Resident #4 away from Resident #3. In an interview on 9/14/16 at 5:30 p.m. Staff R, certified nurse aide, stated he was in the hallway on 8/21/16 when Resident #4 struck Resident #3 in the chest two to three times. Staff R stated it happened without notice. Staff R stated he helped separate the two residents. Staff R stated since the incident they try to keep Resident #4 and Resident #3 separated and know their whereabouts at all times. Staff R stated he has never known Resident #4 to be aggressive towards other residents. In an interview on 9/14/16 at 5:20 p.m. Staff S, certified nurse aide, stated she has worked at the facility a couple of months. Staff S knew of no interventions related to Resident #4's potential for aggression. Staff S stated they try to redirect Resident #4 when he/she approaches other residents or exit seeks. Staff S stated not aware of any interventions regarding keeping Resident #4 separated from Resident #3. On 9/14/16 at 10:27 a.m. Staff T, certified nurse aide, was interviewed and stated Resident #4 can become agitated with staff when assisting with toileting, but she has never know Resident #4 to direct his/her agitation towards other residents. When Resident #4 becomes agitated, staff would provide 1:1 supervision or redirect in an attempt to


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get him/her to calm. Staff T knew of no interventions to maintain separation of Resident #4 from Resident #3. On 9/15/16 at 8:20 a.m. the Director of Nursing, was interviewed and stated the Care Plans are developed by the management team. The Director of Nursing stated regarding the altercation between Resident #4 and Resident #3 on 8/21/16, the management team discussed moving one of the residents to another unit, but didn't believe this would be in the best interest of either. The Director of Nursing stated Resident #3 has a pretty set routine in which he only leaves his/her room during meals and promptly returns after meals. Resident #3 has been known to raise his/her voice towards staff. Resident #4 is more known as the protector and seems to want to defend staff from Resident #3. The Director of Nursing stated she thought the Care Plan was to keep Resident #4 separated from Resident #3 at meal times. Record review noted one similar incident in which Resident #4 struck Resident #3 in the chest on 5/25/16. Review of Resident #4's Care Plan found no indication Resident #4 had two previous acts of aggression towards another resident or of his/her potential to re-offend. The Care Plan was void of interventions which would ensure Resident #4 and Resident #3 are kept separated at all times. RESIDENT #6


Citation





1555 Hull Avenue


Ds/pg/td/mw

Class Fine Amount

Correction date

According to the Minimum Data Set (MDS) assessment with a reference date of 6/26/16, Resident #6 had short and long term memory deficits and impaired cognitive abilities for daily decision making. The MDS determined Resident #6 as independently mobile, but required total dependence with dressing, toilet use and personal hygiene needs. Resident #6 resides on a chronically confused demented individual (CCDI) unit and diagnosis included Alzheimer's disease. According to the MDS assessment with a reference date of 8/14/16, Resident #12 had short and long term memory deficits and impaired cognitive abilities for daily decision making. The MDS identified Resident #12 as independently mobile and required limited assistance with dressing, toilet use and personal hygiene needs. Resident #12 resides on a CCDI unit and diagnosis included Alzheimer's disease, hallucinations and paranoid personality disorder. In an interview on 9/13/16 at 10:15 p.m. Staff W, certified nurse aide, stated during the early hours on 9/6/16, she and another aide were sitting in the unit hallway to monitor resident activity, when Staff W heard a moaning sound. Staff W responded immediately and discovered Resident #12 standing over the bed of Resident #6 with a pillow pressed across Resident #6's face. Staff W immediately separated the residents and contacted the charge nurse. Resident #12 was shaking and not coherent. Resident #12 was moved to a private room and Staff W was positioned in the hallway to monitor


Citation





1555 Hull Avenue


Ds/pg/td/mw

Class Fine Amount

Correction date

Resident #12. FACILITY RESPONSE:


Citation


iowa department of inspections and appeals health ... · iowa department of inspections and appeals...

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