PRINTED: 05/20/2015 DEPARTMENT OF HEALTH AND HUMAN ... · HARBOR VILLA CARE CENTER ANAHEIM, CA...

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IDENTIFICATION NUMBER:

STATEMENT OF DEFICIENCIES

AND PLAN OF CORRECTION

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PRINTED: 05/20/2015FORM APPROVED

(X2) MULTIPLE CONSTRUCTION

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DEPARTMENT OF HEALTH AND HUMAN SERVICES

CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391

055742 08/01/2014

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STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER

861 S. HARBOR BLVDHARBOR VILLA CARE CENTER

ANAHEIM, CA 92805

PROVIDER'S PLAN OF CORRECTION

(EACH CORRECTIVE ACTION SHOULD BE

CROSS-REFERENCED TO THE APPROPRIATE

DEFICIENCY)

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SUMMARY STATEMENT OF DEFICIENCIES

(EACH DEFICIENCY MUST BE PRECEDED BY FULL

REGULATORY OR LSC IDENTIFYING INFORMATION)

F 000 INITIAL COMMENTS F 000

The following reflects the findings of the

California Department of Public Health during an

ABBREVIATED survey to investigate

COMPLAINT No: CA00407629.

Inspection was limited to the specific complaint(s)

investigated and does not represent the findings

of a full inspection of the facility.

Representing the California Department of Public

Health: 28908, HFEN; 27007, HFEN; 06845,

HFES; 06783, Branch Chief; and 26819,

Pharmacy Consultant.

The facility was entered on 7/31/14 at 0930

hours, and contact was made with the

Administrator. The census was 86 with one bed

hold.

THE DEPARTMENT WAS ABLE TO

SUBSTANTIATE THE COMPLAINT

ALLEGATION(S).

Glossary:

ADL: Activity of Daily Living

BIMS: Brief Interview for Mental Status

CAA: Care Area Assessment

cm: centimeter(s)

CNA: Certified Nursing Assistant

CNS: Central Nervous System

CVA: Cerebrovascular Accident

DON: Director of Nursing

DSD: Director of Staff Development

IDT: Interdisciplinary Team

LVN: Licensed Vocational Nurse

MDS: Minimum Data Set

mg: milligram(s)

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE

08/28/2014

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that

other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days

following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14

days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued

program participation.

FORM CMS-2567(02-99) Previous Versions Obsolete 25VH11Event ID: Facility ID: CA060000113 If continuation sheet of 28

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F 000 Continued From page 1 F 000

MRI: Magnetic Resonance Imaging (a medical

imaging procedure that uses strong magnetic

fields and radio waves to produce cross-sectional

images of organs and internal structures in the

body)

OT: Occupational Therapy/Therapist

P&P: Policy and Procedure

PRN: As needed

PT: Physical Therapy/Therapist

QAA: Quality Assessment and Assurance

RN: Registered Nurse

RP: Responsible Party

SSD: Social Service Director

UTI: Urinary Tract Infection

F 309

SS=G

483.25 PROVIDE CARE/SERVICES FOR

HIGHEST WELL BEING

Each resident must receive and the facility must

provide the necessary care and services to attain

or maintain the highest practicable physical,

mental, and psychosocial well-being, in

accordance with the comprehensive assessment

and plan of care.

This REQUIREMENT is not met as evidenced

by:

F 309 8/28/14

Based on observation, interview and review of

the clinical record and facility document, the

facility failed to provide the necessary care and

services to ensure the highest practicable level of

psychosocial well-being related to dementia care

and implement person-centered interventions for

six of seven sampled residents (Residents 1, 2,

4, 5, 6 and 7).

- For Resident 2, the facility failed to ensure the


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treating physicians evaluated the resident to

determine a diagnosis of dementia prior to the

administration of psychoactive medications.

- For Resident 7, the facility failed to consistently

communicate in her preferred language, resulting

in functional decline, physical and psychological

distress.

- For Resident 5, the facility failed to have

person-centered interventions.

- The facility diagnosed Residents 1, 4 and 6 with

dementia without clinical indications.

These failures have affected psychosocial

suffering to residents with dementia.

Findings:

1. Clinical record review for Resident 2 was

initiated on 7/31/14. Resident 2 was admitted to

the facility on 3/17/09, with diagnoses, including

senile dementia (decrease in cognitive abilities),

unspecified psychosis and bipolar disorder (mood

swings that range from the lows of depression to

the highs of mania). Review of Resident 2's

admission face sheet identifies her as the

responsible party for her care. Her occupation is

listed as "unknown."

Review of Resident 2's History and Physical

dated 5/23/12, showed a diagnosis of senile

dementia.

Review of Resident 2's physician orders dated

2/12/13, showed an order to administer an Exelon

patch 9.4 mg/24 hours every day for the

treatment of senile dementia. A physician's order

dated 10/8/13, showed an order for the

administration of Zyprexa 2.5 mg every evening

and 5 mg every morning for the treatment of


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psychosis manifested by outbursts of anger.

The www.lexi.com (a web-based internet site)

showed:

a. Exelon patch is used for the treatment of mild,

moderate, or severe dementia associated with

Alzheimer's disease; treatment of

mild-to-moderate dementia associated with

Parkinson's disease. A warning included: may

cause CNS depression which may impair

physical or mental abilities and may exacerbate

or induce extrapyramidal symptoms; worsening of

symptoms (e.g., tremors).

b. Zyprexa is used for the treatment of acute or

mixed mania episodes associated with bipolar I

disorder. A Black Boxed Warning showed elderly

patients with dementia-related psychosis treated

with antipsychotics are at an increased risk of

death compared to placebo. It is not approved for

the treatment of dementia-related psychosis.

Review of Resident 2's MDS dated 5/1/14,

showed she was cognitively intact and had no

behavior episodes. Her active diagnoses included

Alzheimer's and non-Alzheimer's disorders.

Review of Resident 2's Behavior Tracking record

for June, 2014, showed she had 42 episodes of

recurrent outbursts of anger and mood swings.

Review of Resident 2's Psychologist Progress

Note dated 7/17/14, showed the resident had

"very irritated, multiple suspiciousness, symptoms

of senile dementia was apparent in the beginning

of the session."

No documentation was available to show

Resident 2 was evaluated or re-evaluated to

confirm her diagnosis of dementia or for


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alternative methods prior to the administration of

psychoactive medications.

On 7/31/14 at 1205 hours, Resident 2 was

observed in the dining room. She was able to cut

her own food and feed herself.

During an interview on 7/31/14 at 1455 hours,

LVN 4 stated Resident 2 was alert and oriented.

She stated Resident 2 had no behavior episodes

but had tremors of her hands.

On 7/31/14 at 1545 hours, an interview was

conducted with Resident 2. She was alert and

oriented and stated her previous occupations

were a CNA and a clerk. Resident 2 stated she

had hand tremors and was receiving Ativan

(antianxiety) and Cogentin (aid in the treatment of

drug-induced symptoms, including tremor, slurred

speech, anxiety) to control her tremors. She

stated she is able to ambulate with a walker when

assisted by staff.


observed in the dining room waiting for breakfast.

She stated she is an early riser and goes to bed

early.

During an interview on 8/1/14 at 0605 hours, LVN

1 stated Resident 2 has a daily routine. She

stated if the resident's routine is changed, it

messes up the resident's whole day.

During an interview on 8/1/14 at 0615 hours, CNA

2 stated Resident 2 is alert and orient and is able

to make her needs known. She stated Resident 2

always gets up and out of bed by 0500 hours.

CNA 2 stated she is unaware of Resident 2

having angry outbursts. She said Resident 2 is a


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very social person and likes to talk.

During an interview on 8/1/14 at 0700 hours, LVN

2 stated Resident 2 is alert and oriented and able

to make her needs known. She was unaware of

Resident 2 having any behavior episodes, except

that the resident gets upset about gaining weight.

During a telephone interview on 8/1/14 at 0925

hours, Resident 2's psychologist stated Resident

2 has diagnoses, including senile dementia.

When asked how she has determined the

diagnosis of senile dementia, the psychologist

stated she "looked" at the history and physical

completed by Resident 2's physician. The

psychologist stated she did not complete a

mini-mental examination on Resident 2. When

asked if she felt Resident 2 had dementia, the

psychologist stated she would have to do a

further examination to make that determination,

she only took the information from physician's

assessment of Resident 2.


hours, Resident 2's psychiatrist stated Resident 2

has a diagnosis of bipolar affective disorder. He

said Resident 2 has angry outbursts, yells if she

does not get what she wants and is sometimes

unreasonable. The psychiatrist stated Resident 2

has some memory loss but does not have

"full-blow dementia."


1 stated Resident 2 is alert and oriented and able

to make her needs known. She stated Resident 2

sometimes will scream out if the staff does not

attend to her needs fast enough.



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hours, Resident 2's physician stated Resident 2

has "senile dementia." He stated if a resident is

"old and confused, that is dementia." Her

physician stated he could not recall if Resident 2

had any radiology tests to determine dementia.

He stated if the test does not show any (brain)

atrophy, it still can be dementia. Resident 2's

physician stated Resident 2's mentation

fluctuates, some days she is forgetful. He

reiterated dementia is based on a clinical

examination; if old and confused then the resident

has dementia.

On 8/1/14 at 1025 hours, a follow-up interview

was conducted with Resident 2. She stated she

has had a bipolar diagnosis for many years and is

aware she is taking Zyprexa for her bipolar

condition.

During an interview on 8/1/14 at 1340 hours, the

DSS stated Resident 2 is receiving medications

for a bipolar disorder. He stated Resident 2 has

episodes of getting angry and yelling if she does

not get help as soon as she wants it. In addition,

the DSS stated the resident attends the monthly

Behavior Management meetings where the

resident's medications are reviewed by the IDT

and the psychiatrist. He was unaware of the

reason the psychiatrist did not attend the

quarterly QAA meetings. When asked about the

plans of care with dementia residents, the DSS

stated every day he sits down and talks to the

dementia residents for approximately five

minutes.

2a. Clinical record review showed Resident 7 was

an 85 year-old admitted to the facility on 7/11/14,

with multiple diagnoses including history of CVA

(stroke) and dementia. According to the


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Alzheimer's Foundation of America, dementia is a

general term that describes a group of symptoms,

such as loss of memory, judgment, language,

complex motor skills and other intellectual

functions due to permanent damage or death of

the brain's nerve cells, or neurons.

Review of Resident 7's multi-disciplinary MDS 3.0

(a federally mandated assessment for nursing

home residents) dated 7/18/14, showed Resident

7 was Hispanic or Latino but did not identify a

preferred language for communication. Resident

7's cognitive assessment (BIMS) indicated a

score of seven, meaning Resident 7 was severely

cognitively impaired. Resident 7 was assessed to

usually be understood and understand

conversations. Resident 7's MDS assessment

further showed an absence of behavioral

symptoms, such as hitting, kicking, or threatening

others. Resident 7 was able to use a walker with

one-person staff assistance and was assessed to

have no pain.

Review of Resident 7's comprehensive plans of

care showed no language preference. The plan of

care for activities did not show a potential

language barrier.

Review of the facility's P&P titled Care

Plans-Comprehensive, revised in 4/10, showed

"The comprehensive care plan is based on a

thorough assessment that includes, but not

limited to, the MDS. Assessments of residents

are ongoing and care plans are revised as

information about the resident and the resident's

condition change...Each resident's

comprehensive care plan is designed to: a.

Incorporate identified problem areas..."


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Administrator and DON stated the facility's

resident population included primarily English and

Spanish speaking residents.


observed sitting in a wheelchair outside of her

room across from the nursing station by herself

wearing a sling on her right arm and shoulder.

Resident 7 was occasionally verbalizing short

phrases in Spanish and appeared somewhat

anxious and fidgety.

Further review of Resident 7's clinical record

showed the x-ray report dated 7/22/14 (11 days

after Resident 7's admission) indicating a

probable rotator cuff (tendons and muscles that

allow movement of the upper arm) tear of her

right shoulder, an MRI (equipment that uses a

large magnet and radio waves to view body

tissues and diagnose conditions such as torn

ligaments) was ordered. Resident 7's clinical

record contained documentation the MRI was not

performed on 7/29/14, due to "patient very

uncooperative, unable to hold still."

According to

www.webmd.com/fitness-exercise/guide/rotator-c

uff-tear, rotator cuff tears usually cause shoulder

and arm pain.

During a telephone interview on 8/1/14, beginning

at 0935 hours, Resident 7's RP stated her mother

was conversant in Spanish and English, and she

had brought the staff's attention to Resident 7's

right shoulder and arm pain when visiting on

7/21/14. The RP stated she was unable to

accompany Resident 7 when the MRI was

scheduled on 7/29/14, and was told by the staff


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that Resident 7 was not cooperative for the MRI

procedure. Resident 7's RP stated, "she is

different since she came here [to the facility] -

kind of scared."

b. Further clinical record review indicated

Resident 7 had a physician's order dated 7/14/14,

for physical therapy four times weekly.


observed for treatment in the PT department. PT

1 and another staff who spoke only English to

Resident 7 assisted the resident to stand up from

the wheelchair.


Director of Rehabilitation Services stated she had

assessed Resident 7 on 7/14/14, (three days

after admission) and no right arm or shoulder

problem was identified. She further stated since

the 7/22/14 rotator cuff injury, Resident 7 could

no longer use a walker but was wheelchair

bound.


3 stated Resident 7 was cooperative with care

when provided explanation as to what care was

going to be provided. CNA 3 stated Resident 7

was now a two person (not one person) transfer

from the bed due to her unsteadiness and

wheelchair bound. CNA 3 further indicated she

spoke Spanish in response to Resident 7's

preference to speak Spanish or English based on

Resident 7's preference.

On 8/1/14 at 1200 hours, CNA 3 and another

CNA were observed transferring Resident 7 from

her bed to her wheelchair. Both CNAs were

observed speaking English. Resident 7 appeared


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unsteady during the transfer.

c. During an interview on 8/1/14, the Activities

Director confirmed she spoke Spanish to

Resident 7 as she was able to engage Resident 7

better than when she spoke English.

During an interview on 8/1/14, beginning at 1325

hours, the DON confirmed the facility had not

developed a comprehensive plan of care to guide

staff with regard to Resident 7's language

preferences and acknowledged residents with

dementia who prefer speaking Spanish should be

provided care by staff conversant in Spanish. The

DON was unable to explain what behavior

interventions could have been implemented on

7/29/14, to ensure Resident 7 did not refuse the

diagnostic MRI procedure and delay appropriate

and timely treatment. The DON acknowledged

Resident 7's functional decline with regard to her

mobility since the probable rotator cuff tear was

identified on 7/22/14.


initiated on 8/1/14 at 1245 hours. Resident 5 was

admitted in 2008, with diagnoses including

Alzheimer's disease, dementia condition not

classified elsewhere without behavioral

disturbances and status post hip replacement. A

readmission in 2011 included diagnoses of

unspecified schizophrenia, extrapyramidal

disease and abnormal movement disorder.

Resident 5's most recent admission dated 1/8/13,

included diagnoses of unspecified psychosis and

schizoaffective disorder.

Resident 5 was discharged to the acute hospital

on 11/1/12, after she became aggressive,

agitated and was experiencing poor judgement.


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The facility cleared Resident 5 of any medical

issues and sent her to the acute hospital's

emergency department to be evaluated. The

psychiatrist diagnosed Resident 5 with psychosis

not otherwise specified and moderate to severe

medical and psychosocial decline.

Psychology notes dated 5/1/14, showed Resident

5 talked to angels. Instructions to staff included to

encourage expression of feelings and provide

support.

Recent psychiatry notes dated 5/14 to 7/14,

showed Resident 5 had impaired judgement, was

fixated on going home and still had auditory

hallucinations. She was experiencing further

memory loss and becoming accusatory.

a. The Psychotropic Tracking Record, dated

2014, showed Resident 5 still had visual

hallucinations ranging from 1 to 51 per month.

The care plan for risk for increasing confusion

secondary to dementia was initiated on 5/16/14.

The goal was "Resident will not have increased

confusion demonstrated by knowledge of:_____".

The space was left blank, indicating it had not

been personalized for Resident 5. The

approaches were all preprinted with no

person-centered adjustments.

There was a second care plan dated 7/29/14,

addressing altered thought process related to

dementia. The care plan did not have any

person-centered information entered and all

approaches were preprinted and indicated by a

checkmark.

Review of the CAA dated 1/25/14, showed


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Resident 5's cognitive loss and dementia put her

at a risk for decline. The CAA reflected the facility

would care plan the dementia in order to slow or

minimize the decline, avoid complications and

minimize risks.

Review of the SSD notes dated 7/11/14 showed

Resident 5 had confusion due to mental illness.

There were no updates to her care plan and no

indications for non-pharmalogical interventions.

The note further showed she required 24 hour

nursing care and Resident 5 had no unmet needs

at this time.

Review of the Quality of Life Quarterly

Assessment dated 7/9/14, showed Resident 5

was alert and oriented X 3 (person, place and

time) with episodes of confusion. The facility was

to provide Resident 5 with a monthly activity

calendar and encourage and remind her to attend

group activities. Her preferred activities were

listed as group, independent and in room, and

she enjoyed sitting in the front lobby socializing

with others. There was no reference to music or

dance, her favorite activities per her RP. The RP

also mentioned during an interview on 8/1/14, that

Resident 5 was a ballet dancer for a large

internationally known ballet company.

b. On 7/31/14 at 1935 hours, LVN 1 was

observed trying to administer medications to

Resident 5. LVN 1 informed the surveyor it was

her third attempt to give Resident 5 her evening

medication. Resident 5 was sitting on the couch

in the front lobby with her eyes closed. Upon

arousal, Resident 5 refused to get up and go to

her room. Resident 5 told LVN 1 if she wanted

her to take medications, she should have brought

them with her. LVN 1 told Resident 5 she needed


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to be in her room to take her medications. There

was no explanation or documentation as to why

Resident 5 could not take her medications at her

preferred location.

On 8/1/14, clinical record review showed LVN 1

completed a communication form stating

Resident 5 refused to take her medications.

Documentation showed LVN 1 contacted the

physician who ordered laboratory tests to rule out

medical indications for her refusal of medications.

Documentation showed each time LVN 1 offered

Resident 5 medications, at 1800, 1900 and 1935

hours, she documented the resident refused to

go to her room. The LVN documented she

explained the risks and benefits each time and

approached the resident in a calm manner. The

LVN did not say why Resident 5 could not take

her medications in the front lobby.

Review of the facility's P&P titled Documentation

of Medication Administration dated 2001 and

revised 4/07, shows privacy should be provided if

appropriate.

The P&P titled Change in a Resident Condition or

Status dated 2001 and revised 4/07, indicates the

physician should be notified for refusal of

treatments or medications if refused more than 2

consecutive times.

c. On 8/1/14 at 1330 hours, an interview was

conducted with Resident 5's RP. When asked if

he had brought up any issues with the facility, he

stated Resident 5 is always complaining her teeth

hurt. Resident 5 has a smile full of natural teeth

which are quite worn down with brown and black

stains on them.


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Clinical record review on 8/1/14, showed

Resident 5 sees the dental technician at least

quarterly. Review of the Dentition note dated

5/28/14, showed Resident 5 had good motivation

for treatment but refused any x-rays or fillings and

desired treatment on emergency bases only.

There was no documentation to show the nursing

staff was aware of the dental notes.


initiated on 8/1/14. Resident 6 was admitted to

the facility on 6/20/14, with diagnoses, including

depression, dementia - unspecified without

behavior disturbances and unspecified psychosis.

Resident 6 was admitted from the acute care

hospital following a short stay related to recent

falls at her assisted living facility. Her primary

care physician is the facility's Medical Director.

Resident 6 had a neurology consult in the acute

care hospital at the request of her primary care

physician. The neurological evaluation included a

history of psychiatric illness which was "unclear"

and medications which include Risperdal (an

antipsychotic used to treat problem behaviors).

The evaluation further notes Resident 6 was alert

and oriented, and her gross mental status and

speech appear normal. The assessment included

no mention of dementia, psychosis, or any

behaviors.

On admission to the facility, Resident 6 had a

psycho-social assessment form completed and

dated 6/20/14. This form notes her diagnoses

included COPD (an obstructive lung disease),

neuropathy (nerve damage that causes

weakness, numbness and pain) and depression;

and she was her own RP. Resident 6 was noted

to be alert and oriented to person, place, time and


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event; had short-term and long-term memory

intact and had good judgement. The form further

listed she had no history of mental illness,and

referral to psychology and psychiatry will be as

needed. There were no psychology or psychiatry

visits in the clinical record.

The nursing admission and assessment dated

6/20/14, listed Resident 6 was alert and verbal,

able to make decisions and cooperative. There

were no behaviors or altered cognition noted.

The nurse's notes dated 7/31/14, indicated

Resident 6's Risperdal was discontinued per

pharmacy recommendations because Resident 6

did not have any auditory hallucinations.

Review of an IDT note dated 7/1/14, showed

Resident 6 was alert and oriented to person,

place, time and event. The note further states her

outcome was listed as stable, and the team

reviewed all medications and treatment with the

MD__, family__, and the Resident__, although

none were indicated with check marks. Her

pyschotherapeutic drugs were listed as Ambien (a

sleeping pill), Ativan, Celexa (antidepressant) and

Risperdal, with no indication for use, but it was

documented Resident 6 was "recently admitted".

The box indicating the medications continue to be

appropriate and necessary was marked "yes".

Review of Resident 6's CAA sheet dated 7/3/14,

showed a BIMS of 15/15, showing Resident 6

was cognitively intact. The narrative notes

documented psychotropic medications use for

psychotic mood disorder but listed no symptoms

or behaviors.

Review of a care plan for dementia showed the


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plan was initiated on 6/22/14. The only goal was

Resident 6's daily ADL needs would be

anticipated for 3 months. There was no indication

as to which approaches would be used, but they

were all pre-printed.

Review of the care plan for anti-psychotic

medication dated 6/22/14, showed Risperdal was

used for psychotic mood disorder, manifested by

auditory hallucinations, or hearing voices. The

only goal was to have no side effects from the

medication for 3 months. The only approach

indicated was to always approach resident calmly

and unhurriedly and speak in a calm voice. This

care plan was noted to be discontinued on

7/31/14.

A care plan for psychotropic medication dated

7/3/14, had only one goal to show minimal/no

side effects of medication by 90 days. The

appropriate interventions for Resident 6 were all

pre-printed and not person centered.

Review of the PRN psychoactive/psychotropic

assessment flowsheet for the month of July 2014,

showed the only PRN medication used in July

was Ambien which was used every night, with

one exception since it was ordered.

During an interview with Resident 6 on 7/31/14 at

1900, she stated she is unaware of any

diagnoses of memory problems. She stated

everyone with any brain trauma would be forgetful

and the resident was in a coma for a month at

one time. During two days of observations,

Resident 6 was able to recognize and remember

the surveyor, answer questions appropriately,

showed no behaviors and could appropriately

state the schedule of her favorite baseball team.


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Resident 6, being her own RP, was not aware of

any diagnoses, including dementia or psychosis.

5. On 7/31/14, the Administrator was requested

for a list of all their residents with dementia.

Review of the list showed Resident 1's name was

included.


observed laying in bed. The surveyor introduced

herself to Resident 1. The resident stated the

surveyor's name sounded like her name since the

first two letters on the resident's name is the

surveyor's name. The surveyor told Resident 1

her full name and the resident said it is a Spanish

name. The resident then informed the surveyor

she has been staying in bed because she has

been sick the past days with "pneumonia"

(infection of the lungs) and her doctor had

ordered a chest x-ray and an antibiotic. Resident

1 also said she preferred to stay in her room

because of her poor eyesight and she loves

listening to her talking books. She also stated she

loves detective stories like Perry Mason and

Agatha Christie. When asked how she gets her

books, she said the Activity Director gets it for

her. She stated when she is done with the book

that she is listening to, she would wheel herself to

the Activity Director's office to have it exchanged.

On 7/31/14 at 1445 hours, LVN 1 was

interviewed. When asked about Resident 1's

cognition, LVN 1 stated the resident is alert and

oriented.

On 7/31/14 at 1446 hours, clinical record review

for Resident 1 was initiated. Documentation

showed the resident's primary care physician is

the Medical Director. Review of the physician's


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orders confirmed the resident had a chest x-ray

and was started on antibiotic on 7/30/14 for

pneumonia.

On 7/31/14 at 1550 hours, the surveyor went

back to Resident 1's room. When the surveyor

asked the resident if she could enter the room,

the resident said, "Oh it is you .......(surveyor's

name)!" The resident was able to remember the

surveyor's name.

On 8/1/14, review of the clinical record was

continued. Review of the Order Summary Report

dated 6/26/14, and signed by the Medical Director

on 7/7/14, showed the listed diagnoses included

"Dementia CCE w/behavioral disturbances."

Review of the MDS, with an assessment

completion date of 5/2/14, showed under Section

I, one of the resident's active diagnoses in the last

7 days included non-Alzheimer's dementia.

Section C of the same MDS showed a BIMS

score of 15,which is indicative of a cognitively

intact resident.

Further review of the clinical record failed to find a

care plan addressing the resident's dementia nor

was there documented evidence Resident 1 was

evaluated to confirm her diagnosis of dementia.

During two days of observations, Resident 1 was

able to recognize and remember the surveyor,

answer questions appropriately, showed no

behaviors, and could appropriately name the

staff, the years the staff had worked at the facility

and their positions.

On 8/1/14 at 1030 hours, the DON was requested

to find documentation when Resident 1 was first


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diagnosed with dementia and any documentation

of evaluation to confirm her diagnosis of

dementia. At 1400 hours, the DON provided to

the surveyor Resident 1's archived clinical record

and the only reference to dementia in the record

was an OT evaluation dated 10/19/10, and a

podiatry progress note dated 10/8/12.

There was no documentation in the current

clinical record and the archived clinical record

showing Resident 1 was evaluated to confirm the

diagnosis of dementia nor was there

documentation to show the Medical Director has

referred Resident 1 to be evaluated for this

diagnosis.

6. Resident 4's clinical record was reviewed on

8/1/14. Review of the Order Summary Report

dated 7/29/14, showed the listed diagnoses

included "Dementia, unspecified, without

behavioral disturbance", "unspecified

schizophrenia" and "bipolar disorder unspecified."

The medications listed in the Order Summary

Report included Depakote sprinkles 500 mg two

times per day related to bipolar disorder

manifested by laughing loudly to self; lithium

carbonate 300 mg one tablet three times per day

related to unspecified schizophrenia manifested

by persistent expansive mood; and Zyprexa 10

mg two times per day for unspecified

schizophrenia manifested by hallucinations.

Review of the comprehensive care plan showed a

care plan problem, addressing the risk for

increasing confusion secondary to dementia.

Review of the MDS, signed as complete by the

RN Assessment Coordinator on 6/17/14, showed

a BIMS total of 9 (moderately impaired).


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Further review of the clinical record showed no

documented evidence the resident was evaluated

to confirm the dementia diagnosis.

F 497

SS=F

483.75(e)(8) NURSE AIDE PERFORM

REVIEW-12 HR/YR INSERVICE

The facility must complete a performance review

of every nurse aide at least once every 12

months, and must provide regular in-service

education based on the outcome of these

reviews. The in-service training must be

sufficient to ensure the continuing competence of

nurse aides, but must be no less than 12 hours

per year; address areas of weakness as

determined in nurse aides' performance reviews

and may address the special needs of residents

as determined by the facility staff; and for nurse

aides providing services to individuals with

cognitive impairments, also address the care of

the cognitively impaired.


by:

F 497 8/28/14

Based on interview and document review, the

facility failed to ensure staff was educated,

in-serviced and demonstrated competencies in

consistently applying the interventions necessary

to meet the needs of caring for residents with

cognitive impairment and/or dementia. The facility

identified their census as 86 residents with 45

residents having the diagnosis of dementia. This

has the potential for a decline in their medical

condition.

Findings:


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Review of the DSD's In-service Training Program

dated 9/4/13, showed the content of the

in-service program shall be consistent with the

needs of the facility's residents. One of the topics

identified was six hours of "Dementia

Training/Hand in Hand Program (six modules)."

Review of the facility's yearly in-service calendar

for 2014, showed the Dementia/Hand in Hand

Program training was scheduled for January,

March, May, July, August, September and

November, 2014.

Review of the monthly in-service calendars for

January, April, May and July, 2014, showed

identical titles of the in-services for "Dementia

Training/Hand in Hand Program." No indication

was available to alert staff these in-services were

mandatory for all staff. The following was

identified:

1. Review of the DSD's In-service Lesson Plan

and Attendance Record for 1/27/14-1/31/14 titled

"Hand in Hand Dementia Training, What is

Abuse?" showed 83 signatures of staff attending.

The sign-in sheet had four RNs and six LVNs'

signatures. No documentation was available to

identify all staff were given the training from all

three shifts.


and Attendance Record for 4/7/14-4/11/14 titled

"Hand in Hand Dementia Training, Being a

person with dementia: listening and speaking"

showed 59 signatures of staff attending. The

sign-in sheet had two RNs and eight LVNs

'signatures. No documentation was available to

identify all staff were given the training from all

three shifts.


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and Attendance Record for 7/7/14 titled

"Dementia Training" showed 31 signatures of

staff attending. The sign-in sheet had no RN's

signatures and had three LVNs' signatures. No

documentation was available to identify all staff

were given the training from all three shifts.


DSD stated dementia training is mandatory for

"All" staff. He stated the "Hand in Hand" videos

have six modules, and staff was required to

watch. The DSD confirmed the monthly in-service

calendars had identical titles making it difficult for

the staff to identify if the dementia training

in-services were a repeat in-service or an

additional mandatory in-service. The DSD stated

he had no tracking method in place to ensure all

staff had been in-serviced on the Hand in Hand

training videos. In addition, he stated the facility's

skill checks and competencies are not focused

on dementia residents, and he has no follow-up

to ensure staff is competent in caring for

residents with dementia.


SSD stated his background includes

non-pharmacological interventions (i.e.: reality

orientation, art/music therapy, aromatherapy) for

care of the dementia residents. He stated he has

not participated in any staff training for the care of

dementia residents.

F 501

SS=E

483.75(i) RESPONSIBILITIES OF MEDICAL

DIRECTOR

The facility must designate a physician to serve

as medical director.

F 501 8/28/14


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The medical director is responsible for

implementation of resident care policies; and the

coordination of medical care in the facility.


by:

Based on interview and record review, the

Medical Director failed to:

- differentiate dementia diagnoses from elderly

residents who were "old and confused",

- address non-pharmalogical interventions for

residents with dementia, and

- identify the nationally recognized dementia

guidelines the facility had employed.

This causes residents to be diagnosed as having

dementia and receive dementia treatment without

proper medical interventions and evaluations.

Findings:

1. On 8/1/14 at 1000 hours, a telephone

interview was conducted with the Medical

Director. When asked about his definition of

dementia, he stated when a resident is "confused

and old, that is dementia." He stated obtaining a

MRI that does not show atrophy still can be

dementia. The Medical Director reiterated

"dementia is based on clinical: old and confused."

-http://www.ncbi.nlm.nih.gov (web-based internet

site) showed neuroimaging techniques aimed at

studying structural changes of the brain may

provide useful information for the diagnosis and

the clinical management of patients with

dementia. MRI may show abnormalities


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amenable to surgical treatment in a significant

percentage of patients with cognitive impairment.

2. On 7/31/14 at 1725 hours, an interview with the

Medical Director was conducted. He stated often

times people with dementia have psychosis (a

mental state that causes abnormal perceptions

and reality) as well. He further stated the nurses

would call complaining of a behavior, and he

would refer them to the psychiatrist who would

order a medication. When the Medical Director

would come to the facility to make rounds, the

residents would not have behaviors because they

were on medication. He stated, "pharmalogical

interventions help in small doses."

When prompted, the Medical Director stated he

would rule out medical causes of confusion,

including pain, UTI, dehydration, or pneumonia.

If there are no medical reasons for the residents

behaviors he would refer them to a psychiatrist.

When prompted to offer any forms of

non-pharmalogical therapy, the Medical Director

was unable to articulate any kind of intervention.

Towards the end of the interview, the Medical

Director mentioned the nursing home is "the

worst place to be, everyone just sits around" and

it makes residents "angry and anxious". He stated

the residents do better when the family is involved

and when music and animal therapies are used.

Review of the P&P titled Dementia-Clinical

Protocol dated 2005 and revised in 2013, showed

the, "staff and physician will evaluate individuals

with new or progressive cognitive impairment and

help identify symptoms and findings that

differentiate dementia from other causes."

The P&P further showed, "The attending


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physician will retain an active roll by reviewing

consultant medications, addressing medical

issues...and evaluating subsequent progress. The

physician should not simply defer to the

consultant for everything related with dementia

and related behavior problems."

3. During an interview conducted on 7/31/14 at

1725 hours, the Medical Director was asked if he

knew what nationally recognized guidelines the

facility had adopted to promote and improve care

for residents diagnosed with dementia. He was

not aware the facility had adopted any programs

for dementia care.

Review of the P&P titled Dementia-Clinical

Protocol dated 2005 and revised in 2013, did not

reflect the use of the national guidelines which

the administrative staff stated the facility followed

and was not customized to be facility specific.

F 520

SS=E

483.75(o)(1) QAA

COMMITTEE-MEMBERS/MEET

QUARTERLY/PLANS

A facility must maintain a quality assessment and

assurance committee consisting of the director of

nursing services; a physician designated by the

facility; and at least 3 other members of the

facility's staff.

The quality assessment and assurance

committee meets at least quarterly to identify

issues with respect to which quality assessment

and assurance activities are necessary; and

develops and implements appropriate plans of

action to correct identified quality deficiencies.

F 520 8/28/14


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A State or the Secretary may not require

disclosure of the records of such committee

except insofar as such disclosure is related to the

compliance of such committee with the

requirements of this section.

Good faith attempts by the committee to identify

and correct quality deficiencies will not be used as

a basis for sanctions.


by:

Based on interview and record review, the

facility's QAA Committee failed to ensure

deficiencies identified during the last survey were

not repeated during the current survey. In

addition, the facility identified their census as 86

residents with 45 residents having the diagnosis

of dementia. The facility failed to ensure residents

were accurately evaluated and assessed for

alternative interventions prior to administering

psychoactive medications. This has the potential

for a delay in improvement in resident care.

Findings:

During the facility's recertification survey from

8/27/13 through 8/29/13, the survey team

identified deficiencies regarding the

administration of antipsychotic medications

without adequate indication and no specific

system to ensure the use of antipsychotic

medications were evaluated (cross reference to

F309). The facility's plan of correction (completion

date of 9/26/13) showed the licensed nurses

would be in-serviced on the facility's P&P for the

use of psychoactive medications, including

documentation of non-pharmacological


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interventions.

During the facility's dementia care special survey

from 7/31/14 through 8/1/14, the survey team

identified quality deficiencies relating to the care

of residents with dementia and the use of

antipsychotic medications prior to evaluating

non-pharmacological interventions for residents

with dementia. No documentation was available

to show dementia residents were accurately

evaluated and assessed for alternative

interventions prior to administering psychoactive

medications

During an interview and facility document review

on 8/1/14 at 1415 hours, the Administrator

reviewed the facility's QAA reports since prior

survey of 8/29/13. She was unable to locate

documentation to show the QAA Committee had

developed an action plan for the care of dementia

residents. The Administrator stated last week a

plan was developed for the evaluation and

alternative interventions for the care of dementia

residents and the plan will be reviewed and

discussed during the August 2014 meeting. She

confirmed the psychiatrist did not attend the QAA

meetings to assist in the care and treatment of

dementia residents.


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