HospitalInspections.org

Based on observation, interview, and record review, the facility failed to follow standards of infection control for glove use and hand hygiene for 2 (#s 3 and 4) of six sampled patients; and failed to provide proactive infection control measures, surveillance measures, and training for a community ran store within the facility to mitigate the risk of infection. Findings include:

1. During an observation, interview, and record review on 10/13/20 at 4:03 p.m., an area in the 500 wing of the facility contained: a screen partition midway in the hallway, a table with COVID screening tools that included a questionnaire titled "COVID-19 U-SHOPPE SCREENING LOG", a container of hand sanitizer, and a thermometer. NF3 stated she was the volunteer working in the store for the day. She stated this was her first day working in the store. NF3 stated the store had just reopened last Thursday, and would be scheduled to be open to the community every Tuesday and Friday. NF3 stated she did not have a formal training presented to her by the facility regarding the expectations for how to operate the store and follow COVID requirements. NF3 referred to an instruction list given to volunteers for how to operate the store. Review of the instruction list titled "INSTRUCTIONS FOR OPENING AND CLOSING U SHOPPE DURING COVID YOU AND ALL CUSTOMERS MUST WEAR A MASK" gave instructions that included the process for setting up the area in the hallway so that customers could be screened. The instructions included only 2 to 3 customers in the store at one time. The instructions showed "there are folding chairs available for you to use while testing or people waiting [sic]." The instructions showed no public coming to the store were to use the bathroom in the storage/sorting room, and were not to come by the screen curtain in the hallway in either direction. The instructions showed donated items were to be dated 7 days from the day the individual worked, and to place the items in the store room. Staff member C stated no patients in the facility were allowed to come to the store since the COVID restrictions. Staff member C stated the volunteers working in the store were required to first enter at the ancillary door to be screened. Located on the screening table were two different screening tools. Staff member C had to check to be sure which screening tool was to be used. Staff member C reported the screening tool, dated 5/14/2020, was the one to be used for the store.

During an observation on 10/13/20 at 4:03 p.m., there was a single door that shoppers were to enter and exit through. Signage on the door visible to community members coming to the store showed "ATTENTION STAFF AND VISITORS ALL NORTH ENTRANCES ARE CLOSED TO THE PUBLIC AND TO STAFF." Another sign on the door showed "OPEN" and included "U-Shoppe open if 4 or less cases of covid." There was no signage observed on the entrance door that instructed the public to don a mask before entering, or to maintain a distance of six feet after entering. The entrance did not include information for only 2-3 persons to be in the store at one time. The entrance did not include information regarding the daily number of cases in the community. The door was unlocked when the surveyor accessed it from the outside during the observation. The storage room where the donated items were brought and stored was observed to contain multiple black trash bags filled with clothing items, and open boxes with other household type items. The bags and boxes covered the entire floor of the storage room up to the entrance door leading into the 500 hallway. There was little space between the entrance into the room and the pile of bags and boxes. The pile of bags and boxes were from two to four feet high. There was no access or capability to walk to the other side of the storage room; an individual could only enter just inside the doorway. The bags close to the entrance doorway were taped and dated. The room had a stale odor. Due to the bags and boxes being piled on one another, it was not possible to see if all of them had been labeled with a date of when they were received. Staff member A stated she was not aware the items were being stored in the observed manner and the facility would address it and get the area organized.

During an interview on 10/14/20 at 9:06 a.m., staff members A and C stated the screening tool to be used for the public coming in to the U-Shoppe was the one dated 5/14/2020. Review of the screening tool had an algorithm that applied to patients in the facility and did not apply to the general public coming in to the facility. Staff member A acknowledged that the algorithm section would not apply to general public coming in to shop. Staff members A and C stated if individuals answered yes to the questions on the screening tool, the shopper would be asked to report to their provider if they had a fever or other symptoms, and would not be allowed to shop. Staff member A stated the facility did not have documentation to show what was included in the training for the individuals that volunteered at the U-Shoppe, nor who had received the training. Staff member A stated the facility did have a Facebook page that the community could access regarding the requirements for coming into the facility. Staff member C stated there was no formal process for surveillance in the U-Shoppe area, other than the screening that is done when the public entered, and the instructions that the U-Shoppe volunteers followed.


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2. During an observation on 10/13/20 at 4:14 p.m., staff member N used hand sanitizer, donned gloves, and administered 44 units of HumaLog 75/25 Kwikpen Lispro Pro and Lispro insulin, to patient #4. Staff member N removed her gloves, obtained the HumaLog Lispro Kwikpen, donned gloves, and administered 8 units to patient #4. Staff member N then removed her gloves and sanitized her hands.

A policy titled "[facility name] & Nursing Home, Inc. Dba [facility name] Infection Control Manual of Policies and Procedures, Subject: Safe Injection Practices C-0278" showed, ... Gloves are removed, disposed of, and hands are cleansed with soap and water or sanitized with alcohol hand sanitizer...



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3. During an observation on 10/13/20 at 2:45 p.m., staff member L was providing toileting and peri care for patient #3. Hand hygiene was not observed before the care was begun. Staff member L had not donned gloves, touched her face mask and grabbed resident #3's walker. Staff member L donned gloves for the toileting process, performed peri care, and doffed her gloves to pull up patient #3's brief and pants. Hand hygiene was not performed between tasks and glove changes.

During an interview on 10/14/20 at 9:20 a.m., staff member L stated she should wash her hands before any patient care.

Review of the facility Policy and Procedure of Handwashing Hand Hygiene, dated 7/19/20, showed:
"Use of an alcohol-based hand rub containing at least 62 percent alcohol; or soap and water for the following situations:"

...b. Before and after direct contact with Patients;
...f. Before donning sterile gloves;
...i. After contact with a resident's intact skin;
...m. After removing gloves...

Due to the degree of the deficient practice, the facility failed to meet the Condition of Participation for Abuse and Neglect.

Based on interview and record review, the facility failed to investigate, protect, and report allegations of abuse. (Refer to 1612 for findings.)

Based on observation, interview, and record review, the facility failed to document, investigate, protect, and report allegations of abuse for 2 (#s 1 and 2) of six sampled patients. Findings include:

1. During an interview on 10/13/20 at 12:06 p.m., resident #1 stated she did not recall any incident with the staff at the facility, and said she had no concerns.

During an interview on 10/13/20 at 1:45 p.m., staff member I stated she had been aware of an incident on 9/16/20 involving patient #1 and staff member H. Staff member I received a verbal report from staff member N, that staff member H had been abusive to resident #1 during care that morning. The incident was described as a "bonk" to the head of patient #1. Staff member I stated she visited with patient #1 approximately three hours later. Patient #1 said morning cares were fine, and she did not remember anything unpleasant. Staff member I stated patient #1 did have short term memory loss. Staff member I stated she did not report the incident because it did not fit the definition of abuse. She said if patient #1 had confirmed the allegation, there would have been a full blown investigation and reported to the State Agency.

During an interview on 10/13/20 at 2:45 p.m., staff member N stated NF1 had reported the alleged abuse to her on 9/16/20, after morning cares were provided to patient #1. NF1 was in patient #1's room with staff members H and O.

Review of a typed statement, dated 10/9/20, by staff member I, showed she observed no indication of distress or injury and observed no facial expression or body language that might indicate mistreatment had occurred even if patient #1 had not remembered the event. Staff member I reported back to staff member N, the nurse on duty, that patient #1 had denied being mistreated.

During an interview on 10/13/20 at 1:20 p.m., staff member N stated the incident was "A-typical" and the investigative and reporting procedures were not followed.

During an interview on 10/13/20 at 1:50 p.m., staff member H denied the allegation involving patient #1, and stated hitting a patient's head would be inappropriate.

Review of patient #1's nursing progress notes showed no documentation of the incident on 9/16/20. The facility did not investigate the incident until a notification from Adult Protective Services was received on 9/28/20, with the intent to investigate a referral received on 9/16/20 regarding the allegation of physical abuse of patient #1.

During an interview on 10/13/20 at 2:00 p.m., staff member stated C staff member NF1 was a traveling CNA, and new to the building. She had been struggling with the job, so was assigned a mentor (staff member H). Staff member C was not in the building on 9/16/20, and became aware of the incident on her return. She stated the incident was not reported as an abuse allegation, because the allegation was "not taken seriously" by facility staff. She stated the nurse should have documented the incident. Facility staff perceived NF1 was unhappy and wanted to leave the facility.

During an interview on 10/14/20 at 9:00 a.m., staff member C stated staff member H had not been interviewed by the facility regarding the allegation. Staff member H continued to work her shift. Staff member O, who was also in patient #1's room during morning care on 9/16/20, was not interviewed regarding the incident. Staff member C stated there were no interventions implemented to protect patients from potential abuse.

During a phone interview on 10/14/20 at 10:01 a.m., NF2 stated staff member O denied any knowledge of the incident. Staff member O did not return a phone call and message for the surveyor interview.

a. Review of the facility Freedom from Abuse Policy and Procedure showed "The facility will respond to allegation of abuse by:

Ensuring that all alleged violations are reported immediately, but not later than 2 hours after the allegation is made, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials in accordance with the State Law:

Have evidence that all alleged violations are thoroughly investigated.

Prevent further potential abuse while the investigation is in progress."

b. Review of the facility Abuse Reporting and Investigation Policy and Procedure showed the facility will conduct interviews with the alleged victim, alleged perpetrator, and witnesses.

The facility will respond immediately to protect the alleged victim, and put effective measures in place to ensure that further potential abuse does not occur while the investigation is in process...

. . .Employees of the facility that have been accused of patient abuse will be suspended until the CEO has reviewed the results of the investigation.

The facility did not have documentation of the allegation and investigation of abuse, interviews of staff involved, and evidence of protecting patients from further abuse.

2. Review of staff member H's personnel file showed an Employee Warning Notice, dated 9/30/20, for a violation of facility policies and a "Breach of Confidentiality." The reason for counseling showed "Message sent via Facebook messenger contained pictures of a resident in his brief and identified the resident by name (resident #2). Facebook is not considered a secure method of communication in the healthcare setting and therefore is seen as a HIPAA violation."

The Corrective Plan of Action for staff member H included:
Do not use cell phones in patient care areas.
Do not use social media for communication regarding patients at (facility).

Review of the facility Unusual Occurrence Report Form, dated 9/22/20, showed staff member H had taken pictures of patient #2's brief and sent them via Messenger to prove a point to a co-worker.

During an observation on 10/13/20 at 4:20 p.m., staff member Q was attempting to transfer resident #2 out of his bed with a mechanical lift. His eyes were closed, and he was unable to move or reposition himself. He was only able to say his name when asked questions. Staff member Q stated resident #2 was dependent on staff for all care, and had cognitive impairment.

During an interview on 10/14/20 at 10:30 a.m., staff member C stated the incident was not reported to the State Agency because the facility designated it a HIPAA violation, and not abuse or exploitation.

During an interview on 10/14/20 at 11:30 a.m., staff member A stated no staff education had been provided related to abuse and exploitation for posting resident photographs on social media. Staff member C stated the charge nurses were reporting to her anything regarding staff member H not following facility policies and procedures or mistreatment of patients. She stated she could not monitor staff member H's social media, and the facility was trying to enforce no cell phones in patient areas. Staff members C and A could not say how they were protecting other vulnerable residents from exploitation. Patient #2's family member was not notified of the incident.

During an interview on 10/14/20 at 11:40 a.m., staff member H stated she had received social media training. She stated she had reported to staff member B that she felt patient #2 had been neglected, but the nurse did not back her up, so she took the pictures. She stated she had not received training or education after the incident, but was told to leave her phone in the breakroom.

During an interview on 10/14/20 at 11:59 p.m., staff member C stated the photograph was reported to staff member P, who spoke with staff member H, and wrote the "Unusual Occurrence Report form." Staff member C stated the Report did not address HIPAA, so there was a delay in disciplinary action for staff member H, until 9/30/20. She stated she would expect the acting DON to follow the facility policy and procedure for abuse. The facility has not provided any training on photographs of patients, but the Policy and Procedure showed phones must be left in the breakroom. Nursing staff was monitoring phone use through observations with no other interventions for protecting residents.

During an interview on 10/14/20 at 1:10 p.m., staff member P stated she had talked to staff member H, and told her it was inappropriate to take photographs of residents, and completed the Unusual Occurrence Report Form., dated 9/22/20.

During an interview on 10/14/20 at 1:20 p.m., staff member I stated she was not involved in the incident but had heard about it. She said the facility staff would notify her regarding incidents if a patient was involved. She said the incident was definitely a violation of dignity, privacy, and an abuse situation.