cms_SD: 47
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| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 47 | MONUMENT HEALTH CUSTER CARE CENTER | 435032 | 1065 MONTGOMERY ST | CUSTER | SD | 57730 | 2018-03-28 | 740 | G | 1 | 1 | CZRE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, and record review, the provider failed to ensure four of six sampled residents (17, 21, 42, and 58) who exhibited symptoms of mental health instability had been assessed, monitored, and evaluated in a timely manner to ensure their psychosocial well-being. Findings include: 1. Observations, interviews, and record reviews during the survey from 3/12/18 through 3/15/18 and from 3/27/18 through 3/28/18 related to resident 17 revealed his mental health had been unstable with inappropriate behaviors exhibited towards other residents and staff. Those behaviors had created the potential for mental and physical harm towards them and himself. Refer to F550 and F600. 2. Review of resident 21's 11/18/17 revised care plan revealed: *Focus area: I have specific activity preferences. -Goal for that focus area: My activity preferences will be honored when ever possible during my stay in this facility with current interventions through the next review date. -Interventions for that focus area: --Activity staff will provide me with tools to knit or crochet. It is one of my favorite activities. --I enjoy listening to a variety of country music. Invite me to participate in musical activities. --I enjoy reading. I have a subscription to Readers Digest. I will need my glasses when I choose to read. --I have a TV in my room and enjoy the following programs: Wheel of Fortune, Jeopardy, and Dancing with the Stars. --My religion of choice is Catholic. Remind me when rosary is taking place. *She had a focus area regarding her depression and mood. -That focus area did not support: --Her tendency to self-isolate. --The loss of her two children to ensure staff support through her grieving process had occurred. --Her history and involvement with grief counseling prior to her admission. *The staff had not implemented her care plan to support: -Her activity preferences and requests. -A focus area for her grief over the loss of her children. -Interventions for the staff to follow, so they could help the resident manage her loss of those children. Observation and interview on 3/12/18 at 5:22 p.m. of resident 21 revealed: *She had appeared: -Very thin, weak, frail, and her hair was unkempt. -To be able to move her arms without difficulty, but no spontaneous movement of her legs was observed. *She had been: -Laying in her bed best resting. -Awake and talked very little when spoken to. *She had responded with short yes/no answers and closed her eyes frequently. -Her facial expressions remained flat. *At times she had opened her eyes and just stared towards the bathroom door. *The head of her bed had been elevated to approximately thirty-five degrees. *She had scooted down in the bed, so her chin rested on her chest. *Her feet had been hanging over the foot board that was attached to the bed. *There had been a few family pictures on a bulletin board hanging on one of the walls. *She had a small TV that was placed on top of a bedside stand to her right and against the wall. -Other items on the bedside table were a cell phone and Ipad. -All of those items were not within her reach. *There had been no other: -Personal pictures or wall hangings on the other walls located in her area. -Personal items observed in her area. *The TV was not on, and the room was very quiet. *There was a bedside table next to her bed with drinks and a remote control for the TV on it. *She had resided in a shared room. *The divider curtain was opened, so she could look out the window. -That window curtain had only been partially opened. *Her roommate had been sitting in her recliner right next to the divider curtain. -There was no conversation witnessed between the two. *The room was not well lit. Continued observation and interview on 3/12/18 at 5:34 p.m. with resident 21 revealed: *An unidentified staff member brought a tray in containing her supper. *There had been various nutritional items on her tray including sealed containers of juice and yogurt. *The unidentified staff member: -Placed the supper tray on the bedside table and positioned it in front of the resident. -Rolled the head of her bed up further. -Had not: --Attempted to reposition the resident nor asked the resident if she would like to be moved up higher in the bed. --Asked the resident if she wanted the lids on the juice and yogurt containers removed. *The unidentified staff member left the room. *The resident made no response when the surveyor inquired if she was comfortable in that position. *The surveyor asked the resident if she could open the juice and yogurt containers on her own. -The resident stated If I can't open it I will call the staff. *She had shook her head no when asked if she went out to the dining room for supper. Interview on 3/12/18 at 5:49 p.m. with the DON regarding resident 21 confirmed the resident had stayed in bed for most of the meals. She stated, She maybe will get up for lunch. Observation and interview on 3/13/18 from 8:11 a.m. through 8:57 a.m. with resident 21 revealed: *She had: -Been laying in bed. -The same shirt on as the day before, and her hair remained unkempt. -Been positioned higher up in the bed, so her feet were not hanging over the foot board. -Been drinking a cup of coffee. *Her facial affect and appearance remained unchanged when spoken to. *She had not eaten breakfast yet and decided to remain in her bed for that meal. *Her room remained quiet and unchanged from the day before. *Certified nursing assistants (CNA) F and W assisted her with personal care, changed her clothes, and positioned her up higher in the bed. -She refused to get out of her bed. *The activities coordinator stopped in quickly and asked if she would like to attend the resident group meeting. -She declined. *Prior to leaving the room the CNAs and activities coordinator had not: -Made sure her phone and Ipad were moved, so they would have been within her reach. -Offered to turn on her TV or play some music for her. Random observations on 3/13/18 from 9:10 a.m. through 5:15 p.m. of resident 21 revealed: *Her appearance and interactions with her roommate and others remained minimal. *She was: -Out of her bed for approximately an hour the entire day. --That had been during dinner time. -Not observed reading, crocheting, watching TV, listening to music, using her Ipad, or visiting on her phone. *Her cell phone and Ipad always remained out of her reach. *No staff had been observed offering to: -Visit with her between personal care. -Make her room more pleasant and mentally stimulating. -Assist her with moving and stretching her legs and arms. -Assist her with any of the mentally, visual, tactile, and audio stimulating items documented above in her care plan. Interview on 3/13/18 at 5:15 p.m. with resident 21 revealed: *She confirmed: -What activities she participated in and how she spent her day was her choice. -The interventions listed in her care plan for activities were enjoyable to her. -The only staff who had visited with her that day was the CNAs. --That visitation had occurred while they had assisted her with ADLs. -This surveyor had been the only person to stop and visit with her that day. *When asked if: -She would like to use her cell phone and Ipad she had shook her head no. --She stated I didn't ask for them and I don't need it. -She would like to watch TV she shook her head no. -She wished others had stopped and visited with her, she got tears in her eyes and stated Yes. Review of resident 21's medical record revealed: *An admission date of [DATE]. *Her [DIAGNOSES REDACTED]. *She was dependent upon the staff to assist her with all activities of daily living (ADL). *She had a Brief Interview Mental Status (BIMS) score of fourteen indicating she had good memory recall. *She had two children who had passed away within the last two years. *What activities she had participated in outside of her room was her choice. *She had: -Occasional panic attacks when any shortness-of-breath episodes would have occurred. -Recent medication changes to help with her mood and appetite. -Therapy services for strengthening upon admission to the facility. --Those services had been discontinued d/t (due to) the resident's refusal to participate. *On 1/25/18 she had: -Attended the care conference meeting to review her health and any other concerns she might have with the interdisciplinary department team (IDT). -Said she was very depressed and would like to visit with a counselor to help her handle the grief from the passing of her son. *No documentation to support: -An order and referral for grief counseling had been received until 2/1/18. --That order had been obtained per family request and occurred seven days after her own request. -On 1/30/18 and 2/13/18 the staff had informed the physician during those visits of her and the family's request for grief counseling. -The physician had been notified of that request until 3/20/18. --The physician had completed another ordered for the resident to continue with grief counseling. --That order was not obtained until seven days after the surveyor had completed interviews with the staff regarding that request and fifty-five days after her initial request. -The resident had received any type of grief counseling after her request on 1/25/18 until 3/23/18. Review of resident 21's nursing progress notes from 1/25/18 through 3/20/18 revealed: *No documentation to support: -The resident had requested to visit with a counselor regarding the loss of her son. -The physician had been notified of that request until 3/20/18. That had been fifty-five days after her initial request to receive grief counseling. -The resident had been referred to a grief counselor or a priest for mental health support during that time frame. -What action the administrative staff and IDT had done to ensure the resident received some type of grief counseling prior to 3/20/18. -The social service department had been actively involved to ensure the resident had received those services. *On 3/23/18 there was documentation to support (psychologist's name) would have been visiting with the resident on Thursday or Friday of that week. Interview on 3/13/18 at 5:26 p.m. with the activities coordinator regarding resident 21 revealed she: *Confirmed the resident had [MEDICAL CONDITION] and was having difficulties dealing with the loss of her son. *Had not considered putting the resident on a one-to-one list for the staff to see due to: -The resident was: --Capable of making choices on her own and attended those activities of her choice. --Not on end-of-life care. --Her family visited often, and those visits had been included as part of her activities. *Had not: -Considered assessing her room for adequate stimulation. -Recognized the resident was at risk for self-isolating and could have benefited from those one-to-one visits. *She confirmed: -The care plan supported the resident's activity preferences. -The staff had not ensured those interventions had been implemented for the resident on a regular basis and should have. *Agreed they should have been more aware of the resident's activity needs. Interview on 3/14/18 at 8:07 a.m. with the social services coordinator (SSC) S and DON regarding resident 21 revealed: *They confirmed the resident had a tendency to self-isolate and was having difficulties dealing with the loss of her children. *They had been aware: -She had requested to see a grief counselor. -Of the orders for her to receive grief counseling. *They agreed she would have benefited from those services. *The DON was to have followed-up with that request made by the resident on 1/25/18. -She was not sure where they were with that process. *They confirmed the resident had not received any type of mental health support since her admission and request on 1/25/18. Interview on 3/14/18 at 8:45 a.m. with the medical director revealed he had: *Been the resident's primary physician. *Confirmed her record review and the recent loss of children in her family. *Been aware of the order and request for her to seek grief counseling. -He had not followed-up on that request and was unsure as to where they were in that process. Interview on 3/15/18 at 8:15 a.m. with SSC S and the DON confirmed the activities coordinators interview. They agreed the resident had a tendency to self-isolate and would have benefited from staff one-to-one visits. They had no policy on one-to-one visits, as it was considered an intervention. They agreed the care plan should have identified the resident's recent loss of her children with interventions to help support her through that grieving process. Observation and interview on 3/27/18 at 12:35 p.m. with resident 21 revealed: *She remembered the state surveyor from two weeks ago and was excited to see her. *She was: -Laying in bed visiting with her roommate. -Well positioned and had pillows under each arm for further support. *The window curtain was pulled all the way back to allow for better viewing of the outdoors. -The room was very bright and provided a cheerful atmosphere. *The TV was on and was playing country music. *Her bulletin board had been covered with a pretty fabric allowing for a better view of the family photos. *Her Ipad and cell phone had been placed on her bedside table for easy access. *She: -Was well groomed, smiling, and very talkative. -Visited freely about her family that had included her son and mother. -Confirmed the difficulties she was having with the worsening of her depression after her son passed away. -Had been active with grief counseling groups and helping others battling with depression like herself prior to her admission. -Had believed in that process and the importance of what it offered to ensure her healing had occurred mentally. *A gentleman had been in last week to visit with her, and she appreciated it very much. -She stated It was very helpful. *She confirmed: -Her request for grief counseling some time ago. -Her and her family were not made aware of why there had been a delay in providing those services. -Her religion was very important to her, and no one had offered the support of a priest to visit with. -Visiting with a priest would have also helped her depression and healing. -She still continued to make her own choices about going out to meals and which activities she attended. Interview on 3/27/18 at 4:45 p.m. with the DON regarding resident 21 revealed she: *Confirmed: There had been a breakdown in communication and with the process to ensure the resident had received some type of mental health support. -They had not considered having a priest visit with her and should have. *Stated Honestly the process got broken, I did not go back and see what happened and should have. *Was not clear on the entire process to ensure that had occurred for the resident. *Agreed the social service department should have been more involved with mental health concerns for all the residents to ensure follow-through had occurred. *Confirmed the psychologist was in the facility on 3/22/18 to assess and visit with the resident. *Agreed: -There should have been clearer documentation in the medical record to support that visit. -The care plan should have been updated to support a grieving concern. *A policy for behavioral services and mental health had been requested and was not received upon exit from the facility on 3/28/18. Interview on 3/28/18 at 8:05 a.m. with the SSC S regarding resident 21 revealed she: *Confirmed there had been a communication breakdown with the process in making sure the resident received some type of counseling services. *Had not been a part of that process for a few months now. *Was not sure what had caused the change. *Agreed: -As a SSC and resident representative she should have been involved with all the residents and their mental health concerns as delineated in her job description. -She should have had the opportunity to facilitate for the residents and families when mental health concerns and behavioral concerns. -As a SSC her role was vital in ensuring: --Those services were carried through for the mental health well-being of the residents. --The families of those residents were comfortable and kept informed of what is put in place for their loved one. *Stated Currently the HUK (Health Unit Coordinator) will schedule any appointments for counseling services after she has received that order. I have no idea what happens after she receives that order. *Had been involved in completing assessments, monitoring, and documenting on the residents' behaviors. -That process had changed when the changes took place with administration. -Had not been sure why that change had occurred. -Agreed as a SSC reviewing behaviors and monitoring them had been a vital role of hers in the past but had not questioned the change. Interview on 3/28/18 at 12:46 p.m. with the health unit coordinator revealed she: *Confirmed the process the SSC had described in her interview. *Had worked part-time on Monday, Tuesday, and Wednesday. *Had not been aware of any order and request from the family for resident 21 to have grief counseling. -That order had been received on one of her days off. -She had not seen that order. *Reviewed the order in the chart to confirm the DON had written the order, and the charge nurse that day had initialed it. -The charge nurse had notified the family regarding the order. *Stated: -The nurse has the option to schedule the appointments or leave her a copy of the order and I'll take care of it when I return to work. -I have no idea what the nurse did with that order, I never got a copy of it. *Would have confirmed the order with the SSC and physician prior to making an appointment for the resident. -She stated I can't make the determination on who they see. *Would have contacted the families after she made an appointment for the residents. *Confirmed there had been mental health services available for the residents with referrals made. *Stated (Psychologists name) is available and his wife is a counselor. They come to the facility to see the residents. Interview on 3/28/18 at 3:45 p.m. with the administrator revealed he agreed the SSC S played a vital role in the process and advocacy for the residents with mental health concerns and should have been involved. 3. Observation on 3/13/18 at 8:51 a.m. of resident 58 with CNAs F and W during personal care and a transfer revealed: *He had been awake and laying in his bed. *He was very crabby and short tempered with the CNAs while they had assisted him. *They were patient and had explained all the processes involved with the care he required assistance with. *He had continually referred to everything they attempted to assist him with as rules. -He stated There are rules for everything, even wearing shoes in bed. Review of resident 58's medical record revealed: *An admission date of [DATE]. *His [DIAGNOSES REDACTED]. *He had: -Required assistance from the staff to assist him with all ADL. -Been working with therapy department for strengthening, memory recall, swallowing concerns, and mobility. *On 3/13/18 the physician had written an order for [REDACTED]. -The charge nurse working that day had written and noted the order. *He had a BIMS Score of fourteen indicating he had good memory recall and was interviewable. Review of resident 58's nursing progress notes from 2/21/18 through 3/13/18 revealed: *On 3/13/18 at 1:16 p.m. the SSC S had documented: SS spoke with daughter today about reports of (resident 58's name) telling therapies and staff about wanting a gun so he could shoot himself. Daughter states that he is seeing his pastor weekly and had talked honestly about suicide. SS will forward information to nursing to request order for psychologist visit. *No documentation to support: -He had voiced any suicidal ideation's until 3/13/18. -The staff had initiated any type of process or procedure for those [MEDICAL CONDITION]. -A suicidal assessment had been completed on the resident to determine his level of mental instability and if there were concerns for his safety. *No documentation to support the psychologist had been in the facility to see the resident. Review of resident 58's initial and comprehensive 3/2/18 care plan revealed no focus areas with interventions to support a desire to end his life until 3/13/18. Interview on 3/14/18 at 8:50 a.m. with the medical director regarding resident 58 and his [MEDICAL CONDITION] revealed he: *Had been the resident's primary physician. *Had not been surprised about the [MEDICAL CONDITION] voiced by the resident. *Stated With the general population of the residents in the nursing home that have dementia and depression would expect this to happen. *Would have expected the provider to have: -A policy in place or some type of guidelines to follow. -Notified the resident's primary physician. -Them to have some type of monitoring process in place for those situations. On 3/14/18 at 8:00 a.m. the DON had been asked for their policy on residents with [MEDICAL CONDITION] at the times below: *At 8:30 a.m. the surveyor was provided with a policy for the hospital. *At 9:35 a.m. they had given the surveyor a piece of paper with no date or signature on it. -That piece of paper had CRSC Suicidal Ideation Process and Procedure typed on it with steps for the staff to follow in case a resident voiced suicidal thoughts. Interview on 3/14/18 at 9:46 a.m. with the DON revealed: *They had no policy or procedure in place for [MEDICAL CONDITION]. *The MDS assessment coordinator had given the above procedure to her and said that was the facility's protocol. *She confirmed that protocol had not been officially approved by the administrative staff. *She would have expected the staff to have placed any resident who voiced suicidal thoughts on fifteen minute checks. -That statement had been repeated several times. Interview on 3/14/18 at 2:13 p.m. with the DON and MDS assessment coordinator revealed: *On 3/13/18 was the first time they had knowledge resident 58 had of a history suicidal thoughts. *They agreed that type of information should have been available to them upon admission. *The psychologist had been in the facility yesterday to assess and visit with the resident. -They agreed there should have been documentation in his medical record to support that visit. *They were not aware there was no documentation to support the resident had been monitored for [MEDICAL CONDITION]. *Would have expected the staff to initiate one-to-one monitoring to ensure his safety. *The procedure above had not been available for the staff use. *The DON stated I didn't even know we had that, I'm sure the staff don't know we have it either and they should. Interview with resident 58 was attempted multiple times on 3/14/18 from 9:50 a.m. through 3:30 p.m. The resident had been either sleeping, out for a meal, or working with the therapy department. He had refused to visit for long periods at a time with the surveyor and would state repeatedly There are a lot of rules here, I'm hard of hearing, did you need something? Interview on 3/14/18 at 4:15 p.m. with the administrator, DON, MDS assessment coordinator, SSC S regarding resident 58 revealed: *They became aware of the resident's [MEDICAL CONDITION] in a care conference with him and his family on 3/8/18. -That had not been documented. -They agreed they should have documented and followed-up on those comments and concerns and had not. *The SSC S had received an email on 3/12/18 from the therapy department supervisor stating the resident continued to talk about wanting to die, and asking the staff to bring him a gun so he could shoot himself. *The MDS assessment coordinator had been working that day and completed an assessment of the resident to identify any risk of harm. -That assessment had been visual with no documentation found in the medical record to support any type of suicidal or harm risk assessment had been completed. -She stated I used to work with these types of people and he did not appear to be at risk of suicide. -She agreed that assessment should have been documented. *A copy of the therapist's notes had been requested for review. *They had: -Been working with the physicians to support a behavioral resource and service for them to utilize. --That process had been taking a long time d/t the lack of understanding from the physicians and their support to utilize them as a resource. -Access to two psychologists for support and one would have been able to come directly to the facility. --Those services required a referral from the resident's primary physician. -Been aware of the need for those behavioral services in the facility. Interview on 3/15/18 at 8:25 a.m. with licensed practical nurse A regarding resident 58 revealed: *She had been aware he had made comments about wanting to kill himself. -The other nurses had been aware of those comments also. -They had not reported it to the administration. *She stated: -His family said he says it all the time, and that its more out of annoyance. -He will say get me a gun and shoot me when we get him out of bed and when his family is here. *His comments had been sporadic and not daily. *She confirmed they had never charted on his behaviors and voicing wanting to kill himself. -She agreed they probably should have. *They had monitored and documented on him per his usual status. *She stated We are supposed to report these types of comments and situations to the SSC S but we haven't. *She agreed they probably should have to ensure there had been further investigation and assessment for his safety. *She had not been aware of any specific policy or protocol they were to have followed. Interview on 3/15/18 at 9:20 a.m. with the director of rehabilitation revealed: *She had: -Been in the process of locating resident 58's therapy documentation. -Confirmed he had made comments of wanting to go home and shoot himself during his therapy sessions. --Those comments had been sporadic and not daily. *The certified occupational therapist aide had stepped up during the interview and stated He had mentioned to us about bringing in a gun here too, so he could do it here. -That comment had happened last week. Review of the 3/12/18 at 2:05 p.m. email sent to the SSC S from the director of rehabilitation revealed: I want to let you know that (resident 58's name) continues to talk about wanting to die, that he wants to go home and kill himself, asks for a specific gun for someone to bring so he can shoot himself. Can we adjust or start an antidepressant? Can he see someone with (behavioral services name)? Any other suggestions? Review of resident 58's 3/13/18 therapy progress note entered by the physical therapist aide revealed: Pt (resident) continues to make comments about wanting to go home and shoot himself. or how he wishes he'd have another stroke so he can just die. Social Worker and Staff and family are aware of these suicidal thoughts and comments. Interview on 3/15/18 at 11:00 a.m. with the DON revealed: *She: -Had not been aware the staff nurses knew he had [MEDICAL CONDITION]. -Would have expected them to document on it and refer those concerns to the administrative staff. -Would have expected some type of monitoring to have occurred. -Would have expected the staff to have taken his comments seriously to ensure his safety and well-being. -Stated We can do fifteen minute checks, ect. On 3/15/18 at time the surveyor's left the facility there had not been any monitoring for [MEDICAL CONDITION] put in place for resident 58. Interview on 3/27/18 at 1:00 p.m. with CNA F regarding resident 58 revealed she: *Had been aware of his statements regarding suicidal ideation's. *Stated: -He does voice suicidal thoughts of 'just shoot' me when we help to the bathroom and stuff. -It's more in general, I don't think it's in a serious way. -We are to watch him for these comments and behaviors. *Was to have reported those comments of suicidal ideation to the charge nurse. Follow-up interview on 3/27/18 at 11:12 a.m. with the physical therapy assistant and certified occupational therapy assistant regarding resident 58 revealed they: *Confirmed he made sporadic comments of wanting to be dead and wanting to go home to kill himself. *Had been doing a co-treatment with him on 3/13/18 when they had reported his comments, to the nursing department. -The PTA had charted his comments, and the COTA informed the nursing department. *Were not aware of what the nursing department had done after it was reported, but his behaviors had improved. Interview on 3/27/18 at 5:25 p.m. with the DON regarding resident 58 revealed she:*Agreed the nursing department had not taken his comments of suicidal ideation as serious as the therapy department had. -She would have expected them to. *Confirmed there was a lack of documentation by all staff in his medical record to: -Support his history of suicidal comments. -Support the staff had done everything possible to ensure his mental health well-being had been assessed appropriately for safety. *Agreed SSC S should have been more involved with all the residents who had concerns of mental health instability and behavioral concerns. *Had not been able to identify when that process of SSC S involvement with those concerns had changed. Interview on 3/28/18 at 9:25 a.m. with the MDS assessment coordinator confirmed she: *Had been responsible to review and complete the behavioral documentation on all the residents' MDS assessments. -The process had been that way since she became the MDS assessment coordinator. *She had not recognized a concern with that and the SSC S not having as much involvement in that area. *Stated Everywhere else that I have worked the SSC would have been responsible for the behavioral monitoring, assessments, and documentation for the residents. *Had reviewed that concern and process with the SSC S. -The SSC S had been okay with the current process. Review of resident 58's 2/28/18 admission MDS section D revealed: *SSC S had completed his interview in that section to determine his mood and depression level. *Letter I.: Thoughts that you would be better off dead, or of hurting yourself someway. *The resident had responded yes with those thoughts occurring nearly everyday. Review of resident 58's 3/2/18 progress note documented by the SSC S revealed: *She had: -Completed a narrative from his admission MDS assessment. -Documented he had mild depression, no [MEDICAL CONDITION], and his BIMS score was fifteen. *There had been no documentation to support his interview above regarding thoughts of better off being dead. Review of resident 58's 3/8/18 care conference summary revealed: *His daughter had attended the meeting. *There had been no documentation to support the resident had a history of [REDACTED]. | 2020-09-01 |