Haven of Tucson

Based on observations, staff interviews, and policy review, the facility failed to ensure medications were disposed of according to accepted professional standards. The deficient practice of erroneous medication disposal may result in undesirable medication- induced harm. Findings include: During a medication administration observation conducted on December 17, 2024 at 7:32 A.M. the Licensed Practical Nurse (LPN/Staff #242) was observed to split a medication tablet (Mirapex) in half and proceed to place one half of the medication tablet into a clear unlabeled medication cup and place it back into the medication cart stating to "save for the afternoon". The LPN also disposed of a medication (Geri-Kot) in the resident's room trashcan after the resident refused the medication. An interview was conducted on December 17, 2024 at 8:07 A.M. with the LPN (staff #242) who stated that he was not sure what the facility policy was regarding saving half of the Mirapex medication. He further stated that he could waste the other half of the medication and then in the afternoon do the same thing. The LPN stated that he would dispose of the medication by throwing it in the sharps container. The LPN also stated that he should have asked the resident to retrieve the medication the resident refused from the medication container and then disposed of it in the sharps container. The LPN stated that placing the unused half of the Mirapex into an unlabeled container for later use and disposing of a medication in the resident's room trash did not meet facility expectations. An interview was conducted on December 17, 2024 at 2:05 P.M. with the Director of Nursing (DON/Staff #94) who stated that the facility expectation would be to follow the state guidelines and regulations regarding the disposal of medications. The DON stated that the process for cutting a medication in half would include to dispose of the unused half of the medication and not save it for later use. The DON also stated that if it was a single pill then it should go into either the sharps container or the drug buster, and to not dispose of medications in the trash. She further stated that not disposing of the unused half of the Mirapex and disposing of the Geri-Kot in the resident's room trash did not meet facility expectations. Review of the facility policy titled, Medications: Discarding Medications, version 051123 revealed that non-controlled and Schedule V (non-hazardous) controlled substances are disposed of in accordance with state regulations and federal guidelines regarding the disposition of non-hazardous medications.

Based on observation, record review, interviews, and facility policy, the facility failed to ensure that monitoring and evaluation of physical restraints are completed for the continued use of physical restraints for one resident (Resident #62). Findings include: Resident #62 was initially admitted into the facility on April 16, 2024, and then re-admitted on August 8, 2024 with the diagnosis of metabolic encephalopathy, pneumonitis due to inhalation of food and vomit. A review of a care plan focus initiated on August 13, 2024 revealed that Resident #62 used a form of physical restraints, bilateral soft mitts. The focus also revealed interventions to ensure the resident is positioned correctly with proper body alignment while restrained, and, as well as monitoring and assistance every 2 hours for daily care. An order dated August 13, 2024 revealed that staff will ensure proper placement of bilateral soft mitts are released every two hours for ten to fifteen minutes. An order dated August 19, 2024 revealed that staff will provide frequent checks for safety and positioning of mitts, and to notify the provider for any skin breakdown. A review of a quarterly Minimum Data Set (MDS) assessment dated November 14, 2024 revealed no evidence of a Brief Interview for Mental Status (BIMS) score. The MDS also revealed that the resident is completely dependent on staff assistance. The MDS also revealed that the resident had a limb restraint for daily use in bed. On December 16, 2024 at 12:00 P.M. an observation was done on Resident #62, where Resident #62 was observed in bed with bilateral soft mitts on. In an interview conducted on December 16, 2024 at 12:25 P.M. with the power of attorney (POA) for Resident #62, the POA stated their approval of the restraint and the communication received, regarding the bilateral soft mittens. The POA also stated that they were provided the education and the expectations regarding the restraints and shared that they believe the facility had not provided regulation accordingly, and properly, as it was discussed with them. An interview conducted on December 16, 2024 at 12:46 P.M. with a Certified Nursing Assistant (CNA/Staff #206), where Staff #206 stated they had been provided training on the usage of restraint devices, including bilateral mitts, and to remove the restraint every two hours. Staff #206 stated that specifically for Resident $62, the were to observe the resident's hands for any skin tares and skin abnormalities, and as well as if the resident states of any itchiness and sweating in the mitts. Staff #206 stated that any CNA and nurse has the capability to assist the resident with the removal of the restraint and that the restraint had been ordered for the resident as Resident #62 had a history of pulling out their tracheostomy tube and their peripherally inserted central catheter (PICC) line. Staff #206 stated that their role in this process is to document their checks on the Resident #62's tasks chart on the faci

Based on observations, interviews, review of clinical records, and review of facility policy, the facility failed to ensure one resident (#46) received assistance to maintain hearing ability. Findings Include, Resident # 46 was admitted to the facility on November 27, 2024, with diagnoses of a right pelvic fracture, atrial fibrillation, anticoagulant therapy, anxiety, depression, and lack of coordination. The resident's inventory dated November 27, 2024 failed to list hearing aids under the resident's personal property. The resident's order dated November 27, 2024 revealed the resident could be seen by an audiologist. The care plan dated November 27, 2024 with the download date of December 16, 2024, revealed no focus, goals, or interventions for resident's hearing. The admission Minimum Data Set (MDS) dated December 3, 2024 revealed the resident scored a 15 on the Brief Interview for Mental Status (BIMS), indicating the resident was cognitively intact. The MDS also revealed the resident had minimal difficulty in the ability to hear. The MDS did not reveal the resident use of hearing aids as an assistive device. A psychological evaluation note dated December 10, 2024 revealed the resident's cognitive functioning and fund of knowledge were intact and age appropriate. A progress note dated December 10, 2024 revealed the resident required multiple verbal cues for redirection, after revealing resident demonstrated compromised cognition. A progress note dated December 13, 2024 revealed the resident was alert and oriented, but needed redirection during the day, and exhibited some signs confusion in the evening. A progress note dated December 16, 2024 revealed resident did not have dementia or any other neurological concerns at the time . Review of the clinical record revealed no other information about the resident's hearing aid, such as when the hearing aid should be used, how much assistance the resident needed with the hearing aid, or that the resident had used the hearing aid while in the facility. Review of the clinical record revealed no information regarding the escalation of any concerns regarding resident confusion. A resident observation was conducted on December 15, 2024 at 2:40 p.m. Resident laying in bed. No writing materials, sensory boards, or any other hearing assistive device in resident's area with the exception of the left ear hearing aid. The resident was observed on December 16, 2024 at approximately 9:30 a.m. during breakfast. No writing materials, sensory boards, or any other hearing assistive device in resident's area, with the exception of the left ear hearing aid. The resident was observed speaking with a Certified Nurse Assistant (CNA) and the unit manager regarding her hearing aid. The CNA stated to the resident and unit manager that she charged the resident's hearing aid for her every night. No writing materials, sensory boards, or any other hearing assistive device in resident's area, with the exception of the resident's he

Based on staff interviews, clinical record review, and facility policy, the facility failed to ensure that one resident (#149) was not discharged with an unnecessary device. Resident #149 was admitted on December 7, 2023 with diagnoses of urinary tract infection, Klebsiella pneumoniae and type 2 diabetes. This resident was discharged to an assisted living facility on February 6, 2024. A care plan initiated on January 16, 2024 included that the resident was on Antibiotic Therapy including Meropenem for a urinary tract infection. Interventions included to observe for possible infection every shift. A physician's order dated January 16, 2024 included Meropenem (antibiotic) Intravenous Solution Reconstituted 1 gram Use 1 gram intravenously every 8 hours for urinary tract infection for 3 Days was discontinued on January 19, 2024. A review of the clinical record did not find any medications administered intravenously after January 19, 2024. A physician's order dated January 16, 2024 included to flush PICC Line with 10ml of NS Q Shift, PRN and Pre and Post Medication every shift for PICC Line Usage. This order was discontinued on January 30, 2024. Review of the clinical record included that the last notation of this cap being changed was on January 30, 2024. However, review of the record indicated that this resident had the PICC line until February 7, 2024. A physician's order dated January 16, 2024 included monitor PICC Line insertion site every shift for signs/symptoms of infection including redness, warmth, swelling, drainage every shift for PICC line usage. This order was discontinued on January 30, 2024. Review of the clinical record included that the last notation of this cap being changed was on January 30, 2024. However, review of the record indicated that this resident had the PICC line until February 7, 2024. A physician's order dated January 16, 2024 included to change PICC line dressing every 7 days and as needed using sterile technique every day shift every Thursday for PICC Line Usage. This order was discontinued on January 30, 2024. Review of the clinical record included that the last notation of this cap being changed was on January 25, 2024. However, review of the record indicated that this resident had the PICC line until February 7, 2024. A physician's order dated January 16, 2024 included discontinue intravenous (IV)/PICC line after completion of IV antibiotics, however review of the clinical record did not reveal documentation that the IV/PICC line had been removed. A medication administration note dated January 25, 2024 included that the resident was no longer on IV antibiotics and that a message was sent to the MD to remove the PICC line and that the writer was awaiting a response. However, no further record of the PICC line was included until February 7, 2024. A progress note dated February 6, 2024 included "Patient was discharged today at 1800 hours. patient unable to sign paperwork. Personal belongings and leftover meds were ta

Based on observations, staff interviews, and policy review, the facility failed to ensure medications were disposed of according to accepted professional standards. Findings include: During a medication administration observation conducted on December 17, 2024 at 7:32 A.M. the Licensed Practical Nurse (LPN/Staff #242) was observed to split a medication tablet (Mirapex) in half and proceed to place one half of the medication tablet into a clear unlabeled medication cup and place it back into the medication cart stating to "save for the afternoon". The LPN also disposed of a medication (Geri-Kot) in the resident's room trashcan after the resident refused the medication. An interview was conducted on December 17, 2024 at 8:07 A.M. with the LPN (staff #242) who stated that he was not sure what the facility policy was regarding saving half of the Mirapex medication. He further stated that he could waste the other half of the medication and then in the afternoon do the same thing. The LPN stated that he would dispose of the medication by throwing it in the sharps container. The LPN also stated that he should have asked the resident to retrieve the medication the resident refused from the medication container and then disposed of it in the sharps container. The LPN stated that placing the unused half of the Mirapex into an unlabeled container for later use and disposing of a medication in the resident's room trash did not meet facility expectations. An interview was conducted on December 17, 2024 at 2:05 P.M. with the Director of Nursing (DON/Staff #94) who stated that the facility expectation would be to follow the state guidelines and regulations regarding the disposal of medications. The DON stated that the process for cutting a medication in half would include to dispose of the unused half of the medication and not save it for later use. The DON also stated that if it was a single pill then it should go into either the sharps container or the drug buster, and to not dispose of medications in the trash. She further stated that not disposing of the unused half of the Mirapex and disposing of the Geri-Kot in the resident's room trash did not meet facility expectations. Review of the facility policy titled, Medications: Discarding Medications, version 051123 revealed that non-controlled and Schedule V (non-hazardous) controlled substances are disposed of in accordance with state regulations and federal guidelines regarding the disposition of non-hazardous medications.

Based on observations, staff interviews, and facility policy review, the facility failed to ensure appropriate infection control practices were followed during medication administration. Findings include: A medication administration observation was conducted on December 17, 2024 at 7:32 A.M. with Licensed Practical Nurse (LPN/Staff #242). The LPN was observed to dispense a Mirapex tablet into his ungloved hand, split the medication with ungloved hands, and then place the medication into a clear medication cup. The LPN was also observed to reach into a medication cup with ungloved hands and retrieve a medication that the resident refused and then give the medication cup back to the resident with other medications for administration. An interview was conducted on December 17, 2024 at 8:07 A.M. with LPN (staff #242) who stated that he should have asked the resident to retrieve the medication she refused from the medication cup and then dispose of it in the sharps container. He also stated that it did not follow facility expectations to dispense and split the medication with his ungloved hands. The LPN further stated that the risk to the resident could result in contamination of the medications. An interview was conducted on December 17, 2024 at 2:05 P.M. with the Director of Nursing (DON/Staff #94) who stated the process for cutting a medication in half would include making sure to wear gloves and to use a pill cutter. She also stated that dispensing medications, splitting medications, and retrieving medications from a medication cup using ungloved hands did not meet facility expectations. She further stated that the risk to the residents could include the medications becoming contaminated by the nurse not wearing gloves. Review of the facility policy titled, Medications: Administering Oral Medications, version 051123, revealed that tablets or capsules from a bottle, to not touch the medication with your hands. The policy also indicated that for unit dose tablets or capsules to place packaged medications directly into the medication cup.

Based on clinical record review, interviews, facility documentation and policy, the facility failed to ensure that one resident (#74) was weighed on admission. Findings include: Resident was admitted to the facility on November 27, 2024, with diagnoses that included quadriplegia, protein-calorie malnutrition, feeding tube, and difficulty swallowing. A care plan with the initiate date of November 27, 2024 had a noted goal of experience no significant weight changes (i.e. 5% x 1 month, 7.5% x 3 months, and 10% x 6 months). An order dated November 27, 2024, with a start date of December 1, 2024, revealed the resident was to be weighed on admission, and then to follow facility protocol. In addition, the resident was to be weighed every day shift on Sundays. A care plan with the initiate date of December 1, 2024 had a noted goal of to maintain the resident's weight without significant weight variance. The admission Minimum Data Set (MDS) dated December 3, 2024 revealed the resident scored a 15 on the Brief Interview for Mental Status (BIMS), indicating the resident was cognitively intact. The MDS in addition revealed the resident weighed 117 pounds, and experienced a weight loss (either 5% or more over the last month, or a 10% loss over the last 6 months). It clarifies that at the time of weight change the resident was not on a physician-prescribed weight-loss regimen. A progress note for December 12, 2024 revealed the resident weight on December 3, 2024 was used to help determine the resident need for nutritional adequacy and weight management. The note in addition recorded the Ideal Body Weight Range (IBWR) as 126-154 pounds. A Treatment Administration Record (TAR) for December 2024, with the download date of December 16, 2024, revealed a resident weight of 117 pounds on both December 8, 2024, and December 15, 2024. Further review of the clinical record revealed no evidence the resident was weighed on date of admission. An interview was conducted with a Certified Nursing Assistant (CNA/Staff #28) on December 16, 2024 at 8:50 a.m. Staff #28 revealed a job responsibility is to obtain new residents' weights upon admission. The type of scale and frequency of weights depends on the ability of the resident, and the physician order. The CNA further explained that the resident weights are recorded in the clinical record. Staff #28 stated that if the CNA's have any concerns about the weight and resident, they immediately report to the nurse. An interview was conducted with the Dietary Manager (Staff #168) on December 17, 2024 at approximately 1:33 p.m. The dietary manager verified all residents are to be weighed on admission and then weekly for four weeks. The manager reviewed the resident's clinical record and verified the initial weight was not recorded until December 3, 2024. The manager stated that not obtaining the weight upon admission is not facility policy or following physician order. The manager further stated that resident weights, especially the