Surveyors with the state Department of Health Services have been sent to Evansville Manor six times this year, resulting in 13 federal citations and four instances of surveyors believing residents were in immediate jeopardy.
No citations were issued in three investigations, including one launched after a case of COVID-19 was identified at the nursing home, according to documents from the state Department of Health Services.
The other three investigations, conducted March 9, March 19 and June 29, resulted in citations. The nursing home had to submit plans of correction for each.
Evansville Manor Administrator Regina Teska said the nursing home is in full compliance with state standards since the investigations were conducted.
Teska, who started her job at Evansville Manor about two months ago, said state surveyors have returned to the nursing home several times during her tenure and found no issues.
Teska and the facility’s director of nursing are new to their positions and bring a wealth of knowledge, Teska said.
State documents indicate the director of nursing and administrator who were on duty when the nursing home was cited no longer work at Evansville Manor.
“Getting new leaders in the facility has already moved us in the right direction,” Teska said.
The following details were reported in documents from the state Department of Health Services.
The state defines immediate jeopardy as a situation in which “a deficient practice has caused or is likely to cause serious injury, serious harm, impairment or death to a resident receiving care in the facility.”
Corrective action must be taken after immediate jeopardy is identified, and that status remains as long as facility practices show potential of a similar situation happening again, according to the state’s survey guide for long-term care facilities.
Immediate jeopardy was identified at Evansville Manor twice March 3 and twice June 18. It was removed in each circumstance the day it was identified.
On Feb. 26, a resident was given 50 milligrams of morphine, 10 times the prescribed dose of 5 milligrams. Nursing staff later administered Narcan to the resident to prevent an overdose.
The morphine was given by a certified medical assistant, a worker who does not have the state credentials needed to administer medications.
In an interview with surveyors, the medical assistant said he or she asked the director of nursing about the dosage before giving the medication.
The investigation found the pharmacy sent two different morphine orders with different concentration amounts, leading to confusion.
The facility’s failure to ensure staff had proper credentials to perform tasks led to the finding of immediate jeopardy as of July 31, 2019, when the certified medical assistant began administering medication.
The same incident caused a second finding of immediate jeopardy because of the facility’s failure to ensure a resident was free from a significant medication error.
Evansville Manor made several changes to lift the immediate jeopardy orders, including removing the medical assistant from medication duties, reviewing policies, educating staff and auditing medication carts.
On March 17, a hospice nurse found a resident not breathing and presumably dead during a routine visit to the resident’s room. The resident’s daughter told the nurse not to do CPR because it was unclear when the resident had stopped breathing.
The resident was identified as being “full code” in a care plan, meaning that resuscitation efforts should be performed if the resident had no heartbeat or pulse.
The facility’s failure to begin CPR or call 911 after finding the resident and failure to communicate the resident’s full-code status between medical and hospice staff both led to findings of immediate jeopardy.
Since then, Evansville Manor has conducted training and enhanced education to lift the immediate jeopardy status.
Federal citations were issued for these concerns:
- Failure to make prompt efforts to resolve a resident’s grievance. Staff knew a resident was missing his or her hearing aid for months and did not document or investigate the concern.
- Failure to carry out activities of daily living to maintain good nutrition, grooming and hygiene. A resident did not receive weekly showers as scheduled and received two showers in a one-month span instead of four.
- Failure to take action to prevent pressure ulcers or injuries and failure to promote healing of existing injuries. Four residents were found to not have received proper wound care or prevention.
- Failure to ensure the environment remains free of accident hazards. Interventions were not put in place after one resident fell on two different occasions.
- Failure to ensure certified nursing assistants complete 12 hours of in-service training. Three nursing assistants did not complete training.
- Failure to complete performance reviews every 12 months for certified nursing assistants.
- Failure to report alleged misappropriation, neglect or abuse to the nursing administrator and failure to make sure allegations are fully investigated after two incidents of abuse between residents.
Plans of correction were submitted for each citation. The state’s Division of Quality Assurance is tasked with ensuring changes are made.
The nursing home continues to audit practices weekly and monthly to maintain compliance, Teska said.
Staff also meets monthly to discuss quality assurance and to look over various metrics, she said.
The state deems investigations closed when corrective plans are submitted.
No other penalties were given as a result of the findings.
“We have a staff that is dedicated to making improvements,” Teska said.